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Duarte AF, Xavier NF, Sales Sanz M, Cruz AAV. Efficiency and Safety of Tocilizumab for the Treatment of Thyroid Eye Disease: A Systematic Review. Ophthalmic Plast Reconstr Surg 2024:00002341-990000000-00312. [PMID: 38215463 DOI: 10.1097/iop.0000000000002573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
PURPOSE To review existing literature concerning the effectiveness and safety of tocilizumab (TCZ) for managing thyroid eye disease. METHODS A systematic search was conducted across the PubMed and Embase databases to identify studies on TCZ therapy, from inception to May 2023. The search included the keywords "Graves orbitopathy," "thyroid ophthalmopathy," "thyroid eye disease," "thyroid-associated orbitopathy," "thyroid-associated ophthalmopathy," "Graves ophthalmopathy," "endocrine ophthalmopathy," and "Tocilizumab." Only articles written in English, Spanish, or French were considered. RESULTS Among the 1,013 articles initially screened, a total of 29 fulfilled the eligibility criteria and were selected. Most studies were case reports or case series, and only one randomized clinical trial was found. TCZ has been used mainly in glucocorticoid-resistant or relapsing cases, with a dosage ranging from 4 or 8 mg/kg every 4 weeks when intravenous or a weekly subcutaneous dose of 162 mg. Treatment duration is usually adjusted to the clinical response. TCZ is mostly effective in reducing inflammatory signs during the active phase of thyroid eye disease, with an improvement of at least 3 points in clinical activity score and an overall relapsing rate of 8.2%. Numerous studies have shown marked reductions in proptosis; although the only available randomized controlled trial reported a nonstatistically significant improvement 6 months after treatment, a recent meta-analysis indicated that TCZ seems to be the most effective treatment for reducing proptosis. No severe side effects related to intravenous or subcutaneous TCZ administration were reported. DISCUSSION Despite these promising findings, randomized clinical trials to directly compare the efficacy and safety of TCZ and other currently available therapeutic options are needed.
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Affiliation(s)
- Ana F Duarte
- Department of Ophthalmology, Centro Hospitalar Universitario Lisboa Central, Lisbon, Portugal
- Department of Ophthalmology, Cuf Descobertas Hospital, Lisbon, Portugal
| | - Naiara F Xavier
- Department of Ophthalmology, School of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Marco Sales Sanz
- Department of Ophthalmology, Hospital Universitario Ramon y Cajal, Madrid, Spain; and
- IMO Madrid, Grupo Miranza, Madrid, Spain
| | - Antonio A V Cruz
- Department of Ophthalmology, School of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
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Xavier NF, Lucena DT, Cruz AAV. Monoclonal Antibodies for the Treatment of Graves Orbitopathy: Precision Medicine? Ophthalmic Plast Reconstr Surg 2023; 39:307-315. [PMID: 36727923 DOI: 10.1097/iop.0000000000002315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE To summarize the development, nomenclature, and rationale of the reported use of monoclonal antibodies (Mabs) in Graves Orbitopathy (GO) and to undertake a systematic review of the management of GO with Mabs. METHODS The Pubmed and Embase databases and the Federal Brazilian searching site (Periódicos-CAPES) were screened. The authors searched all the keywords "monoclonal antibodies," "adalimumab," "belimumab," "infliximab," "rituximab," "teprotumumab," and "tocilizumab" combined with the terms "Graves Orbitopathy," "Graves eye disease" and "thyroid eye disease." All the articles published in English, French, and Spanish from 2000 to May 2022 were screened. Only publications with quantitative data on the activity of orbitopathy, proptosis, or both were included. RESULTS Seventy-six articles of the 954 screened records met the inclusion criteria. Seven Mabs were described for treating GO. The three most reported Mabs were Rituximab, Tocilizumab, and Teprotumumab. Only eight randomized clinical trials compared the effect of these three Mabs and Belimumab with the effect of steroids or placebos. Adalimumab, Infliximab, and K1-70 only appeared in a few case series and case reports. Frequent mild-to-moderate and few major side effects occurred with the three most used Mabs. Relapse rates ranged from 7.4% for Tocilizumab to at least 29.4% for Teprotumumab. No randomized clinical trials compared Mabs head-to-head. CONCLUSION Considering the lack of head-to-head comparisons between Mabs, the relapse rate, the possibility of severe collateral effects, and the cost of Mabs, it is not clear which Mab is the safest and most useful to treat GO.
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Affiliation(s)
- Naiara F Xavier
- Department of Ophthalmology, School of Medicine of Ribeirão Preto - University of São Paulo, Brasil
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Steroid-Resistant Graves' Orbitopathy Treated with Tocilizumab in Real-World Clinical Practice: A 9-Year Single-Center Experience. J Clin Med 2021; 10:jcm10040706. [PMID: 33670151 PMCID: PMC7916878 DOI: 10.3390/jcm10040706] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 01/29/2021] [Accepted: 02/07/2021] [Indexed: 02/07/2023] Open
Abstract
This study aimed to assess the effectiveness and safety of tocilizumab use for the treatment of active steroid-resistant Graves’ orbitopathy (GO). A retrospective longitudinal study was conducted by reviewing the medical records at a single center between November 2009 and December 2018. A total of 114 patients with steroid-resistant Graves’ orbitopathy were examined and treated with tocilizumab, of which 54 adults met the inclusion criteria. No concomitant medication for the treatment of orbitopathy was used. The main primary outcomes included changes from baseline in the Clinical Activity Score (CAS) and thyrotropin receptor antibody (TRAb) levels throughout therapy with tocilizumab. The absolute responses to treatment were defined as the achievement of CAS ≤ 1 and TRAb ≤ 10 U/L. A composite ophthalmic score including CAS, proptosis, eyelid retraction, and diplopia was used to evaluate individual improvement in GO. Adverse drug reactions were also assessed. Analysis of the patient’s CAS and TRAb levels showed meaningful reductions during tocilizumab treatment. Differences between values at baseline and subsequent time points were statistically significant (p < 0.001 for all comparisons). The absolute CAS response (CAS = 0 or 1) was achieved in 74% (37/50) of patients after the fourth dose of tocilizumab (at week 16), with a TRAb response being achieved in 55% (23/42) of patients. The relative CAS response (reduction ≥ 2 points) was achieved in 90.9% of patients (40/44) after the first dose of tocilizumab (at week 4). Measurements of proptosis (reduction ≥ 2 mm in 78% of patients, 42/54) and eyelid retraction (reduction ≥ 2 mm in 75%, 33/44), and the prevalence of diplopia (improvement in 68%, 19/28) were significantly reduced after the last dose of tocilizumab (p < 0.001 for all comparisons). GO improved in 98% (53/54) of patients when at least two criteria of the composite evaluation were required. Four patients exhibited disease recurrence, defined as an increase in CAS of ≥2 points in the six months following the date of inactivation. Most adverse drug reactions were mild or moderate in severity. In conclusion, our data suggest that a course of at least 4 months (one monthly dose) of tocilizumab therapy provides a significant benefit to patients with active moderate-to-severe steroid-resistant GO.
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Fallahi P, Ferrari SM, Elia G, Ragusa F, Paparo SR, Patrizio A, Camastra S, Miccoli M, Cavallini G, Benvenga S, Antonelli A. Cytokines as Targets of Novel Therapies for Graves' Ophthalmopathy. Front Endocrinol (Lausanne) 2021; 12:654473. [PMID: 33935970 PMCID: PMC8085526 DOI: 10.3389/fendo.2021.654473] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/24/2021] [Indexed: 12/12/2022] Open
Abstract
Graves' disease (GD) is an organ-specific autoimmune disorder of the thyroid, which is characterized by circulating TSH-receptor (TSH-R) stimulating antibodies (TSAb), leading to hyperthyroidism. Graves' ophthalmopathy (GO) is one of GD extra-thyroidal manifestations associated with the presence of TSAb, and insulin-like growth factor-1 receptor (IGF-1R) autoantibodies, that interact with orbital fibroblasts. Cytokines are elevated in autoimmune (i.e., IL-18, IL-6) and non-autoimmune hyperthyroidism (i.e., TNF-α, IL-8, IL-6), and this could be associated with the chronic effects of thyroid hormone increase. A prevalent Th1-immune response (not related to the hyperthyroidism per se, but to the autoimmune process) is reported in the immune-pathogenesis of GD and GO; Th1-chemokines (CXCL9, CXCL10, CXCL11) and the (C-X-C)R3 receptor are crucial in this process. In patients with active GO, corticosteroids, or intravenous immunoglobulins, decrease inflammation and orbital congestion, and are considered first-line therapies. The more deepened understanding of GO pathophysiology has led to different immune-modulant treatments. Cytokines, TSH-R, and IGF-1R (on the surface of B and T lymphocytes, and fibroblasts), and chemokines implicated in the autoimmune process, are possible targets of novel therapies. Drugs that target cytokines (etanercept, tocilizumab, infliximab, adalimumab) have been tested in GO, with encouraging results. The chimeric monoclonal antibody directed against CD20, RTX, reduces B lymphocytes, cytokines and the released autoantibodies. A multicenter, randomized, placebo-controlled, double-masked trial has investigated the human monoclonal blocking antibody directed against IGF-1R, teprotumumab, reporting its effectiveness in GO. In conclusion, large, controlled and randomized studies are needed to evaluate new possible targeted therapies for GO.
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Affiliation(s)
- Poupak Fallahi
- Department of Translational Research of New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | - Giusy Elia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesca Ragusa
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Armando Patrizio
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefania Camastra
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Mario Miccoli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gabriella Cavallini
- Department of Translational Research of New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Salvatore Benvenga
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular & Clinical Endocrinology, and Women’s Endocrine Health, University Hospital, A.O.U. Policlinico Gaetano Martino, Messina, Italy
| | - Alessandro Antonelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
- *Correspondence: Alessandro Antonelli,
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Sánchez-Bilbao L, Martínez-López D, Revenga M, López-Vázquez Á, Valls-Pascual E, Atienza-Mateo B, Valls-Espinosa B, Maiz-Alonso O, Blanco A, Torre-Salaberri I, Rodríguez-Méndez V, García-Aparicio Á, Veroz-González R, Jovaní V, Peiteado D, Sánchez-Orgaz M, Tomero E, Toyos-Sáenz de Miera FJ, Pinillos V, Aurrecoechea E, Mora Á, Conesa A, Fernández-Prada M, Troyano JA, Calvo-Río V, Demetrio-Pablo R, González-Mazón Í, Hernández JL, Castañeda S, González-Gay MÁ, Blanco R. Anti-IL-6 Receptor Tocilizumab in Refractory Graves' Orbitopathy: National Multicenter Observational Study of 48 Patients. J Clin Med 2020; 9:jcm9092816. [PMID: 32878150 PMCID: PMC7563792 DOI: 10.3390/jcm9092816] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/18/2020] [Accepted: 08/29/2020] [Indexed: 12/14/2022] Open
Abstract
Graves' orbitopathy (GO) is the most common extrathyroidal manifestation of Graves' disease (GD). Our aim was to assess the efficacy and safety of Tocilizumab (TCZ) in GO refractory to conventional therapy. This was an open-label multicenter study of glucocorticoid-resistant GO treated with TCZ. The main outcomes were the best-corrected visual acuity (BVCA), Clinical Activity Score (CAS) and intraocular pressure (IOP). These outcome variables were assessed at baseline, 1st, 3rd, 6th and 12th month after TCZ therapy onset. The severity of GO was assessed according to the European Group on Graves' Orbitopathy (EUGOGO). We studied 48 (38 women and 10 men) patients (95 eyes); mean age ± standard deviation 51 ± 11.8 years. Before TCZ and besides oral glucocorticoids, they had received IV methylprednisolone (n = 43), or selenium (n = 11). GO disease was moderate (n =29) or severe (n = 19) and dysthyroid optic neuropathy (DON) (n = 7). TCZ was used in monotherapy (n = 45) or combined (n = 3) at a dose of 8 mg/kg IV every four weeks (n = 43) or 162 mg/s.c. every week (n = 5). TCZ yielded a significant improvement in all of the main outcomes at the 1st month that was maintained at one year. Comparing the baseline with data at 1 year all of the variables improved; BCVA (0.78 ± 0.25 vs. 0.9 ± 0.16; p = 0.0001), CAS (4.64 ± 1.5 vs. 1.05 ± 1.27; p = 0.0001) and intraocular pressure (IOP) (19.05 ± 4.1 vs. 16.73 ± 3.4 mmHg; p = 0.007). After a mean follow-up of 16.1 ± 2.1 months, low disease activity (CAS ≤ 3), was achieved in 88 eyes (92.6%) and TCZ was withdrawn in 29 cases due to low disease activity (n = 25) or inefficacy (n = 4). No serious adverse events were observed. In conclusion, TCZ is a useful and safe therapeutic option in refractory GO treatment.
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Affiliation(s)
- Lara Sánchez-Bilbao
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
| | - David Martínez-López
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
| | - Marcelino Revenga
- Rheumatology and Ophthalmology, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (M.R.); (Á.L.-V.)
| | - Ángel López-Vázquez
- Rheumatology and Ophthalmology, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain; (M.R.); (Á.L.-V.)
| | - Elia Valls-Pascual
- Rheumatology and Ophthalmology, Hospital Universitari Doctor Peset, 46017 Valencia, Spain; (E.V.-P.); (B.V.-E.)
| | - Belén Atienza-Mateo
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
| | - Beatriz Valls-Espinosa
- Rheumatology and Ophthalmology, Hospital Universitari Doctor Peset, 46017 Valencia, Spain; (E.V.-P.); (B.V.-E.)
| | - Olga Maiz-Alonso
- Rheumatology and Ophthalmology, Hospital Universitario de Donosti, 20014 San Sebastián, Spain; (O.M.-A.); (A.B.)
| | - Ana Blanco
- Rheumatology and Ophthalmology, Hospital Universitario de Donosti, 20014 San Sebastián, Spain; (O.M.-A.); (A.B.)
| | - Ignacio Torre-Salaberri
- Rheumatology and Ophthalmology, Hospital Universitario de Basurto, 48013 Bilbao, Spain; (I.T.-S.); (V.R.-M.)
| | - Verónica Rodríguez-Méndez
- Rheumatology and Ophthalmology, Hospital Universitario de Basurto, 48013 Bilbao, Spain; (I.T.-S.); (V.R.-M.)
| | | | | | - Vega Jovaní
- Rheumatology, Hospital General Universitario de Alicante, 03010 Alicante, Spain;
| | - Diana Peiteado
- Rheumatology and Ophthalmology, Hospital Universitario La Paz, 28046 Madrid, Spain; (D.P.); (M.S.-O.)
| | - Margarita Sánchez-Orgaz
- Rheumatology and Ophthalmology, Hospital Universitario La Paz, 28046 Madrid, Spain; (D.P.); (M.S.-O.)
| | - Eva Tomero
- Rheumatology, Hospital de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (E.T.); (S.C.)
| | | | | | - Elena Aurrecoechea
- Rheumatology and Ophthalmology, Hospital Sierrallana, 39300 Torrelavega, Spain; (E.A.); (Á.M.)
| | - Ángel Mora
- Rheumatology and Ophthalmology, Hospital Sierrallana, 39300 Torrelavega, Spain; (E.A.); (Á.M.)
| | - Arantxa Conesa
- Rheumatology, Hospital Clínico Universitario de Valencia, 46018 Valencia, Spain;
| | | | - Juan A. Troyano
- Ophthalmology, Hospital Universitario Clínico San Carlos, 28040 Madrid, Spain;
| | - Vanesa Calvo-Río
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
| | - Rosalía Demetrio-Pablo
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
| | - Íñigo González-Mazón
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
| | - José L. Hernández
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
| | - Santos Castañeda
- Rheumatology, Hospital de La Princesa, IIS-Princesa, 28006 Madrid, Spain; (E.T.); (S.C.)
- Cátedra UAM-Roche, EPID-Future, Universidad Autónoma de Madrid (UAM), 28049 Madrid, Spain
| | - Miguel Á. González-Gay
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
- Correspondence: (M.Á.G.-G.); (R.B.)
| | - Ricardo Blanco
- Rheumatology, Ophthalmology and Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, 39008 Santander, Spain; (L.S.-B.); (D.M.-L.); (B.A.-M.); (V.C.-R.); (R.D.-P.); (Í.G.-M.); (J.L.H.)
- Correspondence: (M.Á.G.-G.); (R.B.)
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De-Pablo-Gómez-de-Liaño L, Fernández-Vigo JI, Merino-Menéndez S, Duque-Muñoz M, Gómez-de-Liaño R. Correlation Between Optical Coherence Tomography and Magnetic Resonance Imaging of Rectus Muscle Thickness Measurements in Graves' Ophthalmopathy. J Pediatr Ophthalmol Strabismus 2019; 56:319-326. [PMID: 31545866 DOI: 10.3928/01913913-20190607-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 05/22/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE To assess the correlation between optical coherence tomography (OCT) and magnetic resonance imaging (MRI) measurements of extraocular rectus muscle thickness in patients with Graves' ophthalmopathy. METHODS This was a cross-sectional observational study conducted in 62 eyes of 31 patients with Graves' ophthalmopathy. The disease phase was inactive in 20 patients and active in the remaining 11. The OCT measurements obtained were: medial rectus thickness at 7.2 and 9.2 mm from the limbus and lateral rectus thickness at 8.5 mm from the limbus. MRI measurements were maximum transversal diameter (T-MRI), craniocaudal diameter (CC-MRI), and muscle area (A-MRI). RESULTS For the whole patient cohort, correlation emerged between the OCT-MR and T-MRI measurements (R = 0.428 to 0.576; P ≤ .002), A-MRI (R = 0.562 to 0.674; P < .001), and CC-MRI (R = 0.286 to 0.293; P ≤ .046). In patients with clinically active Graves' ophthalmopathy, correlations with T-MRI (R = 0.576 to 0.604; P ≤ .010) and A-MRI (R = 0.678 to 0.706; P < .001) were higher. No correlations were detected between OCT and MRI measurements of lateral rectus thickness (P ≥ .177), regardless of disease phase. CONCLUSIONS The correlations observed suggest OCT could be a complementary assessment or screening method to detect thickening of the anterior portion of the medial rectus muscle in patients with Graves' ophthalmopathy, which may be especially useful when MRI is not available. [J Pediatr Ophthalmol Strabismus. 2019;56(5):319-326.].
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