Quality of Life in Patients with Chronic Thyroid Eye Disease in the United States

Teprotumumab Improves Quality of Life in Thyroid Eye Disease: Meta-analysis and Matching-adjusted Indirect Comparison

Context

Teprotumumab and/or intravenous methylprednisolone (IVMP) are first-line treatments for thyroid eye disease (TED)/Graves' orbitopathy. Direct comparisons of these treatments on Graves' Orbitopathy Quality of Life Questionnaire (GO-QoL) are lacking.

Objective

Systematic review, meta-analysis, and matching-adjusted indirect treatment comparison (MAIC) of GO-QoL improvements.

Methods

A literature search was performed using PubMed and Embase between inception to April 1, 2023, including studies of patients with moderate to severe active TED treated with teprotumumab or IVMP.Changes in GO-QoL scores and appearance and visual function subscales were extracted. Two teprotumumab (n = 84) and placebo (n = 87) randomized clinical trials and 5 studies with IVMP (4.5 mg/12 weeks, n = 304) were identified. MAIC compared teprotumumab/placebo by adjusting for baseline GO-QoL, diplopia, proptosis, smoking, age, and sex. Significant improvements in overall GO-QoL were observed for teprotumumab vs IVMP [mean difference (MD): 13.26; 95% confidence interval (CI): 7.44, 19.09) and placebo (MD: 12.57; 95% CI: 5.94, 19.21), but not IVMP vs placebo (MD: -2.06; 95% CI: -8.24, 4.12). Improvements were noted in appearance subscale GO-QoL for teprotumumab vs IVMP (MD: 7.50; 95% CI: 0.35, 14.64) and placebo (MD: 10.80; 95% CI: 3.62, 17.98) but not for IVMP vs placebo (MD: 0.91; 95% CI: -6.36, 8.18). Visual subscale GO-QoL displayed greater improvements for teprotumumab vs IVMP (MD: 17.66; 95% CI: 7.86, 27.47) and placebo (MD: 14.54; 95% CI: 6.10, 22.99), with no significant change for IVMP vs placebo (MD: -3.65; 95% CI: -12.88, 5.57). Orbital pain, teprotumumab treatment, diplopia, proptosis, and male sex were significant independent predictors of overall GO-QoL (P < .05).

Conclusion

This unique analysis demonstrated a more clinically meaningful improvement in the health-related quality of life, as measured by the GO-QoL, for TED patients with teprotumumab vs both the most recommended IVMP dosage and placebo.

Long-Term Impact of Thyroid Eye Disease on Quality of Life: Insights From a Retrospective Cohort Study

OBJECTIVES

Thyroid eye disease (TED) seriously affects patients' quality of life (QoL), even if the disease is stable and nonactive. Data on clinical factors negatively influencing the QoL of patients with TED and long-term outcomes are limited. This study aims to evaluate the lasting impact of TED on QoL, focusing on the effects of previous TED treatments and identifying factors influencing long-term outcomes.

METHODS

A retrospective cohort study included 151 patients treated for active, moderate-to-severe and severe TED, with a mean follow-up of 8 years.

RESULTS

Higher clinical activity scores at diagnosis correlated with lower QoL scores. Thyroidectomy before immunosuppressive treatment was associated with lower QoL and an increased likelihood of orbital decompression. Any disease progression necessitating second-line treatments also negatively affected QoL. A decrease in thyrotropin receptor antibodies during active treatment and early treatment initiation positively affected visual functioning. Time-dependent regression analysis demonstrated no significant trend in QoL changes over time.

CONCLUSION

Our data reveal that disease severity, the timing of interventions and disease progression contribute to less favorable long-term QoL outcomes, extending years beyond active treatment. Early and accurate diagnosis and appropriate treatment can minimize poor long-term QoL in patients with TED.

The burden of illness in thyroid eye disease: current state of the evidence

Introduction

Thyroid eye disease (TED) is a disabling autoimmune condition characterized by proptosis and progressive orbital inflammation involving the extraocular muscles, orbital fat, and connective tissues. Clinical features include facial disfigurement, diplopia, dry eyes, and in severe cases, vision loss. Consequently, individuals with TED suffer significant physical and psychological burdens that impact their quality of life. Currently, there is no standardized definition or International Classification of Diseases code for TED, and the disease landscape remains incompletely understood; moreover, TED diagnostic criteria and treatment recommendations have not been thoroughly assessed across diverse populations. It is necessary to better understand the clinical, humanistic, and economic burden of TED and identify gaps in our knowledge to improve TED management and outcomes.

Methods

To describe the current understanding of TED epidemiology, diagnosis, disease burden, and recent TED treatment guidelines, a targeted literature review was conducted, searching multiple databases using key words of specific search topics (i.e., TED; epidemiology, humanistic, economic, and clinical burden; treatment; and practice guidelines) for articles published between October 2013 and October 2023 in the United States, United Kingdom, and Europe (France, Germany, Italy, and Spain). Articles published between May 2014 and May 2024 describing diverse racial and sociodemographic presentations of TED were included.

Results

TED is a complex disease with an array of risk factors, including thyroid dysfunction, thyroid-stimulating immunoglobin, smoking, and comorbid conditions. The natural history of TED is not clearly defined, and diagnosis is complicated due to the array of phenotypes and orbital symptoms observed. Although novel first-line treatments are available in select countries, there is an unmet need for improved treatments for moderate-to-severe and sight-threatening TED. Individuals with TED continue to experience poor health-related quality of life due to the clinical burden that TED imposes along with large healthcare resource utilization costs and treatment costs, and economic evaluation studies are limited. Importantly, there is still a need for studies that explore diverse populations and the impact of race and ethnicity on the disease landscape.

Conclusion

TED remains an incompletely characterized disease with major knowledge gaps, particularly among historically underserved populations.

"Real Life" Utility of the Graves' Ophthalmopathy-Quality of Life in a Multidisciplinary Thyroid Eye Disease Service

PURPOSE

This study aimed to describe the correlation of demographic and clinical factors with the Graves' ophthalmopathy-quality of life (GO-QOL) visual function (VF) and appearance (A) scores in a cohort attending a metropolitan multidisciplinary thyroid eye disease (TED) service.

METHODS

This is a cross-sectional retrospective study of 152 consecutive TED patients who completed the GO-QOL questionnaire. Clinical parameters, including endocrine diagnosis and status, TED activity and severity, Gorman diplopia score, and TED treatments were recorded at the time of completing each questionnaire and retrospectively analyzed.

RESULTS

A total of 257 GO-QOL questionnaires were completed over 32 months, with 59 patients providing sequential responses. The mean age was 50.0 ± 13.1 years, 77.0% (117/152) were female and 52.0% (79/152) were Caucasian. Graves' disease was present in 86.2% (131/152) of participants, and 91.4% (139/152) were euthyroid at the time of the questionnaire. The mean time since TED onset was 2.5 years (range: 0.25-180 months). The mean ± standard deviation GO-QOL scores in the mild, moderate-to-severe, and sight-threatening disease cohorts for VF were 92.2 ± 15.2, 70.9 ± 28.6, and 56.6 ± 29.6, respectively, and for A were 79.1 ± 22.3, 48.2 ± 29.7, and 66.1 ± 35.3, respectively. VF and A scores were inversely correlated with clinical activity scores. Both scores improved postimmunosuppression but only A scores improved following decompression and rehabilitation surgery. Females and younger patients had lower A but not VF scores. East Asians and Caucasians had higher VF and A scores than African-Caribbeans.

CONCLUSION

The GO-QOL's granularity highlights the diverse functional and psychosocial experiences of TED patients, underscoring the need to integrate this valuable but underutilized tool into routine clinical practice.

The role of IL-6 in thyroid eye disease: an update on emerging treatments

Elevated serum interleukin-6 (IL-6) levels have been shown to correlate with disease activity in patients with thyroid eye disease (TED), a complex, heterogeneous, autoimmune disease affecting thousands of people worldwide. IL-6 plays a pivotal role in the pathogenesis of TED through three key mechanisms that together may contribute to inflammation, tissue expansion, remodeling, and fibrosis within the orbit. First, IL-6 drives an autoimmune response targeting the thyroid-stimulating hormone receptor (TSHR) by promoting the production of autoantibodies (i.e. TSHR-Ab, TSI), thereby triggering TSHR-dependent immune pathways. Second, IL-6 stimulates the activation and differentiation of orbital fibroblasts, which contributes to the inflammatory process and increase adipogenesis. Finally, IL-6 stimulates T-cell-mediated inflammation, amplifying the immune response within orbital tissues. Although corticosteroids and surgery have served as mainstays of TED treatment, a multimodal approach is often required due to the disease's heterogeneous presentation and response to current treatment options. TED is a chronic, lifelong condition characterized by periods of exacerbation and remission, with inflammation playing a central role in disease progression and severity. Because inflammation can flare intermittently throughout a patient's life, there is growing interest in targeting specific components of the immune system to reduce disease activity and severity. This review focuses on the current evidence supporting IL-6 as a key mediator of TED pathogenesis and explores its potential as a diagnostic biomarker and therapeutic target of the disease.

Factors Associated with Response to Intravenous Glucocorticoids in Active Moderate-to-Severe Thyroid Eye Disease

Background: Intravenous glucocorticoids (IVGCs) are the first-line treatment for active moderate-to-severe thyroid eye disease (TED) in many countries worldwide, mainly because of their anti-inflammatory efficacy. Methods: Retrospective cohort study of 64 patients with active moderate-to-severe TED, without dysthyroid optic neuropathy, treated between 2003 and 2023 at a single tertiary centre with the 12 weeks IVGC EUGOGO (European Group on Graves Orbitopathy) protocol. All patients were evaluated for response to IVGC according to the clinical judgment (CL) and 44/64 (69%) patients were also evaluated with the EUGOGO 2021 revised composite index (CI). Results: The mean patients' age at IVGC initiation was 51.7 ± 11 years, 47/64 (73.5%) were women, 56/64 (87.5%) were Caucasians, and 33/64 (51.5%) were active smokers. At 6 months after IVGC, 48 out of 64 (75%) patients evaluated with CL and 32 out of 44 (73%) patients evaluated with EUGOGO CI responded to the treatment. Nonresponders tended to be older than responders (56.6 ± 10.2 vs. 50.1 ± 10.8 years, p = 0.040 for CL and 56.5 ± 11.9 vs. 50.3 ± 11.6 years, p = 0.131 for EUGOGO CI) and had higher clinical activity score (CAS) before IVGC (5.0 ± 1.1 vs.4.2 ± 1.1, p = 0.022 for CL and 4.7 ± 0.6 vs. 3.1 ± 0.8, p < 0.001 for EUGOGO CI). In patients evaluated with CL or EUGOGO CI, respectively, multivariable logistic regression identified age at IVGC initiation (odds ratio [OR] = 0.92 [95% confidence interval (CI) 0.86-0.99], p = 0.024 and OR = 0.88 [CI 0.77-0.99], p = 0.046) and CAS before IVGC (OR = 0.53 [CI 0.31-0.90], p = 0.021 and OR= 0.08 [CI 0.01-0.38], p = 0.001) but not active smoking as independent factors associated with response to IVGC. The optimal cut-off associated with poorer response to IVGC was CAS ≥4.5/7 (66.7% specificity, 56.3% sensitivity; Area Under the Curve [AUC] = 0.689 [CI 0.54-0.83], p = 0.010) in patients evaluated with CL and CAS ≥3.5/5 (65.6% specificity, 91.7% sensitivity; AUC = 0.910 [CI 0.80-1.01], p < 0.001) in patients evaluated with EUGOGO CI. Conclusion: Older age and higher CAS before treatment were associated with poorer response to IVGC. Patients with these characteristics could be offered other immunotherapies as a first-line treatment for active moderate-to-severe TED.

Effect of intravenous methylprednisolone on serum antibody levels in thyroid eye disease

BACKGROUND/AIMS

We evaluated longitudinal autoantibody changes after intravenous methylprednisolone (IVMP), compared them with those in untreated patients and identified prognostic factors for treatment response.

METHODS

In this single-centre, retrospective, observational study, a total of 163 individuals diagnosed with moderate-to-severe thyroid eye disease were enrolled and followed for 12 months. Depending on whether IVMP was administered, we divided the patients into treatment and control groups. Based on the effect of IVMP on TSH receptor (TSH Rc) antibody level, we divided the patients into Ab declined and Ab not declined groups.We evaluated the time, group and interaction associations with the longitudinal autoantibody titres over 12 months using generalised estimating equations. Using multivariable logistic regression, we investigated the prognostic factors for a poor response to IVMP.

RESULTS

In the IVMP group, the TSH Rc antibody (Ab) titre decreased rapidly for 6 months and then decreased slowly until 12 months, becoming similar to the control group at 12 months. This suggests a difference in the decreasing pattern over time between the IVMP and control groups (group and time interaction p=0.029). Total cholesterol (OR 1.0217 (95% CI 1.0068 to 1.0370), p=0.0043) was a significant prognostic factor for the steroid response. The threshold total cholesterol value to distinguish between Ab declined and Ab not declined was 186 mg/dL.

CONCLUSION

IVMP significantly decreased the TSH Rc Ab level for the 3 months after treatment, compared with the no-treatment group, but the groups did not differ significantly after 12 months. Patients with high total cholesterol levels generally showed a poor response to IVMP.

The Efficacy and Safety of Intravenous Tocilizumab to Treat Graves' Ophthalmopathy: A Systematic Review and Single-arm Meta-analysis

PURPOSE

This study aims to evaluate the efficacy and safety of intravenous (IV) tocilizumab (TCZ) in the treatment of Graves' ophthalmopathy (GO).

METHODS

A comprehensive search was conducted across the Web of Science, PubMed, Embase, Cochrane Library, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov databases from inception to April 2024. Randomized controlled trials and cohort studies that used IV TCZ for treating GO were included.

RESULTS

Twelve studies encompassing 219 patients with active, steroid-resistant GO were analyzed. The meta-analysis demonstrated significant improvements in Clinical Activity Score (CAS) response (effect size [ES] = 0.98; 95% confidence interval [CI], 0.93-1.00), proptosis response (ES = 0.50; 95% CI, 0.27-0.73), and diplopia response (ES = 0.48; 95% CI, 0.24-0.74). The ES for adverse events was 0.27 (95% CI, 0.22-0.33), with only 3 severe cases necessitating treatment discontinuation, and a low reactivation rate (ES = 0.01; 95% CI, 0.00-0.04). TCZ treatment led to a mean CAS reduction of 4.60 points (95% CI, 3.88-5.32) across 10 studies, a mean proptosis reduction of 2.04 mm (95% CI, 1.42-2.65) across 7 studies, and a mean decrease in TSH receptor antibodies levels of 10.62 IU (95% CI, 4.67-10.62) across 5 studies.

CONCLUSION

This meta-analysis provides robust evidence supporting the efficacy and safety of IV TCZ in patients with GO who are resistant to glucocorticoid therapy. The results highlight TCZ's comparable efficacy to glucocorticoids and suggest that TCZ could significantly expand clinical management options for GO. In the future, more high-quality, large-scale randomized controlled trials are still needed to confirm these findings.

Assessment of Hearing Dysfunction in Patients With Graves' Disease and Thyroid Eye Disease Without or With Teprotumumab

CONTEXT

Thyroid eye disease (TED) negatively affects quality of life. TED occurs predominantly in Graves' disease (GD). Teprotumumab improves TED but concern for hearing adverse events (AEs) has emerged. Hearing dysfunction is reported in thyroid autoimmune disease but the background prevalence in GD/TED without teprotumumab remains uncertain.

OBJECTIVE

This work aimed to quantify ear-related diagnostic codes/hearing AEs in GD, TED, and patients receiving teprotumumab by examining medical claims and clinical trials.

METHODS

Deidentified claims for ear/labyrinth-related International Classification of Disorders, Tenth Revision codes (KOMODO) were examined in GD patients without TED, and TED patients without/with teprotumumab treatment. Hearing AE incidence/severity was evaluated in teprotumumab clinical trials. Graves' Ophthalmopathy Quality of Life questionnaire (GO-QOL) scores were compared in teprotumumab TED trial patients without/with hearing AEs.

RESULTS

GD (469 720), TED (38 566) and teprotumumab-treated (967) patients were identified in the claims database. Ear-related codes (including those not specific for hearing) occurred in 24% GD, 33% TED, and 32% teprotumumab-treated patients. "Sensorineural hearing loss bilateral" was most frequent: 7% (32 961/469 720) GD, 11.1% (4279/38 566) TED, and 10.8% (104/967) teprotumumab patients. Before teprotumumab use, 17.1% (165) patients had ear-related codes, while 10.1% (98) had new ear-related codes post treatment.Eight teprotumumab oncology trials revealed 8.1% (51/633) had ear/labyrinth disorders with 2.1% (13) considered study-drug-related and 3.8% (24) hearing impairment/tinnitus-related AEs with 1.3% (8) considered study-drug-related. Similar rates occurred in TED trials.GO-QOL improved in teprotumumab-treated patients without/with hearing AEs. Incidence/severity was consistent across patients with chronic and acute TED.

CONCLUSION

These analyses indicate similar prevalence of hearing claims in patients with GD/TED alone as following teprotumumab treatment. Future analyses of incremental hearing risk from teprotumumab should use a priori study designs accounting for background hearing dysfunction in patients with GD/TED.

The selection of target areas for orbital imaging, application of diethylenetriaminepentaacetic acid orbital imaging, clinical factors, alkaline phosphatase, and thyrotropin receptor antibodies in the staging and grading of thyroid-associated ophthalmopathy

PURPOSE

This study aimed to investigate the active phase of thyroid-associated ophthalmopathy (TAO), its correlations with clinical factors, serological tests, and orbital imaging parameters, and evaluate the diagnostic value of different orbital imaging target areas.

METHODS

A total of 45 patients with thyroid-related eye disease underwent imaging, serological tests, and clinical data collection. Clinical Activity Score (CAS) assessment, diplopia scores, and NOSPECS grading were conducted. Radioactive counts of extraocular muscles and tear glands were measured. Computed tomography scans assessed exophthalmos and extraocular muscle thickening. Correlations and differences among study parameters and grades were evaluated using receiver operating characteristic curves.

RESULTS

Active TAO correlated significantly with radioactive counts of muscles and tear glands, alkaline phosphatase (ALP), thyrotropin receptor antibody (TRAb), and age. Significant differences were found among NOSPECS grades for studied variables (except ALP and TRAb). Extraocular muscle thickening was confirmed as a reliable diagnostic criterion. High consistency was found between orbital imaging and CAS staging. Treatment showed varying degrees of improvement in active patients, while nonactive patients showed no progression during follow-up. Receiver operating characteristic curves demonstrated high diagnostic efficacy for tear gland radioactive counts.

CONCLUSION

Tear glands and extraocular muscles have high diagnostic value in TAO, with tear glands showing a higher value. Orbital imaging provides an objective and comprehensive assessment compared with CAS scoring alone. ALP, TRAb, and age also play significant roles in staging.

Investigating factors influencing quality of life in thyroid eye disease: insight from machine learning approaches

Aims

Thyroid eye disease (TED) is an autoimmune orbital disorder that diminishes the quality of life (QOL) in affected individuals. Graves' ophthalmopathy (GO)-QOL questionnaire effectively assesses TED's effect on patients. This study aims to investigate the factors influencing visual functioning (QOL-VF) and physical appearance (QOL-AP) scores in Chinese TED patients using innovative data analysis methods.

Methods

This cross-sectional study included 211 TED patients whose initial visit to our clinic was from July 2022 to March 2023. Patients with previous ophthalmic surgery or concurrent severe diseases were excluded. GO-QOL questionnaires, detailed medical histories and clinical examinations were collected. The distribution of GO-QOL scores was analyzed, and linear regression and machine learning algorithms were utilized.

Results

The median QOL-VF and QOL-AP scores were 64.29 and 62.5, respectively. Multivariate linear regression analysis revealed age (P = 0.013), ocular motility pain (P = 0.012), vertical strabismus (P < 0.001) and diplopia scores as significant predictors for QOL-VF. For QOL-AP, gender (P = 0.013) and clinical activity (P = 0.086) were significant. The XGBoost model demonstrated superior performance, with an R2 of 0.872 and a root mean square error of 11.083. Shapley additive explanations (SHAP) analysis highlighted the importance of vertical strabismus, diplopia score and age in influencing QOL-VF and age, clinical activity and sex in QOL-AP.

Conclusion

TED significantly affects patient QOL. The study highlights the efficacy of XGBoost and SHAP analyses in identifying key factors influencing the QOL in TED patients. Identifying effective interventions and considering specific demographic characteristics are essential to improving the QOL of patients with TED.

CT-based artificial intelligence prediction model for ocular motility score of thyroid eye disease

PURPOSE

Thyroid eye disease (TED) is the most common orbital disease in adults. Ocular motility restriction is the primary complaint of patients, while its evaluation is quite difficult. The present study aimed to introduce an artificial intelligence (AI) model based on orbital computed tomography (CT) images for ocular motility score.

METHODS

A total of 410 sets of CT images and clinical data were obtained from the hospital. To build a triple classification predictive model for ocular motility score, multiple deep learning models were employed to extract features of images and clinical data. Subgroup analyses based on pertinent clinical features were performed to test the efficacy of models.

RESULTS

The ResNet-34 network outperformed Alex-Net and VGG16-Net in prediction of ocular motility score, with the optimal accuracy (ACC) of 0.907, 0.870, and 0.890, respectively. Subgroup analyses indicated no significant difference in ACC between active or inactive phase, functional visual field diplopia or peripheral visual field diplopia (p > 0.05). However, in the gender subgroup, the prediction model performed more accurately in female patients than males (p = 0.02).

CONCLUSION

In conclusion, the AI model based on CT images and clinical data successfully realized automatic scoring of ocular motility in TED patients. This approach potentially enhanced the efficiency and accuracy of ocular motility evaluation, thus facilitating clinical application.

The efficacy and safety of selenium supplementation versus placebo in the treatment of Graves' orbitopathy: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Selenium is a trace element crucial for thyroid function, and has potential therapeutic benefits in Graves' orbitopathy (GO). Therefore, we aim to evaluate its efficacy and safety in GO patients to provide valuable insights into its role as a therapeutic option for this condition.

DESIGN

Systematic review and meta-analysis.

PATIENTS

GO Patients treated with selenium compared to placebo.

MEASUREMENTS

Clinical activity score (CAS), Graves' orbitopathy quality of life (GO-QOL), eye symptoms and signs, and adverse events.

RESULTS

Out of 1684 records screened, four randomised controlled trials were included. Selenium was superior at 6 months in lowering the CAS (MD = -1.27, 95% confidence interval [CI] [-1.68, -0.85], p < .0001]), improving total GO-QOL (RR = 2.54, 95% CI [1.69-3.81], p < .00001), and improving the visual and the psychological functioning scores (MD = 10.84, 95% CI [4.94-16.73], p = .003), (MD = 12.76, 95% CI [8.51-17.00], p < .00001) respectively. Similarly, it significantly improved these outcomes at 12 months. It also showed a significant decrease in the palpebral aperture at 6 months (MD = -1.49, 95% CI [-2.90, -0.08], p = .04). However, no significant differences were observed in proptosis, soft tissue involvement, ocular motility, and adverse effects.

CONCLUSIONS

Selenium is effective in reducing CAS and improving the palpebral aperture and GO-QOL in patients with GO. Additionally, it is safe and has promising therapeutic implications. However, further research is needed to validate its long-term efficacy and safety.

A Comprehensive Review of Thyroid Eye Disease Pathogenesis: From Immune Dysregulations to Novel Diagnostic and Therapeutic Approaches

Thyroid eye disease is a complex inflammatory disorder of the orbit that has gained tremendous interest over the past years, and numerous scientific efforts have been deployed to elucidate its pathophysiology for novel drug development. Our manuscript will delve into the molecular dysregulations involved in the pathogenesis of thyroid eye disease that led to its clinical manifestations. Abnormalities within the apoptotic pathway, inflammatory cascade, and autoimmune regulatory systems will be covered. We will further discuss the challenges involved in its diagnosis and management and provide a summary of the current diagnostic tools (i.e., molecular biomarkers, diagnostic scores) from the perspective of clinicians. Finally, our comprehensive literature review will provide a thorough summary of most recent preclinical and clinical studies around the topic of thyroid eye disease, with an emphasis on the manuscripts published within the last five years. We believe our manuscript will bring novelty within the field by bridging the fundamental sciences with the clinical aspect of this disease. This review will be a great tool for clinicians in better understanding the pathogenesis of thyroid eye disease while providing an outlook on future perspectives (i.e., liquid biopsies, artificial intelligence).

Psychological aspects of Graves' ophthalmopathy

Purpose

This review aims to discuss the psychological aspects of Graves' ophthalmopathy (GO), estimate the prevalence of depression and anxiety disorders in GO, examine whether these psychiatric disorders are more prevalent in GO than in Graves' disease (GD) without eye disease, and evaluate the main contributors for depression and anxiety in GO.

Methods

A review of the literature.

Results

Both depression and anxiety are associated with GO. The prevalence of depression and anxiety disorders specifically in GO patients was estimated at 18-33% and 26-41%, respectively. The reported prevalence in GD patients ranged from 9% to 70% for depression and from 18% to 88% for anxiety disorders. Significantly higher levels of depression and anxiety were found in GD patients compared with patients with non-autoimmune hyperthyroidism. Conflicting results have been reported regarding the association of antithyroid autoantibodies with depression and anxiety disorders. Serum thyroid hormone levels do not correlate with the severity of depression and anxiety. An improvement of psychiatric symptoms is observed in hyperthyroid patients after treatment of thyrotoxicosis. Moreover, depression and anxiety are significantly related to impaired quality of life (QoL) in GO. Exophthalmos and diplopia were not associated with depression nor anxiety, but orbital decompression and strabismus surgery do seem to improve QoL in GO patients.

Conclusions

The results of this review suggest that altered thyroid hormone levels and autoimmunity are prognostic factors for depression and anxiety in GO. With regard to the visual and disfiguring aspects of GO as contributing factors for depression and anxiety, no decisive conclusions can be made.

Teprotumumab improves light sensitivity in patients with thyroid eye disease

BACKGROUND

Teprotumumab, a novel IGF-1R antibody, has been shown to significantly reduce the signs of acute and chronic Thyroid Eye Disease (TED). Light sensitivity is a reported symptom in patients with TED. There is a lack of a prospective study that has explored the effects on light sensitivity in a large cohort of patients with acute and chronic TED following treatment with teprotumumab.

METHODS

Consecutive patients who were diagnosed with TED and reported light sensitivity at baseline were considered for study eligibility. All patients had measurements of Visual Light Sensitivity Questionnaire-8 (VLSQ-8), proptosis, clinical activity score (CAS), and MRD1 (distance between the upper eyelid margin and corneal reflex, mm) and MRD2 (distance between the lower eyelid margin and corneal reflex, mm) before and after treatment.

RESULTS

Ninety patients (41 acute, 49 chronic) met the inclusion criteria. The mean (SD) age was 47.3 (14.3). Eighty-six (95.6%) patients completed all 8 infusions. There was a significant reduction in the total score and across all categories of the VLSQ-8 (p <  0.01 for all). Seventy-two (80%) patients had a clinically significant improvement (≥2 reduction) in at least one category. There was no significant difference in the total VLSQ-8 score between the acute and chronic group (p = 0.8).

CONCLUSION

Teprotumumab improves light sensitivity in patients with acute and chronic TED. The results of this study highlight that the improvements in light sensitivity following treatment are not directly related to the mechanical changes in TED, suggesting another underlying mechanism is potentially involved.

Bayesian network analysis of drug treatment strategies for thyroid associated ophthalmopathy

BACKGROUND

The first line treatment for moderate to severe active thyroid associated ophthalmopathy is glucocorticoid pulse therapy, but for patients with contraindications to hormone therapy or hormone resistance, it is urgent to find a suitable treatment plan.

AIMS

To find a reliable alternative to hormone pulse therapy for thyroid associated ophthalmopathy by comparing the efficacy with first-line treatment regimens.

METHODS

Search PubMed, Ovid, Web of science, Cochrane library, and Clinical Trials.gov for randomized controlled trials on the treatment of thyroid associated ophthalmopathy published as of July 7, 2024. Quality evaluation and Bayesian network analysis were conducted using RevMan 5.3 software, STATA15.0 software, and ADDIS 1.16.8 software.

RESULTS

A total of 666 patients were included in 11 studies and 8 interventions. Network analysis showed that the three interventions of mycophenolate mofetil combined with glucocorticoids, Teprotumumab and 99Tc-MDP were superior to glucocorticoid pulse therapy in improving clinical activity scores and proptosis. The regimen of glucocorticoids combined with statins can improve the quality of life score and diplopia score of patients. Neither methotrexate combined with glucocorticoids nor rituximab alone showed additional advantages when compared with glucocorticoid pulse therapy.

CONCLUSION

Mycophenolate mofetil combined with glucocorticoid therapy is very beneficial for moderate to severe active thyroid associated ophthalmopathy. Mycophenolate mofetil may be a good choice when patients have contraindications to hormone use or hormone resistance. Teprotumumab is very promising and may be able to avoid patients undergoing orbital decompression surgery. The durability and safety of its long-term efficacy need to be further observed.

Long-Term Efficacy of Teprotumumab in Thyroid Eye Disease: Follow-Up Outcomes in Three Clinical Trials

Introduction: Thyroid eye disease (TED) is an autoimmune process characterized by extraocular muscle and orbital fat remodeling/expansion resulting in swelling, pain, redness, proptosis, and diplopia. Teprotumumab, an insulin-like growth factor-I receptor inhibitor, demonstrated improvements in TED signs and symptoms in three adequately powered clinical trials of 24 weeks duration. Here we analyze the long-term maintenance of responses with teprotumumab from these trials. Methods: A total of 112 patients who received 7 or 8 infusions of teprotumumab in the Phase 2, Phase 3 (OPTIC study), and OPTIC Extension (OPTIC-X) studies were included in this analysis. Responses, including clinical activity score (CAS ≥2-point improvement), the European Group of Graves' Orbitopathy ophthalmic composite outcome, diplopia (≥1 Gorman grade improvement), proptosis (≥2 mm improvement), Overall (improvement in proptosis + CAS), and disease inactivation (CAS ≤1), were assessed and pooled from study baseline to week 24 (formal study) and up to week 72 (formal follow-up). Graves' Ophthalmopathy quality-of-life (GO-QoL) scores were also assessed. Outcomes included the percentages of observed patient responses from the study baseline. Additional alternative treatments for TED were assessed as a surrogate of persistent benefit from week 24 through week 120 (extended follow-up). Studies differed in the timing of follow-up visits, and data from some visits were unavailable. Results: At week 72, 52/57 (91.2%), 51/57 (89.5%), 35/48 (72.9%), 38/56 (67.9%), and 37/56 (66.1%) of patients were responders for CAS, composite outcome, diplopia, proptosis, and Overall response, respectively. The mean reduction in proptosis was 2.68 mm (SD 1.92, n = 56), mean GO-QoL improvement was 15.22 (SE 2.82, n = 56), and disease inactivation (CAS ≤1) was detected in 40/57 (70.2%). Over 99 weeks following teprotumumab therapy, 19/106 (17.9%) patients reported additional TED therapy during formal and extended follow-up. Conclusion: The long-term response to teprotumumab as observed 51 weeks after therapy was similar to week 24 results in the controlled clinical trials. Inflammatory and ophthalmic composite outcome improvements were seen in 90% of patients with nearly 70% reporting improvement in diplopia and proptosis. Further, 82% of patients in this analysis did not report additional TED treatment (including surgery) over 99 weeks following the final teprotumumab dose.

The changing landscape of thyroid eye disease: current clinical advances and future outlook

AIMS

This review aims to provide an overview of the current understanding of TED and its pathophysiology. To describe the evidence base for current consensus treatment recommendations and newer biological therapies available as well as to present future therapeutic research.

METHODS

We reviewed and assessed the peer-reviewed literature placing particular emphasis on recent studies evaluating the pathophysiology of TED, landmark trials forming the basis of current management and recent clinical trials informing future therapeutics. Searched were made in MEDLINE Ovid, Embase Ovid, US National Institutes of Health Ongoing Trials Register and EU Clinical Trials Register. Keywords included: "Thyroid Eye Disease", "Graves Orbitopathy", "Thyroid Orbitopathy" and "Graves' Ophthalmopathy".

RESULTS AND CONCLUSIONS

The pathophysiology of TED involves a complex array of cellular and humoral based autoimmune dysfunction. Previous therapies have been broad-based acting as a blunt instrument on this mechanism with varying efficacy but often accompanied with a significant side effect profile. The recent development of targeted therapy, spearheaded by Teprotumumab has led to an array of treatments focusing on specific components of the molecular pathway optimising their impact whilst possibly minimising their side effect profile. Future challenges involve identifying the most effective target for each patient rather than any single agent being a panacea. Long-term safety profiles will require clarification as unintended immunological consequence downstream may become manifest as seen in other diseases. Finally, future novel therapeutics will entail significant expenditure and may lead to a divergence of available treatment modalities between healthcare systems due to funding disparities.

Bridging and Validation of the Specific Graves Ophthalmopathy Quality of Life Questionnaire With Health State Utility Values

OBJECTIVE

In thyroid eye disease (TED), inflammation and expansion of orbital muscle and periorbital fat result in diplopia and proptosis, severely impacting patient quality of life (QOL). The reported health state utility (HSU) scores, which are QOL measures, allow quantification of TED impact and improvement with therapies; however, no current QOL instrument has been validated with HSU scores for TED. Here, we used the disease-specific Graves Ophthalmopathy Quality of Life (GO-QOL) questionnaire and HSU scores to validate QOL impact.

METHODS

The GO-QOL scores from patients in 2 randomized, masked, placebo-controlled teprotumumab trials (N=171) were compared with 6 HSU values based on severity of proptosis/diplopia in those studies. Patient GO-QOL and HSU scores were compared at baseline and after 6-month treatment via regression analyses. GO-QOL and HSU scores were correlated for validation and quantification of QOL impact by severity state and to estimate quality-adjusted life year improvement.

RESULTS

GO-QOL scores were correlated with TED severity, indicating that worse severity was associated with lower (worse) GO-QOL scores. Less severe health states were represented by higher (better) GO-QOL scores. Importantly, GO-QOL scores were positively correlated with utility scores of the 6 health states, allowing for conversion of the GO-QOL scores to utility scores. A positive (improved) 0.013 utility change was found for each 1-point (positive) improvement in GO-QOL score produced by teprotumumab versus placebo.

CONCLUSION

Patients with moderate-to-severe active TED health states demonstrate increasing TED severity associated with declining utility values and worsening GO-QOL scores. These results indicate that the GO-QOL scores can be used to bridge to the HSU scores for benefit quantification.

A meta-analysis of the efficacy of two-wall orbital decompression operations for thyroid-associated ophthalmopathy

BACKGROUND

The main treatment for the symptoms of proptosis and optic nerve compression caused by thyroid-associated ophthalmopathy is orbital decompression surgery. Medial inferior wall decompression and balanced decompression are two frequently used surgical procedures. However, there is no unified consensus on how to choose different surgical options for orbital decompression in clinical practice.

AIMS

To compare the effects of medial inferior wall decompression and balanced decompression surgery through meta-analysis and to provide reference for clinical optimal decision making.

METHODS

Databases, including PubMed, Web of Science, Ovid, Cochrane Library, and ClinicalTrials.gov, were searched for randomized controlled trials and cohort studies on decompression surgery for thyroid-associated ophthalmopathy published from inception to March 21, 2023. Using RevMan 5.3 software, a meta-analysis was conducted based on the following outcome indicators: proptosis, diplopia rate, intraocular pressure, visual acuity, and complication rate.

RESULTS

Two randomized controlled trials and five cohort studies with a total of 377 patients were included in this analysis. After balanced decompression surgery, patients with thyroid-associated ophthalmopathy experienced a significant decrease in proptosis [MD = 4.92, 95% CI (4.26, 5.58), P < 0.0001]. Balanced decompression can improve postoperative visual acuity [MD = - 0.35, 95% CI (- 0.56, - 0.13), P = 0.001] and intraocular pressure [MD = 5.33, 95% CI (3.34, 7.32), P < 0.0001]. The rates of proptosis [MD = 0.33, 95% CI (- 1.80, 2.46), P = 0.76] and diplopia [OR = 1.20, 95% CI (0.38, 3.76), P = 0.76] did not differ between patients who underwent medial inferior wall decompression and those who underwent balanced decompression.

CONCLUSION

Balanced decompression and medial inferior wall decompression are both effective options for surgical treatment of thyroid-associated ophthalmopathy in clinical practice.

SOX9 Induces Orbital Fibroblast Activation in Thyroid Eye Disease Via MAPK/ERK1/2 Pathway

Purpose

To evaluate the expression of sry-box transcription factor 9 (SOX9) in orbital fibroblasts (OFs) of thyroid eye disease (TED) and to find its potential role and underlying mechanism in orbital fibrosis.

Methods

OFs were cultured from orbital connective tissues obtained from patients with TED (n = 10) and healthy controls (n = 6). SOX9 was depleted by small interfering RNA or overexpressed through lentivirus transduction in OFs. Fibroblast contractile activity was measured by collagen gel contraction assay and proliferation was examined by EdU assay. Transcriptomic changes were assessed by RNA sequencing.

Results

The mRNA and protein levels of SOX9 were significantly higher in OFs cultured from patients with TED than those from healthy controls. Extracellular matrix-related genes were down-regulated by SOX9 knockdown and up-regulated by SOX9 overexpression in TED-OFs. SOX9 knockdown significantly decrease the contraction and the antiapoptotic ability of OFs, whereas the overexpression of SOX9 increased the ability of transformation, migration, and proliferation of OFs. SOX9 knockdown suppressed the expression of phosphorylated ERK1/2, whereas its overexpression showed the opposite effect. Epidermal growth factor receptor (EGFR) is one of the notably down-regulated genes screened out by RNA sequencing. Chromatin immunoprecipitation-qPCR demonstrated SOX9 binding to the EGFR promoter.

Conclusions

A high expression of SOX9 was found in TED-OFs. SOX9 can activate OFs via MAPK/ERK1/2 signaling pathway, which in turn promotes proliferation and differentiation of OFs. EGFR was a downstream target gene of SOX9. SOX9/EGFR can be considered as therapeutic targets for the treatment of orbital fibrosis in TED.

Efficacy and Safety of Teprotumumab in Patients With Thyroid Eye Disease of Long Duration and Low Disease Activity

CONTEXT

Early inflammatory thyroid eye disease (TED) can lead to symptomatic chronic disease, including disabling proptosis. Teprotumumab, an insulin-like growth factor-1 receptor (IGF-1R) inhibitor, previously demonstrated efficacy in acute, high-inflammation TED trials.

OBJECTIVE

We present data from the first placebo-controlled trial with teprotumumab in chronic/low disease activity TED.

METHODS

This randomized double-masked, placebo-controlled trial, conducted at 11 US centers, enrolled adult participants with TED duration of 2 to 10 years, Clinical Activity Score (CAS) ≤ 1 or no additional inflammation or progression in proptosis/diplopia for ≥1 year, proptosis ≥3 mm from before TED and/or from normal, euthyroid/mildly hypo/hyperthyroid, no prior teprotumumab, and no steroids within 3 weeks of baseline. Patients received (2:1) intravenous teprotumumab or placebo once every 3 weeks (total 8 infusions). The primary endpoint was proptosis (mm) improvement at Week 24. Adverse events (AEs) were assessed.

RESULTS

A total of 62 (42 teprotumumab and 20 placebo) patients were randomized. At Week 24, least squares mean (SE) proptosis improvement was greater with teprotumumab (-2.41 [0.228]) than with placebo (-0.92 [0.323]), difference -1.48 (95% CI -2.28, -0.69; P = .0004). Proportions of patients with AEs were similar between groups. Hyperglycemia was reported in 6 (15%) vs 2 (10%) and hearing impairment in 9 (22%) vs 2 (10%) with teprotumumab and placebo, respectively. AEs led to discontinuation in 1 teprotumumab (left ear conductive hearing loss with congenital anomaly) and 1 placebo patient (infusion-related). There were no deaths.

CONCLUSION

Teprotumumab significantly improved proptosis vs placebo in longstanding/low inflammation TED, demonstrating efficacy regardless of disease duration/activity. The safety profile was comparable to that previously reported.

How patients experience thyroid eye disease

Objective

To determine the impact of thyroid eye disease (TED) on patients in various stages of the disease.

Background

TED is a debilitating and potentially sight-threatening inflammatory autoimmune disease that is frequently misdiagnosed. Challenging quality-of-life (QoL) issues can persist long after the active phase of disease has subsided.

Methods

A 62-question survey was designed as a hypothesis-generating instrument to identify key issues confronting patients ≥18 years old with physician-diagnosed TED. Questions focused primarily on physical and emotional status, and QoL experiences in the 2 months prior to the survey. Data for individual questions are presented as summary statistics. Correlations between questions were determined using χ2 analyses.

Results

The 443 respondents were 18 to >80 years old; >90% female, and >80% from the United States. Time since TED diagnosis ranged from <1 year to >10 years. Participants provided >500 free-form responses describing experiences of living with TED. Physical signs/symptoms were experienced by 307/443 (69%) patients. Of those responding to the QoL questions (N = 394), 53 (13%) reported symptoms improving, 73 (19%) reported symptoms worsening, and 255 (65%) reported no change in the 2 months prior to the survey. The most bothersome signs/symptoms were dry/gritty eyes, light sensitivity, bulging eyes, and pressure or pain behind the eyes. Respondents <60 years were significantly (p < 0.0001) more likely to report symptomatic TED than older patients. Of 394 respondents, 179 (45%) reported feeling depressed and/or anxious, 174 (44%) reported concern about their appearance, and 73 (19%) avoided public situations; 192 (49%) reported declines in confidence or feelings of general well-being, and 78 (20%) reported an inability to achieve goals. Activities limited by TED included reading, driving, and socializing. The proportion of respondents experiencing these negative QoL measures was higher when patients reported experiencing >5 symptoms, had been diagnosed within the last 5 years, or were <60 years of age.

Conclusions

Physical manifestations of TED impact QoL for patients through all phases of the disease. It is essential that physicians and healthcare professionals become more familiar with patient experiences such as those described here to better help patients manage their disease.

Altered dynamic brain activity and functional connectivity in thyroid-associated ophthalmopathy

Although previous neuroimaging evidence has confirmed the brain functional disturbances in thyroid-associated ophthalmopathy (TAO), the dynamic characteristics of brain activity and functional connectivity (FC) in TAO were rarely concerned. The present study aims to investigate the alterations of temporal variability of brain activity and FC in TAO using resting-state functional magnetic resonance imaging (rs-fMRI). Forty-seven TAO patients and 30 age-, gender-, education-, and handedness-matched healthy controls (HCs) were enrolled and underwent rs-fMRI scanning. The dynamic amplitude of low-frequency fluctuation (dALFF) was first calculated using a sliding window approach to characterize the temporal variability of brain activity. Based on the dALFF results, seed-based dynamic functional connectivity (dFC) analysis was performed to identify the temporal variability of efficient communication between brain regions in TAO. Additionally, correlations between dALFF and dFC and the clinical indicators were analyzed. Compared with HCs, TAO patients displayed decreased dALFF in the left superior occipital gyrus (SOG) and cuneus (CUN), while showing increased dALFF in the left triangular part of inferior frontal gyrus (IFGtriang), insula (INS), orbital part of inferior frontal gyrus (ORBinf), superior temporal gyrus (STG) and temporal pole of superior temporal gyrus (TPOsup). Furthermore, TAO patients exhibited decreased dFC between the left STG and the right middle occipital gyrus (MOG), as well as decreased dFC between the left TPOsup and the right calcarine fissure and surrounding cortex (CAL) and MOG. Correlation analyses showed that the altered dALFF in the left SOG/CUN was positively related to visual acuity (r = .409, p = .004), as well as the score of QoL for visual functioning (r = .375, p = .009). TAO patients developed abnormal temporal variability of brain activity in areas related to vision, emotion, and cognition, as well as reduced temporal variability of FC associated with vision deficits. These findings provided additional insights into the neurobiological mechanisms of TAO.

Alemtuzumab-Induced Thyroid Eye Disease: A Comprehensive Case Series and Review of the Literature

PURPOSE

To present 5 cases of alemtuzumab-induced thyroid eye disease (AI-TED) and review the literature to highlight the natural history, severity, and outcomes as compared with conventional thyroid eye disease (TED).

METHODS

A multi-institutional retrospective case series of patients with AI-TED was compiled. Chart review evaluated for clinical characteristics, imaging findings, and treatment for AI-TED. Additionally, a comprehensive review of the literature identified all previously published cases of AI-TED.

RESULTS

Five new patients with AI-TED were included in this series. The average clinical activity score on presentation was 2.8 (range 1-4) and reached an average peak of 5.0 during the active phase of the disease (4-7). Patients were treated medically with selenium (40%) or monoclonal antibodies including teprotumumab or tocilizumab (40%). Surgical treatment with orbital decompression for compressive optic neuropathy was performed on 2 (40%) patients. Combined with 11 previously reported cases, these 16 patients with AI-TED had an average clinical activity score on presentation of 3.3. The average length of the AI-TED phase was 14.0 months, and all patients were treated with medical and/or surgical interventions for their disease.

CONCLUSIONS

Clinical and imaging findings in AI-TED mirror that of conventional TED, however, AI-TED may present with greater severity. AI-TED may develop many months after Graves' disease; therefore, providers should be aware of this association and monitor patients for the development of severe TED.

Efficacy and Safety of intravenous monoclonal antibodies in patients with moderate-to-severe active Graves'ophthalmopathy: a systematic review and meta-analysis

Backgrounds

The effects of various treatments on Graves' ophthalmopathy (GO) have been studied. As monoclonal antibodies (mAbs) have been proposed for the treatment of moderate to severe GO, direct comparisons between different mAbs are lacking.We therefore conducted this meta-analysis to objectively compare the efficacy and safety of intravenous mAbs.

Methods

To identify eligible trials, references published before September 2022 were electronically searched in PubMed, Web of Science, Pubmed, Embase,Cochrane Library, CBM, CNKI,Wan-Fang and ICTRP databases.The Newcastle-Ottawa scale (NOS) and the Cochrane Risk of Bias Assessment Tool were used to assess the risk of bias of the original studies.The primary and secondary outcomes were the response and inactivation rates, with the secondary outcomes being the clinical activity score (CAS),the improvement of proptosis and diplopia improvement,and the adverse event rate. Publication bias was evaluated, along with subgroup and sensitivity analyses.

Results

A total of 12 trials with 448 patients were included. The meta-analysis showed that TCZ (tocilizumab) was most likely to be the best treatment in terms of response according to indirect contrast, followed by TMB (teprotumumab) and RTX (rituximab).TCZ, followed by TMB and RTX, was also most likely to be the best treatment in terms of reducing proptosis. In terms of improving diplopia, TMB was most likely to be the best treatment, followed by TCZ and RTX.TCZ was the highest probability of safety, followed by RTX and TMB.

Conclusions

Based on the best available evidence,TCZ should be the preferred treatment for moderate to severe GO.In the absence of head-to-head trials,indirect comparisons of treatments are routinely used to estimate the effectiveness of the treatments of interest. In addition,the optimal dose and potential mechanism of action of monoclonal antibodies remain to be established,and it is encouraging that the treatment paradigm for GO may change in the future.This study was designed in accordance with the Preferred Reporting Items for conducting Systematic Reviews and Meta-Analyses (PRISMA)(27).

Systematic Review Registration

http://www.crd.york.ac.uk/prospero, identifier CRD42023398170.

Evaluation of Depression and Anxiety in a Diverse Population With Thyroid Eye Disease Using the Nationwide NIH All of Us Database

PURPOSE

To evaluate the prevalence of depression and anxiety among individuals with thyroid eye disease (TED) and identify sociodemographic risk factors using the NIH All of Us database.

METHODS

Three hundred ninety eight cases with TED were compared with 1,592 controls with demographics matching the 2020 US Census. Primary outcomes were diagnosed depression or anxiety; Patient Health Questionnaire-9 (PHQ-9) scores and General Anxiety Disorder-7 (GAD-7) scores were included as secondary outcomes. We performed multivariable logistic regression to generate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between TED and depression and anxiety.

RESULTS

Patients with TED were more likely to have depression (OR 2.72, 95% CI 2.08-3.56, p < 0.001) and anxiety (OR 2.82, 95% CI 2.16-3.70, p < 0.001) than controls. In patients with TED, female gender was an independent risk factor for both depression (OR 1.72; 95% CI 1.00-5.07, p = 0.05) and anxiety (OR 2.17, 95% CI 1.25-3.85, p = 0.006). Unemployment (OR 1.72, 95% CI 1.03-2.94, p = 0.04) and lower income (OR 0.88 for income as a continuous variable, 95% CI 0.79-0.99, p = 0.03) were risk factors for anxiety. Risk factors for more severe depression as assessed by PHQ-9 included lower income (OR 0.70, 95% CI 0.57-0.85, p < 0.001), and protective factors included Black race (OR 0.12, 95% CI 0.02-0.45, p = 0.002). Lower income was associated with more severe anxiety as assessed by GAD-7 (OR 0.77, 95% CI 0.64-0.94, p = 0.009).

CONCLUSIONS

Patients with TED were more likely to develop depression and anxiety compared with controls. This study highlights the psychosocial impact of TED and associated socioeconomic risk factors.

Change in lacrimal gland volume and aqueous tear production following treatment with teprotumumab

BACKGROUND

Dry eye syndrome occurs in up to 85% of patients with thyroid eye disease (TED). Lacrimal gland enlargement correlates with subjective tearing and a reduction in quality of life in patients with TED.

METHODS

In this prospective longitudinal study, patients presenting for the treatment of TED were considered for eligible. Primary outcomes included a change in the volume of the lacrimal gland and the production of tears following treatment with teprotumumab. The volume of lacrimal glands and proptosis was calculated using 3D volumetric analysis. Tear production was measured by Schirmer's test and associated symptoms were assessed using the VLSQ-8. The orbit with the most proptosis was designated the study orbit and the contralateral orbit was designated the fellow orbit.

RESULTS

Twenty patients were included. Mean (SD) age was 61 (18) and mean duration of TED prior to therapy was 48 months (47). Lacrimal gland volume in the study orbit decreased from 768 mm³ (288) to 486 mm³ (173) (p < 0.01) following therapy. For the fellow orbit, volume reduced from 637 mm³ (261) to 379 mm³ (147) (p < 0.01). Schirmer's test reading (STR) in the study orbit increased from 14.5 mm (8.2) to 23 mm (10) (p < 0.01) (59%) following treatment. In the fellow orbit, STR increased from 12.7 mm (7) to 21 mm (9) post therapy (69%) (p < 0.01). There was a significant improvement on all parts of the VLSQ-8.

CONCLUSION

Teprotumumab significantly reduces TED related expansion of the lacrimal gland, increases tear production, and improves dry eye symptoms.

Teprotumumab for the treatment of thyroid eye disease

INTRODUCTION

Thyroid eye disease (TED) is an autoimmune disease characterized by inflammation of orbital and extraocular muscles. It induces proptosis and diplopia, leading to a worsening of quality of life (QoL) because of its impact on physical appearance, and visual function. The natural history involves an 'active TED,' which is an autoimmune inflammatory response targeting orbital soft tissues, and 'inactive TED,' where there is tissue expansion remodeling. To date, glucocorticoids represent the main medical therapy, even if often ineffective and associated with side effects.

AREAS COVERED

In TED, the autoimmune process leads to production of TSH-R and IGF-1 R autoantibodies. This induces inflammatory changes in the orbital tissue, and activation of fibroblasts with accumulation of glycosaminoglycans, leading to consequent proptosis, and diplopia. In two previous randomized, double-masked, placebo-controlled, parallel-group, multicenter trials, teprotumumab has been shown to be effective in improving proptosis, inflammation, diplopia, and QoL. More recently, it has been shown that teprotumumab is also effective in chronic-inactive TED. Teprotumumab was approved by the FDA on 21 January 2020 for the treatment of TED.

EXPERT OPINION

For the above-mentioned reasons teprotumumab represents a potential first line therapy for TED that could replace the use of steroids in the next future.

Comprehensive analysis of key genes and pathways for biological and clinical implications in thyroid-associated ophthalmopathy

Background

Thyroid-associated ophthalmopathy (TAO) is a common and organ-specific autoimmune disease. Early diagnosis and novel treatments are essential to improve the prognosis of TAO patients. Therefore, the current work was performed to identify the key genes and pathways for the biological and clinical implications of TAO through comprehensive bioinformatics analysis and a series of clinical validations.

Methods

GSE105149 and GSE185952 were obtained from the Gene Expression Omnibus (GEO) database for analysis. The data were normalized to identify the common differentially expressed genes (DEGs) between the two datasets, and the Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were conducted to assess key pathways in TAO. Protein–protein interaction (PPI) networks and hub genes among the common DEGs were identified. Furthermore, we collected the general information and blood samples from 50 TAO patients and 20 healthy controls (HCs), and the expression levels of the proteins encoded by hub genes in serum were detected by enzyme-linked immunosorbent assay (ELISA). Then we further assessed the relationship between the ELISA data and the TAO development.

Results

Several common pathways, including neuroactive ligand-receptor interaction, the IL-17 signaling pathway, and the TNF signaling pathway, were identified in both datasets. In parallel, 52 common DEGs were identified. The KEGG analysis showed that these common DEGs are mainly enriched in long-term depression, the VEGF signaling pathway, the IL-17 signaling pathway, the TNF signaling pathway, and cytokine-cytokine receptor interactions. The key hub genes PRKCG, OSM, DPP4, LRRTM1, CXCL6, and CSF3R were screened out through the PPI network. As confirmation, the ELISA results indicated that protein expression levels of PRKCG, OSM, CSF3R, and DPP4 were significantly upregulated in TAO patients compared with HCs. In addition, PRKCG and DPP4 were verified to show value in diagnosing TAO, and CSF3R was found to be a valuable diagnostic marker in distinguishing active TAO from inactive TAO.

Conclusions

Inflammation- and neuromodulation-related pathways might be closely associated with TAO. Based on the clinical verification, OSM, CSF3R, CXCL6, DPP4, and PRKCG may serve as inflammation- or neuromodulation-related biomarkers for TAO, providing novel insights for the diagnosis and treatment of TAO.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12864-022-08854-5.

Measuring Health-Related Quality of Life in Thyroid Eye Disease

Health-related quality of life (HQOL) is a concept that aims to understand the totality of an individual's experience of their disease state. This can include the physical, psychosocial, emotional, and psychological effects of a disease state. A complex and multifactorial concept, HQOL can be challenging to measure accurately and reliably. Thyroid eye disease (TED), as a multifaceted physically debilitating and facial disfiguring disorder, presents unique challenges and opportunities in the measurement of HQOL. Multiple distinct tools have been developed for this purpose, each has been constructed, assessed, and utilized. This discussion surveys the landscape of TED-related QOL measurement and presents challenges for the future. Clinicians and clinical researchers should implement TED-related QOL measurement as part of routine TED care and as a primary outcome in TED clinical trials. We recommend utilizing the Graves' ophthalmopathy (GO)-QOL routinely in clinical practice and as a primary outcome in TED clinical trials. If the GO-QOL is too time-consuming or in mild TED, a faster alternative is the TED-QOL.

Update on thyroid eye disease: Regional variations in prevalence, diagnosis, and management

Thyroid eye disease (TED) is a rare disease that can lead to decreased quality of life, permanent disfigurement, and vision loss. Clinically, TED presents with exophthalmos, periorbital edema, extraocular muscle dysfunction, and eyelid retraction, and can lead to vision-threatening complications such as exposure to keratopathy and dysthyroid optic neuropathy (DON). Over the last several years, significant advancements have been made in the understanding of its pathophysiology as well as optimal management. Ethnic variations in the prevalence, clinical presentation, and risk of vision-threatening complications of TED are summarized, and risk factors associated with TED are discussed. Additionally, significant advances have been made in the management of TED. The management of TED traditionally included anti-inflammatory medications, orbital radiation therapy, orbital surgical decompression, and biologic therapies. Most recently, targeted therapies such as teprotumumab, an insulin-like growth factor-1 receptor antagonist, have been studied in the context of TED, with promising initial data. In this review, updates in the understanding and management of TED are presented with a focus on the international variations in presentation and management.

Altered Long- and Short-Range Functional Connectivity Density in Patients With Thyroid-Associated Ophthalmopathy: A Resting-State fMRI Study

Background and Purpose

Although previous neuroimaging studies have demonstrated emotion- and psychology-associated brain abnormalities in patients with thyroid-associated ophthalmopathy (TAO), the changes of brain functional connectivity in TAO were seldom focused. We aimed to investigate interregional and intraregional functional interactions in patients with TAO by using resting-state functional MRI (rs-fMRI) with long- and short-range functional connectivity density (FCD) analysis.

Methods

Thirty patients with TAO and 30 well-matched healthy controls (HCs) were recruited in our study. Long- and short-range FCD values were calculated and compared between the two groups. Correlations between long- and short-range FCD values and clinical indicators were analyzed.

Results

Compared with HCs, patients with showed both increased long- and short-range FCDs in the left middle frontal gyrus (MFG), orbital part of superior frontal gyrus (ORBsup), and dorsolateral part of superior frontal gyrus (SFGdor); meanwhile, both decreased long- and short-range FCDs in bilateral postcentral gyrus (PoCG), left superior parietal gyrus (SPG), and inferior parietal (IPL). In addition, patients with TAO showed increased short-range FCD in the right SFGdor, bilateral medial part of superior frontal gyrus (SFGmed), left orbital part of middle frontal gyrus (ORBmid), and orbital part of inferior frontal gyrus (ORBinf), as well as decreased short-range FCD in the right supplementary motor area (SMA) and the left paracentral lobule (PCL) than HCs. Moreover, the short-range value in the left SFGdor showed a negative correlation with Montreal Cognitive Assessment (MoCA) score (r = −0.501, p = 0.005).

Conclusion

Our findings complemented the functional neural mechanism of TAO, and provided potential neuroimaging markers for assessing the psychiatric, visual, and emotional disturbances in patients with TAO.

Prevalence and Unmet Need for Mental Healthcare of Major Depressive Disorder in Community-Dwelling Chinese People Living With Vision Disability

OBJECTIVE

Mental health services have been recognized as an essential part of the comprehensive eye care services, but data regarding the mental health of people living with vision disability (PLwVD) remain very limited. This study examined the epidemiology of major depressive disorder (MDD) among Chinese PLwVD, as well as their perceived needs for and utilization of mental health services.

METHODS

By using stratified cluster sampling method, a total of 1,753 PLwVD were successfully recruited from 73 urban communities and 169 rural villages in Wuhan, China, and interviewed with the Mini-international Neuropsychiatric Interview 5.0. Standardized questions were used to measure perceived mental healthcare needs and use of mental health services of PLwVD with MDD.

RESULTS

The one-month prevalence of MDD was 24.4%. Among the PLwVD with MDD, 26.0% perceived needs for mental healthcare and only 1.2% sought treatment from mental health specialists for their emotional problems. Factors associated with MDD were middle age [vs. young adulthood, odds ratio (OR) = 1.96, P < 0.001], older adulthood (vs. young adulthood, OR = 1.79, P = 0.004), being never-married (vs. married, remarried, and cohabiting, OR = 1.96, P < 0.001), being separated, divorced, and widowed (vs. married, remarried, and cohabiting, OR = 12.30, P < 0.001), a low level of objective social support (vs. high, OR = 1.83, P < 0.001), currently drinking (OR = 1.81, P < 0.001), having childhood-onset eye conditions (OR = 1.89, P = 0.005), and having difficulties in performing daily activities (OR = 2.78, P < 0.001).

CONCLUSIONS

Chinese PLwVD are at high risk for MDD and have a high level of unmet need for mental healthcare. Public strategies are warranted to improve the mental health literacy of PLwVD and make the mental health services available, accessible, and affordable for PLwVD.

Inflammatory and non-inflammatory thyroid eye disease: comparison of disease signs, symptoms and quality of life in US patients

OBJECTIVE

Thyroid eye disease (TED) is an autoimmune, inflammatory disease resulting in retro-orbital fat and extraocular muscle expansion. TED quiets ("inactivates") as inflammation wanes, but signs/symptoms often persist. Disease signs/symptoms and quality of life (QOL) impact were examined in non-inflammatory and inflammatory TED.

METHODS

Moderate-to-severe TED patient data were collected from treating physicians. Clinical activity score (CAS, 6/7 measures available) assessed TED as inflammatory (CAS≥3) or non-inflammatory (CAS=0-1). QOL impact was scored as 1="not at all impaired" to 7="extremely impaired." Non-inflammatory TED patients were further grouped into longer (>3 years) and shorter (≤3 years) disease.

RESULTS

Inflammatory (N=307) and non-inflammatory (N=281) patients had comparable age (50.0±13.3, 48.3±13.8 years), sex (66%, 64% female), TED duration (4.0±4.9; 4.6±5.5 years), and proportion smokers (15%, 11%). Most common non-inflammatory TED signs/symptoms included ocular dryness/grittiness (77%), proptosis (56%), excessive tearing (43%), soft tissue edema (42%), conjunctival redness (24%) decreased vision (24%) and eye muscle involvement (22%; 14% had diplopia). All were less reported than in patients with inflammatory TED. QOL was impacted by non-inflammatory TED, but to a lesser degree than inflammatory disease (3.6±1.5 vs. 4.7±1.4). However, mental health issues were similarly reported. Non-inflammatory TED patients with longer disease (9.0±6.0 years) had similar QOL impact, mental health diagnoses, and TED sign/symptoms as those with shorter disease (1.4±1.0 years).

CONCLUSION

TED signs/symptoms often chronically persist long after TED has "quieted," continuing to impact patient QOL and mental health. These data suggest that moderate-to-severe TED should be thought of as a robust symptomatic chronic disease, regardless of inflammatory status.

The prevalence of anxiety symptoms and disorders among ophthalmic disease patients

Background:

Progressive and irreversible vision loss has been shown to place a patient at risk of mental health problems such as anxiety. However, the reported prevalence of anxiety symptoms and disorders among eye disease patients vary across studies. Thus, this study aims to clarify the estimated prevalence of anxiety symptoms and disorders among ophthalmic disease patients.

Methods:

Relevant studies on the prevalence of anxiety symptoms and disorders among eye disease patients were collected through international databases, PubMed, Scopus, and Web of Science. A random-effects model was used to determine the pooled prevalence of anxiety symptoms and disorders among ophthalmic disease patients.

Results:

The 95 included studies yielded a pooled prevalence of 31.2% patients with anxiety symptoms and 19.0% with anxiety disorders among subjects with ophthalmic disease. Pediatric patients were more anxious (58.6%) than adults (29%). Anxiety symptoms were most prevalent in uveitis (53.5%), followed by dry eye disease (DED, 37.2%), retinitis pigmentosa (RP, 36.5%), diabetic retinopathy (DR, 31.3%), glaucoma (30.7%), myopia (24.7%), age-related macular degeneration (AMD, 21.6%), and cataract (21.2%) patients. Anxiety disorders were most prevalent in thyroid eye disease (TED, 28.9%), followed by glaucoma (22.2%) and DED (11.4%). When compared with healthy controls, there was a twofold increase on the prevalence of anxiety symptoms (OR = 1.912, 95% CI 1.463–2.5, p < 0.001) and anxiety disorders (OR = 2.281, 95% CI 1.168–4.454, p = 0.016).

Conclusion:

Anxiety symptoms and disorders are common problems associated with ophthalmic disease patients. Thus, comprehensive and appropriate treatments are necessary for treating anxiety symptoms and disorders among ophthalmic disease patients.