Graves' ophthalmopathy: state of the art and perspectives

Evaluation of lamina cribrosa and peripapillary vascular density in thyroid orbitopathy and effect of intravenous methylprednisolone therapy

OBJECTIVE

To evaluate optic nerve head changes in patients with thyroid orbitopathy (TO) and investigate the effects of intravenous methylprednisolone (IV MTP) on these changes.

METHODS

Eighty-two eyes of 41 patients with TO with and without dysthyroid optic neuropathy (DON) and 40 eyes of 40 healthy control subjects were included in the study. Lamina cribrosa thickness (LCT) and depth (LCD) measurements, peripapillary retinal nerve fibre layer thickness (RNFLT), and radial peripapillary capillary vascular density were measured using optical coherence tomography and optical coherence tomography angiography. Visual field examination and proptosis were evaluated. Patients with DON and active non-DON received IV MTP for 12 weeks, and the effect of this treatment was evaluated.

RESULTS

Peripapillary vascular density decreased in patients with DON compared with the other groups (p < 0.001 for all); there was no difference in the total, superior hemi-sector, and inferior hemi-sector of the RNFLT between the groups. LCT was decreased in the TO group (p < 0.001). After IV MTP treatment, the LCT and best-corrected visual acuity were increased. Thyroid-stimulating hormone receptor antibody levels, intraocular pressure, the superior hemi-sector of the RNFLT, and proptosis were decreased compared with the control subjects (p = 0.012, p = 0.008, p = 0.043, and p < 0.001, respectively).

CONCLUSIONS

The RNFLT may not always increase in DON. Lamina cribrosa morphology may change in patients with TO. IV MTP therapy has a positive effect on the LCT but not on radial peripapillary capillary vascular density or LCD.

A Prediction Model for Detecting Dysthyroid Optic Neuropathy Based on Clinical Factors and Imaging Markers of the Optic Nerve and Cerebrospinal Fluid in the Optic Nerve Sheath

OBJECTIVE

This study aimed to develop and test a model for predicting dysthyroid optic neuropathy (DON) based on clinical factors and imaging markers of the optic nerve and cerebrospinal fluid (CSF) in the optic nerve sheath.

METHODS

This retrospective study included patients with thyroid-associated ophthalmopathy (TAO) without DON and patients with TAO accompanied by DON at our hospital. The imaging markers of the optic nerve and CSF in the optic nerve sheath were measured on the water-fat images of each patient and, together with clinical factors, were screened by Least absolute shrinkage and selection operator. Subsequently, we constructed a prediction model using multivariate logistic regression. The accuracy of the model was verified using receiver operating characteristic curve analysis.

RESULTS

In total, 80 orbits from 44 DON patients and 90 orbits from 45 TAO patients were included in our study. Two variables (optic nerve subarachnoid space and the volume of the CSF in the optic nerve sheath) were found to be independent predictive factors and were included in the prediction model. In the development cohort, the mean area under the curve (AUC) was 0.994, with a sensitivity of 0.944, specificity of 0.967, and accuracy of 0.901. Moreover, in the validation cohort, the AUC was 0.960, the sensitivity was 0.889, the specificity was 0.893, and the accuracy was 0.890.

CONCLUSIONS

A combined model was developed using imaging data of the optic nerve and CSF in the optic nerve sheath, serving as a noninvasive potential tool to predict DON.

Dysthyroid Optic Neuropathy

PURPOSE

Dysthyroid optic neuropathy (DON) is a sight-threatening complication of thyroid eye disease (TED). This review provides an overview of the epidemiology, pathogenesis, diagnosis, and current therapeutic options for DON.

METHODS

A literature review.

RESULTS

DON occurs in about 5% to 8% of TED patients. Compression of the optic nerve at the apex is the most widely accepted pathogenic mechanism. Excessive stretching of the nerve might play a role in a minority of cases. Increasing age, male gender, smoking, and diabetes mellitus have been identified as risk factors. Diagnosis of DON is based on a combination of ≥2 clinical findings, including decreased visual acuity, decreased color vision, relative afferent pupillary defect, visual field defects, or optic disc edema. Orbital imaging supports the diagnosis by confirming apical crowding or optic nerve stretching. DON should be promptly treated with high-dose intravenous glucocorticoids. Decompression surgery should be performed, but the response is incomplete. Radiotherapy might play a role in the prevention of DON development and may delay or avoid the need for surgery. The advent of new biologic-targeted agents provides an exciting new array of therapeutic options, though more research is needed to clarify the role of these medications in the management of DON.

CONCLUSIONS

Even with appropriate management, DON can result in irreversible loss of visual function. Prompt diagnosis and management are pivotal and require a multidisciplinary approach. Methylprednisolone infusions still represent first-line therapy, and surgical decompression is performed in cases of treatment failure. Biologics may play a role in the future.

Dysthyroid optic neuropathy: Demographics, risk factors, investigations, and management outcomes

Purpose

To analyze the clinical presentations, risk factors, and management outcomes in patients presenting with dysthyroid optic neuropathy (DON).

Methods

This is a retrospective, single-center study carried out on consecutive patients presenting with DON over a period of 4 years (2013-2016). The VISA classification was used at the first visit and subsequent follow-ups. The diagnosis was based on optic nerve function tests and imaging features. Demographic profiles, clinical features, risk factors, and management outcomes were analyzed.

Results

Thirty-seven eyes of 26 patients diagnosed with DON were included in the study. A significant male preponderance was noted (20, 76.92%). Twenty patients (76.9%, P = 0.011) had hyperthyroidism, and 15 (57.69%, P = 0.02) were smokers. Decreased visual acuity was noted in 28 eyes (75.6%). Abnormal color vision and relative afferent pupillary defects were seen in 24 (64.86%) eyes, and visual field defects were seen in 30 (81.01%) eyes. The visual evoked potential (VEP) showed a reduced amplitude in 30 (96.77%, P = 0.001) of 31 eyes and delayed latency in 20 (64.51%, P = 0.0289) eyes. Twenty-six (70.27%) patients were treated with intravenous methyl prednisolone (IVMP) alone, whereas 11 (29.72%) needed surgical decompression. The overall best-corrected visual acuity improved by 0.2 l logMARunits. There was no statistically significant difference in outcome between medically and surgically treated groups. Four patients developed recurrent DON, and all of them were diabetics.

Conclusion

Male gender, hyperthyroid state, and smoking are risk factors for developing DON. VEP, apical crowding, and optic nerve compression are sensitive indicators for diagnosing DON. Diabetics may have a more defiant course and are prone to develop recurrent DON.

[Transnasal endoscopic orbital decompression in the algorithm of surgical treatment of endocrine ophthalmopathy]

OBJECTIVE

To develop an algorithm for the use of transnasal endoscopic orbital decompression (TEOD) in endocrine ophthalmopathy (EOP).

MATERIAL AND METHODS

The results of 225 TEODs are analyzed. 139 patients with EOP were under observation, who were divided into two groups. Group 1 included 64 patients with an inactive form of EOP, group 2 included 75 patients with EOP complicated by optical neuropathy. Group 2 patients are divided into three subgroups. In the first subgroup there were 36 patients who underwent only TEDO, in the second subgroup there were 17 patients who underwent simultaneous TEOD and lateral bone orbital decompression (LBOD), in the third subgroup there were 22 patients who underwent TEOD and with an interval of 7-14 days - LBOD. After surgery, visual acuity, visual fields and color perception, regression of exophthalmos, as well as the presence of strabismus and diplopia were evaluated.

RESULTS

In patients of group 1 (64 patients, 104 TEODs), the average regression rate of exophthalmos was 5.49±1.22. Diplopia was observed in 23 (36%) patients, strabismus - in 18 (28%) patients. The transient nature of diplopia and strabismus was noted in 11% of cases. Patients of the first subgroup showed an increase in visual acuity from 0.4±0.28 to 0.7±0.2 (p<0.05). Strabismus and diplopia were observed in 54% of cases. In the subgroup with step-by-step performed TEOD and LBOD, the increase in visual acuity was more pronounced and amounted to 74% (from 0.78±0.71 to 0.2±0.3 according to LogMAR, p<0.05), postoperative strabismus and diplopia remained at a high level - 40% of the number of surgical operations performed. The best results of improving visual functions were obtained in patients of the second subgroup with simultaneous TEOD and LBOD (balanced orbital decompression): the increase in visual acuity was 79% (from 0.57±0.47 to 0.12±0.2 according to LogMAR, p<0.05). In patients of this subgroup, strabismus develops less frequently (22% of the number of operated orbits).

CONCLUSION

Transnasal endoscopic decompression of the orbit in the inactive form of the disease is indicated for exophthalmos of more than 4-8 mm. In optical neuropathy, transnasal endoscopic orbital decompression is indicated regardless of the initial visual acuity of the patient and should be supplemented with lateral bone orbital decompression with visual acuity below 0.1. The obtained results allowed us to form an algorithm for surgical treatment of patients with endocrine ophthalmopathy and optical neuropathy using transnasal endoscopic orbital decompression as a surgical intervention.

Functional outcomes and complications in refractory dysthyroid optic neuropathy management: Experience with 3 different surgical protocols

INTRODUCTION

Dysthyroid optic neuropathy (DON) is the most severe complication of Graves' orbitopathy (GO) and its management may require decompression surgery. Clear recommendations do not exist about which surgery should be performed and how extended the decompression should be. In this paper we present our experience regarding the management of DON via 3 different surgical protocols: a modified extended orbital apex decompression, a 2 walls decompression (inferior and lateral) and a 3 walls decompression (inferior, lateral and medial) and evaluate the functional outcomes.

METHODS

Retrospective evaluation of subjects affected by DON not responding to medical therapy has been performed. All patients were submitted to pre- and post-operative ophthalmologic evaluations and orbital and sinuses CT scan in order to evaluate functional and surgical outcomes.

RESULTS

27 patients were enrolled in the study. Surgical procedures were performed on 42 orbits. A statistically significant post-operative improvement was recorded in visual acuity, proptosis, color vision and fundus oculi evaluation for all groups. No patient developed major or minor complications after surgery.

CONCLUSIONS

Extended endonasal approach and 3 walls decompression have been proved effective in the management of DON. The choice between them is done according to degree of proptosis, general status and eye-surface damages.

RAPD as a clinical alert for early evidence of dysthyroid optic neuropathy

Dysthyroid optic neuropathy (DON) is a serious manifestation of thyroid eye disease (TED) resulting in permanent visual loss. There is controversy regarding the diagnostic features of DON. Relative afferent pupil defect (RAPD) in TED is highly specific for DON. Our first patient, a 42-year-old male presented with proptosis and intermittent blurring of vision with best corrected visual acuity of 6/6 in both eyes and right RAPD as an early sign of DON. Our second patient, a 54-year-old female presented with proptosis and clinical activity score <3 at the time of presentation. She developed intermittent blurring of vision with left RAPD on her second presentation as clue of bilateral asymmetric DON in her eyes, though BCVA was 6/6 both eyes. Both cases of bilateral asymmetric DON had RAPD as early specific sign of DON, which prompted us to do detailed radio-imaging to confirm DON, hence highlighting the importance of RAPD.

Early efficacy of teprotumumab for the treatment of dysthyroid optic neuropathy: A multicenter study

Purpose

To study post-interventional findings in patients with dysthyroid optic neuropathy (DON) treated with teprotumumab.

Observations

In this multicenter observational Case series, patients with DON were treated with teprotumumab, an insulin-like growth factor I receptor inhibitor (10 mg/kg for the first infusion then 20 mg/kg for subsequent infusions, every three weeks for a total 8 infusions). This study included patients with acute and chronic thyroid eye disease (TED) with DON who had failed conventional therapies and were not candidates for surgical decompression. Data collected included best corrected visual acuity (BCVA), color vision, RAPD when present, and orbital CT or MRI. Proptosis, clinical activity score (CAS), Gorman diplopia score (GDS), and Humphrey visual fields (HVF) were also evaluated.

Ten patients (6 women, 4 men) with an average age 64 years old were included in this study. Mean follow up after completion of infusions was 15 weeks. Baseline visual acuity (VA) impairment ranged from hand motion (HM) to 20/25 in affected eyes. All patients had pre-treatment orbital CT or MRI that confirmed orbital apex compression. Seventy percent of patients had objective improvement in DON after 2 infusions of teprotumumab measured as significant improvement in visual acuity, resolution of RAPD, or both. After completion of treatment, affected eyes had a mean BCVA improvement of 0.87 logMAR (p=0.0207), proptosis reduction of 4.7 mm (p<0.00001), CAS improvement of 5.25 points (p<0.00001), and GDS improvement of 0.75 points (p=0.160). All 6 patients who presented with an RAPD had resolution or improvement of RAPD. All 7 patients who presented with color vision deficits had normalization or improvement of color vision.

Conclusions and Importance

Teprotumumab infusions resulted in medical decompression and objective resolution or improvement of dysthyroid optic neuropathy. Most patients had rapid improvement of visual acuity and reversal of RAPD. Post-infusion imaging demonstrated reduction in extraocular muscle size that correlated with improvement in visual dysfunction. However, patients who presented with longstanding severe visual loss had limited improvement. There was no recurrence of DON after completion of teprotumumab in our cohort.

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Teprotumumab is effective for the treatment of dysthyroid optic neuropathy.

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Most patients demonstrated rapid objective improvement after 2 infusions.

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Visual acuity improved and relative afferent pupillary defect resolved after treatment.

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Orbital imaging showed improvement of orbital apex crowding after treatment.

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Patients with longstanding severe vision loss had limited improvement in visual acuity.

Comparison of 2-wall versus 3-wall orbital decompression against dysthyroid optic neuropathy in visual function: A retrospective study in a Chinese population

To compare visual function of 2-wall (medial and lateral) versus 3-wall (medial, lateral, and inferior) orbital decompression in patients with dysthyroid optic neuropathy (DON).A total of 52 eyes of 37 patients underwent orbital decompression for DON between 2013 and 2019 were retrospectively reviewed. Two- or 3-wall decompression was performed in 31 eyes of 23 patients and 21 eyes of 14 patients, respectively. We examined best-corrected visual acuity (BCVA), visual field mean deviation (MD) and pattern standard deviation (PSD), pattern-reversed visual evoked potential (PVEP) for P100 latency and amplitude at 60 and 15 arcmin stimulation checkerboard size, as well as proptosis using Hertel exophthalmometry.Whether 2-wall or 3-wall decompression, all parameters of visual function were improved after surgery (all P < .05). The improvement in BCVA, MD, and PSD was not statistically significant between groups (all P > .05). Proptosis reduction was higher after 3-wall decompression (P = .011). Mean increase in P100 amplitude after 3-wall decompression was statistically higher than that of after 2-wall decompression at 60 and 15 arcmin (P = .045 and .020, respectively), while the mean decrease in P100 latency was similar between the groups (P = .821 and .655, respectively). Six patients (66.67%) had persistent postoperative diplopia and 1 patient (20%) had new-onset diplopia in 3-wall decompression group, which were higher than in 2-wall decompression group (46.15% persistent postoperative diplopia and no new-onset diplopia).Both 2-wall and 3-wall decompression can effectively improve visual function of patients with DON. Three-wall decompression provides better improvement in P100 amplitude and proptosis, however new-onset diplopia is more common with this surgical technique.

Teprotumumab (Tepezza): from the discovery and development of medicines to USFDA approval for active thyroid eye disease (TED) treatment

Teprotumumab (TPT) is a type I insulin-like growth factor receptor inhibitor, marketed as Tepezza; recently USFDA approved it for the treatment of thyroid eye disease (thyroid-associated ophthalmopathy (TAO), Graves ophthalmopathy/orbitopathy) in the USA. It is a monoclonal antibody although it was initially developed in collaboration with Genmab and Roche for the treatment of the tumour, but later it was investigated by River Vision Development Corporation and Horizon Therapeutics for its ophthalmic use. The drug has been designated as an orphan drug, breakthrough designation and fast-track designation. This review summarizes the milestones in the research and development including ongoing, clinical trial of TPT till now, foremost to this primary approval for thyroid-associated ophthalmopathy (TAO).

[Dysthyroid optic neuropathy: surgical treatment potential]

PURPOSE

To evaluate the effectiveness of bony orbital decompression in patients with dysthyroid optic neuropathy (DON).

MATERIAL AND METHODS

The study analyzed 255 patients with thyroid eye disease (TED) and bony orbital decompression. Those among them who had DON as an indication for surgery were investigated further. Patients underwent standard ophthalmological examination, computer perimetry, color vision assessment using Ishihara tables, relative afferent pupillary defect (RAPD), computed tomography (CT) of the orbit, and in some cases optical coherence tomography (OCT) of the optic nerve.

RESULTS

Final analysis included 31 patients (52 eyes). On 13 orbits, only lateral wall decompression was performed, and medial wall decompression was the only intervention in 7 orbits. In other cases, these techniques were performed either simultaneously - in 14 orbits, or alternately - in 18 orbits. In the postoperative period, all patients showed significant positive dynamics in terms of visual acuity, visual field, and proptosis. In all cases, decrease of the amount of orbital inflammation was observed. Exophthalmos significantly decreased after surgery and averaged 20.5±3.1 mm, which is 4.7 mm less than the initial one. All changes were statistically significant (p<0.01).

CONCLUSION

Bony orbital decompression is an effective and safe treatment option for DON resistant to high doses of glucocorticoids. In the vast majority of cases, this intervention is the only way to improve and stabilize visual function in this severe category of patients.

An assessment of the ocular tear film in patients with thyroid disorders

Objective: To investigate the ocular tear film in patients with thyroid disorders using various tests. Methods: The study involved the assessment of the ocular tear film in 20 patients with thyroid disorders (6 men and 14 women) aged 18-43 years (mean±standard deviation=34.3±3.2 years). An age-matched control group consisting of 20 subjects (8 males and 12 females) ranging in age from 18 to 43 years (31.3±2.9 years) was also examined under similar conditions. All patients completed the Ocular Surface Disease Index questionnaire, followed by the tear ferning test within the right eye. A phenol red thread test was carried out 10 mins later followed by the fluorescein tear break-up test with a 10-min gap between the tests being implemented. Results: The median score for the Ocular Surface Disease Index (P<0.05) showed the condition of mild dry eyes [median (IQR)=15.5 (21.9)] in patients with thyroid disorders compared to the control group [5.6 (3.6)]. The mean score for the phenol red thread test within both the right and left eyes showed acceptable tear volumes of 11.7±8.1 and 10.5±7.4 mm, respectively, but this was much lower (P<0.05) compared to those recorded within the control group (22.2±6.5 and 20.7±5.2 mm, respectively). In addition, the mean for the tear break-up time (P<0.05) scores in both eyes within the patients with thyroid disorders revealed a certain degree of eye dryness (4.9±1.6 and 4.2±1.9 s), while the control group showed normal eye scores (13.2±2.6 and 12.3±2.2 s). The median score for tear ferning grades showed eye dryness [2.0 (2.2)] within the study group and normal eyes [1.2 (0.9)] within the control group. Conclusions: Patients with thyroid disorders have a significant level of eye dryness compared to normal eye subjects.

Assessment of tear-evaporation rate in thyroid-gland patients

Objective

To assess the tear-evaporation rate in thyroid-gland patients using a VapoMeter.

Methods

Twenty thyroid gland patients aged 18-43 years (mean 34.3±6.3 years) completed the study. Additionally, an age-matched control group of 20 patients aged 18-43 years (32.2±5.1 years) was enrolled in the study for comparison purposes. An Ocular Surface Disease Index dry-eye questionnaire was completed, followed by a test to determine the tear-evaporation rate using the VapoMeter. The test was performed three times per subject by the same examiner. Two readings were obtained each time.

Results

Significant differences (P<0.05) were found between mean Ocular Surface Disease Index and tear-evaporation-rate scores within the study and control groups. The average tear-evaporation rate was much higher in the study group (median 41.2 [IQR 41.4] g/m²⋅h) than the control group (15.7 [13.7] g/m²⋅h). Moreover, the average Ocular Surface Disease Index score for thyroid-gland patients was much higher (15.6 [23.4]) compared to the control group (5.5 [7.50]).

Conclusion

The tear-evaporation rate in thyroid-gland patients was found to be much higher than normal-eye subjects.

Dysthyroid Optic Neuropathy

PURPOSE

Dysthyroid optic neuropathy (DON) is a serious complication of Graves orbitopathy that can result in irreversible and profound visual loss. Controversy exists regarding the pathogenesis and management of the disease. The authors provide an overview of the current understanding of DON and present a therapeutic guideline.

METHODS

A review of the literature.

RESULTS

The mechanism of DON appears to be multifactorial: direct compression of the optic nerve by enlarged extraocular muscles, stretching of the optic nerve by proptosis, orbital pressure, vascular insufficiency, and inflammation. Some or all of these factors may be involved in an individual patient. There has only been one controlled trial comparing high-dose intravenous methylprednisolone to bony orbital decompression for DON. Both 2-wall and 3-wall decompression techniques successfully improve visual functions of patients with DON. There are few case reports/case series that suggest biologic agents may improve visual function in DON.

CONCLUSIONS

DON is a serious complication of Graves orbitopathy, the diagnosis and management of which is complex and requires a multidisciplinary approach. There is little evidence regarding the optimum management strategy. Based on the current literature, the first line of treatment is intravenous methylprednisolone, with the exact timing and indication of bony orbital decompression still to be determined. In addition, there may be a role for the use of biologic agents that will require a systematic program to determine efficacy.

VARIABLES AFFECTING THE LONG-TERM OUTCOME OF GRAVES ORBITOPATHY FOLLOWING HIGH-DOSE INTRAVENOUS GLUCOCORTICOID PULSE THERAPY IN PATIENTS NOT TREATED WITH ORBITAL RADIOTHERAPY

OBJECTIVE

Intravenous (iv) glucocorticoids (GC) (ivGC) are used for active Graves orbitopathy (GO), but factors affecting GO outcome are poorly understood. We performed a retrospective study to investigate the variables affecting GO after ivGC.

METHODS

We evaluated 83 consecutive GO patients treated with ivGC but not orbital radiotherapy (ORT) and re-examined them after a median of 47 months. The endpoints were the relationships between GO outcome or additional treatments with age, sex, smoking habits, thyroid volume, thyroid treatment, time since thyroid treatment, antithyroid-stimulating hormone receptor antibodies (TRAb), GO duration, GO features, and follow-up time.

RESULTS

GO features improved after treatment, resulting in moderate and marked amelioration in ~75% and ~41% of patients respectively. By multivariate analysis, a moderate GO improvement correlated with diplopia at first observation, which was more severe in responders. A marked GO improvement correlated with time between first and last observation and time after thyroid treatment, which were longer in responders. This likely reflected the combination of an early effect of GC and a late, spontaneous improvement of GO, as shown by analyses of GO outcome at various time points. Additional treatments after ivGC correlated by multivariate analysis with eyelid aperture, diplopia and NOSPECS score (NOSPECS stands for no GO signs [N], only eyelid sign [O], soft tissue involvement [S], proptosis [P], extraocular motility restriction [E], corneal involvement [C], and sight loss [S]) at first observation, which were more severe in responders.

CONCLUSION

Our study shows that response to ivGC increases with time, likely reflecting the known tendency of GO to improve spontaneously, and is more pronounced when GO is more severe to begin with, which is associated with more additional treatments.

ABBREVIATIONS

ANOVA = analysis of variance CAS = clinical activity score GC = glucocorticoids GO = Graves orbitopathy ¹³¹I = radioactive iodine iv = intravenous ivGC = high-dose intravenous glucocorticoid pulse therapy MMI = methimazole OD = orbital decompression ORT = orbital radiotherapy TRAb = antithyroid-stimulating hormone receptor antibodies.

Update on thyroid-associated Ophthalmopathy with a special emphasis on the ocular surface

Thyroid-associated ophthalmopathy (TAO) is a condition associated with a wide spectrum of ocular changes, usually in the context of the autoimmune syndrome, Graves’ disease. In this topical review, we attempted to provide a roadmap of the recent advances in current understanding the pathogenesis of TAO, important aspects of its clinical presentation, its impact on the ocular surface, describe the tissue abnormalities frequently encountered, and describe how TAO is managed today. We also briefly review how increased understanding of the disease should culminate in improved therapies for patients with this vexing condition.

Cigarette Smoke Extract-Induced Oxidative Stress and Fibrosis-Related Genes Expression in Orbital Fibroblasts from Patients with Graves' Ophthalmopathy

Cigarette smoking is the most important risk factor for the development or deterioration of Graves' ophthalmopathy. Smoke-induced increased generation of reactive oxygen species may be involved. However, it remains to be clarified how orbital fibroblasts are affected by cigarette smoking. Our study demonstrated that Graves' orbital fibroblasts have exaggerated response to cigarette smoke extract challenge along with increased oxidative stress, fibrosis-related genes expression, especially connective tissue growth factor, and intracellular levels of transforming growth factor-β1 and interleukin-1β. The findings obtained in this study provide some clues for the impact of cigarette smoking on Graves' ophthalmopathy and offer a theoretical basis for the potential and rational use of antioxidants in treating Graves' ophthalmopathy.

Long-term outcome of Graves' orbitopathy following high-dose intravenous glucocorticoids and orbital radiotherapy

OBJECTIVE

Intravenous (iv) glucocorticoids (GC) (ivGC) and orbital radiotherapy (ORT) are commonly used in active Graves' orbitopathy (GO), with favorable outcomes in up to 80% of patients. However, little is known on the factors that may affect GO outcome in the long term, an issue that we investigated here.

METHODS

We studied retrospectively 96 untreated patients with GO, identified out of 787 consecutive patients who came to our GO Clinic for a follow-up visit between September 2010 and June 2013. After the first observation, patients were treated with ivGC and ORT and were then re-examined after a median period of 55.5 months. The primary end-point was the possible relation between GO outcome and several individual variables.

RESULTS

Exophthalmometry, eyelid aperture, CAS, diplopia and visual acuity (the latter only in patients with an initial reduction) improved significantly after treatment. Overall, 67.7% of patients had improved and were considered as responders, whereas the remaining (29.1% stable and 4.5% worsened) were considered as non-responders. Age, smoking, thyroid volume, thyroid treatment, serum anti-TSH receptor autoantibodies and individual GO features at first observation did not affect the outcome of GO, which, in contrast, was affected by gender and by the time elapsed between first and last observation. Thus, the prevalence of responders was higher in females (76.4 vs 48% in males, P = 0.02) and the time elapsed between first and last observation was greater in responders (58 vs 39 months in non-responders, P = 0.02). Whereas the prevalence of responders and non-responders was similar up to 36 months, there was an increase in responders beginning between 37 and 48 months and reaching a peak of ~80% between 61 and 72 months, to plateau thereafter.

CONCLUSIONS

Given the limitations of retrospective investigations, our study confirms that the combination of GC and ORT is effective in GO and shows that females have greater chances to respond to treatment. The notorious tendency of GO to improve spontaneously with time most likely contributes the long-term outcome of the eye syndrome.

The pathophysiology of thyroid eye disease

The pathophysiology of thyroid eye disease (TED) is complex and incompletely understood. Orbital fibroblasts (OFs) seem to be the key effector cells that are responsible for the characteristic soft tissue enlargement seen in TED. They express potentially pathogenic autoantigens, such as thyrotropin receptor and insulin-like growth factor-1 receptor. An intricate interplay between these autoantigens and the autoantibodies found in Graves disease may lead to the activation of OFs, which then leads to increased hyaluronan production, proinflammatory cytokine synthesis, and enhanced differentiation into either myofibroblasts or adipocytes. Some of the OFs in TED patients seem to be derived from infiltrating fibrocytes. These cells originate from the bone marrow and exhibit both fibroblast and myeloid phenotype. In the TED orbit, they may mediate the orbital expansion and inflammatory infiltration. Last, lymphocytes and cytokines are intimately involved in the initiation, amplification, and maintenance of the autoimmune process in TED.

Spontaneous improvement of untreated mild Graves' ophthalmopathy: Rundle's curve revisited

BACKGROUND

According to Rundle's curve, Graves' ophthalmopathy (GO) worsens during an initial phase up to a peak of maximum severity, then improves and reaches a static plateau, with the activity curve preceding the severity curve by a few months. To our knowledge, no studies have tried to replicate Rundle's curve, and very few have investigated the natural history of GO. Here, we studied GO natural history retrospectively and tried to identify factors that may affect it.

METHODS

A total of 65 patients with untreated GO underwent an eye assessment after a median of seven months after the appearance of GO and then after a median of 40 months. The primary endpoints were the variation of the single GO features and of the NOSPECS score, as well as the overall outcome of GO. The secondary endpoint was the influence of several variables (age, sex, smoking, GO and thyroid disease duration, thyroid treatment, thyroid status, thyroid volume, anti-TSH receptor autoantibodies) on the outcome of GO.

RESULTS

The majority of patients had mild, minimally active GO, and only five had a Clinical Activity Score (CAS) >3. There was a significant reduction of CAS (p<0.0001) and NOSPECS (p=0.01) between the first and last observation, with a timing pattern resembling Rundle's curve. This difference was confirmed even when patients with a CAS >3 at first observation were excluded. At the last observation, 50.8% of patients had improved, 33.8% had remained stable, and 15.4% had worsened moderately or substantially. The overall outcome of GO was not affected by any of the variables under examination.

CONCLUSIONS

In confirmation of Rundle's observations, untreated GO improves spontaneously with time in the majority of patients, with an activity peak between 13 and 24 months, which may have implications in determining the proper timing of GO treatments.

Thyroid volume and severity of Graves' orbitopathy

BACKGROUND

Graves' orbitopathy (GO) is thought to be related to one or more autoantigens present in the thyroid and in orbital tissues. Although this may not imply a quantitative relation between thyroid antigens and degree of GO, which in turn is a risk factor for a more pronounced GO, we postulated that the severity of GO may parallel the amount of thyroid tissue, namely, the size of the thyroid gland. This hypothesis is also based on the observation that patients with Graves' disease presenting with large goiters tend to have more severe hyperthyroidism. Thus, we evaluated retrospectively whether there is a correlation between the degree of GO at its first observation and, among other parameters, the thyroid volume.

METHODS

Eighty-six consecutive patients with untreated GO lasting for no longer than 24 months underwent an endocrinological and an ophthalmological evaluation, the latter including: exophthalmometry, eyelid width, clinical activity score (CAS), diplopia, and visual acuity. The overall degree of GO was ranked using the NOSPECS score as well as a modification of the NOSPECS score. The following parameters were considered for correlations: time since GO appearance, time since detection of hyperthyroidism, FT3, anti-thyrotropin receptor antibodies, thyroid volume, and cigarette-years.

RESULTS

Thyroid volume, but not the other parameters, correlated significantly by simple regression with exophthalmometry (p=0.02) and CAS (p=0.02). The standard NOSPECS score correlated with FT3 (p=0.05), thyroid volume (p=0.02), and cigarette-years (p=0.03), by simple, but not by multiple regression analysis. The modified NOSPECS score correlated with thyroid volume (p=0.007) and cigarette-years (p=0.04) by simple regression, and with thyroid volume also by multiple regression analysis (p=0.05).

CONCLUSIONS

Thyroid volume correlates with the severity of GO at its first observation, especially with exophthalmometry and CAS. The finding is in line with a possible pathogenetic role of antigens shared by the thyroid and orbital tissues. Nevertheless, other mechanisms may explain this observation, including an overall more reactive immune system in patients with a large goiter, resulting in more severe thyroid and eye disease, regardless of the nature of the autoantigen, or whether it is shared by the thyroid and the orbit.

Enalapril reduces proliferation and hyaluronic acid release in orbital fibroblasts

BACKGROUND

Orbital fibroblast proliferation and hyaluronic acid (HA) release are responsible for some of the clinical features of Graves' ophthalmopathy (GO). Thus, inhibition of these processes may be a possible therapeutic approach to this syndrome. Enalapril, a widely used antihypertensive drug, was found to have some inhibitory actions on fibroblast proliferation in cheloid scars in vivo, based on which we investigated its effects in primary cultures of orbital fibroblasts from GO patients and control subjects.

METHODS

Primary cultures of GO and control fibroblasts were treated with enalapril or with a control compound (lisinopril). Cell proliferation assays, lactate dehydrogenase release assays (as a measure of cell necrosis), apoptosis assays, and measurement of HA in the cell media were performed.

RESULTS

Enalapril significantly reduced cell proliferation in both GO and control fibroblasts. Because enalapril did not affect cell necrosis and apoptosis, we concluded that its effects on proliferation reflected an inhibition of cell growth and/or a delay in cell cycle. Enalapril significantly reduced HA concentrations in the media from both GO and control fibroblasts.

CONCLUSIONS

Enalapril has antiproliferative and HA suppressing actions in both GO and control fibroblasts. Clinical studies are needed to investigate whether enalapril has any effects in vivo in patients with GO.

Regulation of Lymphocyte Function by PPARgamma: Relevance to Thyroid Eye Disease-Related Inflammation

Thyroid eye disease (TED) is an autoimmune condition in which intense inflammation leads to orbital tissue remodeling, including the accumulation of extracellular macromolecules and fat. Disease progression depends upon interactions between lymphocytes and orbital fibroblasts. These cells engage in a cycle of reciprocal activation which produces the tissue characteristics of TED. Peroxisome proliferator-activated receptor-gamma (PPARgamma) may play divergent roles in this process, both attenuating and promoting disease progression. PPARgamma has anti-inflammatory activity, suggesting that it could interrupt intercellular communication. However, PPARgamma activation is also critical to adipogenesis, making it a potential culprit in the pathological fat accumulation associated with TED. This review explores the role of PPARgamma in TED, as it pertains to crosstalk between lymphocytes and fibroblasts and the development of therapeutics targeting cell-cell interactions mediated through this signaling pathway.

Quercetin decreases proliferation of orbital fibroblasts and their release of hyaluronic acid

BACKGROUND

Inhibition of fibroblast (FB) proliferation and hyaluronic acid (HA) production may be a therapeutic approach to Graves' ophthalmopathy (GO). The flavonoid quercetin has a wide range of activities, including reduction of FB growth.

AIM

To investigate the effects of quercetin in orbital FB from GO patients and control subjects.

METHODS

Primary cultures of orbital FB were treated with quercetin or with its glycosides rutin and quercitrin. Cell proliferation, necrosis, apoptosis, HA production, and cell cycle were measured.

RESULTS

Beginning at a 30 μM concentration, quercetin, but not rutin and quercitrin, reduced cell proliferation, with no difference between GO and control FB. The effect of quercetin on proliferation was due to necrosis and cell cycle blockade, whereas apoptosis was unaffected. Quercetin reduced HA in the cell media, with no difference between GO and control FB.

CONCLUSIONS

Quercetin reduces cell proliferation and HA release in orbital FB. Whether these initial findings have any potential for the use of quercetin in the clinical practice remains to be established.

[Extraocular myositis and comparative pathology: two case reports in the dog]

Two cases of extraocular myositis in dogs are reported in a golden retriever and an Australian shepherd. This condition is characterized by sudden bilateral exophthalmos, the absence of pain and third eyelid protrusion, orbital sonography showing the enlargement of extraocular muscles, and a quick response to systemic steroids at an anti-inflammatory dose. The literature review reports a breed predisposition in the golden retriever, mainly in females. Histopathologic evaluations confirm the inflammation of one or several extraocular muscles. Chronic disease was also described. Canine extraocular myositis shows some resemblance to Graves ophthalmopathy but can better be compared to idiopathic orbital myositis. Both disorders are probably the consequence of an immune dysfunction that still has to be discovered.

Thyroid eye disease: honing your skills to improve outcomes

Thyroid eye disease affects the eyelids, orbital compartment, and extraocular muscles, resulting in a highly variable degree of chemosis and enlargement of the preorbital fat pads, eyelid retraction, proptosis, restrictive strabismus, torticollis, and, rarely, compressive or congestive optic neuropathy. Although most patients with thyroid eye disease are best treated conservatively, those more severely affected may benefit from orbital decompression, strabismus surgery, or eyelid retraction repair after stabilization has occurred. Botulinum A toxin, high-dose intravenous corticosteroids, and radiation treatment are therapeutic options in select cases. Compressive or congestive optic neuropathy and severe corneal exposure warrant consideration of surgical intervention on an urgent basis without waiting for stabilization. Epidemiology and risks and benefits of high-dose steroids and radiation therapy are reviewed along with recommendations to improve conservative as well as surgical management of this disease. Strategies to manage strabismus and optimize outcomes are provided.

Graves orbitopathy: a perspective

Advances in the past few years have helped clinicians understand some of the pathogenetic mechanisms of Graves orbitopathy (GO), particularly the role of receptors for TSH and insulin-like growth factor I in the orbit. Optimal treatment strategies have been formulated and published by the European Group on Graves' Orbitopathy, which are hoped to improve the management of patients with this condition. The administration of intravenous pulses of steroids has been established as a superior treatment approach compared with other steroid regimens. In addition, orbital radiotherapy was effective in a subgroup of patients with GO who had eye dysmotility. The use of immunotherapies for the treatment of GO is currently being explored; of these, rituximab has emerged as a promising new agent.

Serum levels of angiogenic molecules in autoimmune thyroid diseases and their correlation with laboratory and clinical features

CONTEXT

Because angiogenesis has a role in the pathogenesis of inflammatory conditions, we studied angiogenesis soluble markers in autoimmune thyroid diseases.

OBJECTIVE

The aim of the study was to measure concentrations of angiopoietins, Tie-2, and vascular endothelial growth factor in sera from autoimmune thyroid disease patients.

DESIGN

Soluble Tie-2 (sTie-2), angiopoietin-1, angiopoietin-2, and vascular endothelial growth factor were quantified by ELISA in sera from 44 untreated Graves' disease (GD) patients, 25 untreated Hashimoto's thyroiditis (HT) patients, 13 non-GD hyperthyroid patients, and 22 age-matched controls. Subgroups of patients with active and non-active Graves' ophthalmopathy (GO) were analyzed. Correlations among these markers and clinical parameters were assessed by bivariate and multivariate analyses.

RESULTS

STIE-2 levels were higher in GD or HT patients compared to controls (P < 0.01). In addition, serum Ang-2 concentrations were higher in untreated GD patients compared to controls, HT patients, or non-GD hyperthyroid patients (P < 0.01), and no difference was observed between HT patients and controls. Significant correlations were found between free T(4)/sTie-2 and free T(4)/Ang-2 levels (r = 0.464, P < 0.01; and r = 0.463, P < 0.01, respectively) as well as between sTie-2/anti-TSH receptor antibody (r = 0.527; P < 0.01) and sTie-2/Ang-2 (r = 0.563; P = 0.001). Furthermore, sTie-2 levels were significantly higher in patients with active GO when compared to those with inactive GO (P < 0.05). Interestingly, Ang-2 levels decreased significantly after treatment with antithyroid drugs (P < 0.01).

CONCLUSIONS

Ang-2 and sTie-2 could participate in the pathogenesis of GD and potentially be used as markers of GO activity. Antithyroid drugs affect the angiogenic pattern in GD.

Management of Graves' orbitopathy in Latin America: an international questionnaire study compared with Europe

CONTEXT

Management of Graves' orbitopathy (GO) and dysthyroid optic neuropathy (DON) continues to be challenging. Other surveys have been successful in elucidating trends in GO management. Knowledge of current practice by members of the Latin American Thyroid Society (LATS) who manage patients with GO was targeted by distribution of a questionnaire. We compared our results with a previously reported European Thyroid Association (ETA) survey.

OBJECTIVES

To determine how endocrinologists in Latin America access and treat patients with GO and compare the results with the same European survey.

RESULTS

One hundred and two responders representing endocrinologists from 10 countries participated in the survey. Most (57%) participate in a multidisciplinary setting for GO management. Access to a surgeon for orbital decompression was available only 'within months' according to 48.3% of responders. Despite suspected DON, 32.4% were reluctant to recommend urgent referral to an eyecare physician. Steroids were preferred as the first-option therapy by 88.2% of responders (by intravenous route by 57.8% of these). The presence of diabetes reduced the use of steroids to 64.7% (P < 0.001) and increased the use of other immunosuppressive agents (from 1% to 9.8%, P < 0.01). Development of cushingoid features resulted in a reduction in steroid use to 40.2% (P < 0.001), with increased preference for irradiation (from 23.5% to 52.9%, P < 0.001) and nonsteroidal immunosuppressive drugs (from 1% to 10.8%, P < 0.01), along with a nonsignificant trend to higher indication of orbital surgery (from 24.5% to 34.3%).

CONCLUSION

Some potential deficiencies in the diagnosis and management of DON and hyperthyroidism were observed in our survey, highlighting the need for improvement in specialist education and the quality of care offered to patients with GO in Latin America.

Effects of total thyroid ablation versus near-total thyroidectomy alone on mild to moderate Graves' orbitopathy treated with intravenous glucocorticoids

CONTEXT

Graves' orbitopathy (GO) is probably caused by autoimmune reactions against autoantigen(s) shared by thyroid and orbital tissues sustained by intrathyroidal autoreactive T-lymphocytes infiltrating the orbit. Total thyroid ablation (TTA) may be beneficial for GO through removal of shared antigen(s) and autoreactive T-lymphocytes, but randomized studies are lacking.

OBJECTIVE

Our objective was to evaluate the effects of TTA in patients with GO treated with iv glucocorticoids (GC).

DESIGN/SETTING

A prospective, single-blind, randomized study was conducted at a referral center.

PATIENTS/INTERVENTIONS

Sixty patients with mild to moderate GO were randomized into: 1) near-total thyroidectomy (TX); or 2) TX plus (131)I (TTA) groups, and then treated with iv GC. Patients were evaluated 3 and 9 months after iv GC.

MAIN OUTCOME MEASURE

Overall improvement of GO at 9 months was the main outcome measure.

RESULTS

The distribution of GO outcome at 9 months was significantly more favorable in TTA than in TX patients (P = 0.0014 by chi(2) test). A cumulative significant (P = 0.0054) difference between the two groups at 3 and 9 months was found using a generalized linear model. Radioiodine uptake test and thyroglobulin assay in a patient sample showed complete ablation in the majority of TTA, but not of TX patients.

CONCLUSIONS

Compared with thyroidectomy alone, TTA is followed by a better outcome of GO in patients given iv GC. Whether TTA maintains this advantage in the long-term remains to be established.

Smoking and thyroid-associated ophthalmopathy: A novel explanation of the biological link

INTRODUCTION

Cigarette smoking is the strongest modifiable risk factor for developing thyroid-associated ophthalmopathy (TAO), and the severity of TAO is related to the current number of cigarettes smoked per day. We aimed to establish the effects of cigarette smoke extract (CSE) on an in vitro model of TAO.

METHODS

Orbital tissue was taken during surgery from 10 patients with TAO and nine control subjects. Orbital fibroblasts were cultured and exposed to CSE, and intercellular adhesion molecule 1 (ICAM1) expression was measured by flow cytometry. Glycosaminoglycan production was measured by hyaluronic acid ELISA. Orbital fibroblasts were grown in adipogenic media with or without CSE and/or IL-1, and the degree of adipogenesis was quantified.

RESULTS

Fibroblasts from patients with TAO and controls showed similar responses. ICAM1 expression was not affected by CSE. Hyaluronic acid production was stimulated by CSE in a dose-dependent manner (correlation coefficient, 0.978; P = 0.022), with 5% CSE causing an increase of 44% (P = 0.001). CSE increased adipogenesis in a dose-related manner, as did IL-1. The effects of CSE and IL-1 on adipogenesis were synergistic, with the degree of adipogenesis in the well containing both 5% CSE and 0.1 ng/ml IL-1 being double the magnitude of the sum of the values obtained from either stimulus alone (P < 0.001). Addition of an anti-IL-1 antibody to the well containing both 5% CSE and 0.1 ng/ml IL-1 reduced the degree of adipogenesis by 82% (P < 0.001).

CONCLUSION

These findings may help explain how cigarette smoking has a detrimental effect in TAO and suggests that IL-1 may be an attractive therapeutic target in TAO.

Clinical features of dysthyroid optic neuropathy: a European Group on Graves' Orbitopathy (EUGOGO) survey

BACKGROUND

This study was performed to determine clinical features of dysthyroid optic neuropathy (DON) across Europe.

METHODS

Forty seven patients with DON presented to seven European centres during one year. Local protocols for thyroid status, ophthalmic examination and further investigation were used. Each eye was classified as having definite, equivocal, or no DON.

RESULTS

Graves' hyperthyroidism occurred in the majority; 20% had received radioiodine. Of 94 eyes, 55 had definite and 17 equivocal DON. Median Clinical Activity Score was 4/7 but 25% scored 3 or less, indicating severe inflammation was not essential. Best corrected visual acuity was 6/9 (Snellen) or worse in 75% of DON eyes. Colour vision was reduced in 33 eyes, of which all but one had DON. Half of the DON eyes had normal optic disc appearance. In DON eyes proptosis was > 21 mm (significant) in 66% and visual fields abnormal in 71%. Orbital imaging showed apical muscle crowding in 88% of DON patients. Optic nerve stretch and fat prolapse were infrequently reported.

CONCLUSION

Patients with DON may not have severe proptosis and orbital inflammation. Optic disc swelling, impaired colour vision and radiological evidence of apical optic nerve compression are the most useful clinical features in this series.

Role of adipose tissue as an inflammatory organ in human diseases

Reviews on the inflammatory role of adipose tissue outside the field of metabolism are rare. There is increasing evidence provided by numerous basic research studies from nearly all internal medicine subspecializations that adipocytes and adipocytokines are involved in primary inflammatory processes and diseases. Therefore, it is the aim of the present review to discuss and to summarize the current knowledge on the inflammatory role of adipocytokines and special types of regional adipocytes such as retroorbital, synovial, visceral, subdermal, peritoneal, and bone marrow adipocytes in internal medicine diseases. Future clinical and therapeutic implications are discussed.

Antithyroid drug therapy of Graves' hyperthyroidism: realistic goals and focus on evidence

Only a minority of patients with hyperthyroidism caused by Graves' disease will experience cure of disease with a permanent euthyroid state without medication. Antithyroid drugs are useful in attaining euthyroidism, and most patients will gradually enter remission of the autoimmune abnormality after becoming euthyroid. A stable euthyroid state may be sustained by prolonged low-dose medication. The risk of relapse of hyperthyroidism after withdrawal of medication seems to be independent of duration of therapy, once remission has been induced. A number of risk factors influence the outcome of therapy and they should be evaluated when planning duration of therapy with antithyroid drugs.

Pharmacological Treatments for Thyroid Eye Disease

Thyroid eye disease (TED), which affects the majority of patients with Grave's disease, is associated with significant ophthalmic morbidity. In patients with mild disease, supportive treatment with lubricating medication can be sufficient. However, in patients with severe TED and disfiguring proptosis or sight-threatening neuropathy, more aggressive medical or surgical interventions are necessary. Corticosteroids remain the preferred pharmacological treatment modality in the majority of patients with an active inflammatory component. Other immunosuppressive drugs in combination with corticosteroids may be helpful in patients with corticosteroid-resistant TED. Newer agents such as somatostatin analogues have not shown to be of significant clinical benefit; however, initial studies on the use of antioxidants and cytokine antagonists are encouraging.

Surgical or medical decompression as a first-line treatment of optic neuropathy in Graves' ophthalmopathy? A randomized controlled trial

OBJECTIVE

Only a small percentage of Graves' ophthalmopathy (GO) patients develop optic neuropathy with impending loss of visual acuity. Therapy with methylprednisolone pulses is the treatment of first choice in severe and active GO patients. When the effect is insufficient, patients are usually treated with surgical decompression. We investigated whether surgery could become the first-line treatment, thus preventing treatment with steroids.

DESIGN AND SUBJECTS

We performed a randomized trial in 15 patients with very active GO and optic neuropathy. Six patients were treated with surgical decompression, and nine with methylprednisolone i.v. pulses for 2 weeks, followed by oral prednisone for 4 months. The primary outcome was determined by changes in visual acuity. If the eye disease deteriorated despite treatment or did not improve sufficiently, patients were switched to the other treatment arm.

RESULTS

The severity and activity of GO in both groups were similar at baseline. The Clinical Activity Score (CAS) was 6.3+/- 0.8 in the surgical group vs. 6.0+/- 0.5 in the steroids group and the Total Eye Score was 24+/- 6 vs. 25+/- 6. In the surgery group, 5/6 patients (82%) did not respond because of insufficient improvement in vision (n=3) or persistent chemosis (n=2), and all needed further immunosuppression. In the steroids group, 4/9 patients (45%) did not improve in visual acuity (P=0.132 vs. surgery group), and these needed decompressive surgery. All patients in whom therapy failed were switched to the other treatment arm and visual acuity improved in almost all patients. Visual acuity improved from 0.36 (0.02--0.40) to 0.90 (0.63--1.0) in the surgery group and from 0.50 (0.32--0.63) to 0.75 (0.32--1.0) in the steroids group at 52 weeks. At long-term follow-up in the surgery group 3/6 patients required squint surgery and 5/9 patients in the steroids group. Eyelid surgery was performed in 5/6 patients in the surgery group and in 4/9 patients in the steroids group.

CONCLUSION

Immediate surgery does not result in a better outcome and therefore methylprednisolone pulse therapy appears to be the first-choice therapy.