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Men CJ, Amarikwa L, Pham B, Sears C, Clauss K, Lee BW, Lee WW, Pasol J, Ugradar S, Shinder R, Cockerham K, Wester S, Douglas R, Kossler AL. Teprotumumab for the Treatment of Recalcitrant Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg 2024; 40:276-285. [PMID: 37972960 PMCID: PMC11090759 DOI: 10.1097/iop.0000000000002564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
PURPOSE Teprotumumab, an insulin-like growth factor 1 receptor monoclonal antibody, is FDA-approved to treat thyroid eye disease (TED). The initial clinical trials excluded patients with previous orbital irradiation, surgery, glucocorticoid use (cumulative dose >1 gm), or prior biologic treatment. Information on the use of teprotumumab for patients who failed prior therapy is limited. Our purpose is to characterize the efficacy of teprotumumab for the treatment of recalcitrant TED. METHODS This is a multicenter retrospective study of all patients treated with teprotumumab for moderate-to-severe TED after failing conventional therapy with corticosteroids, orbital radiation, surgical decompression, biologics, or other steroid-sparing medications. Treatment failure was defined as an incomplete response to or reactivation after previous treatment. Only patients who received at least 4 infusions of teprotumumab were included in the analysis. Primary outcome measures comprised proptosis response (≥2 mm reduction in the study eye without a similar increase in the other eye), clinical activity score (CAS) response (≥2-point reduction in CAS), and diplopia response (≥1 point improvement in Gorman diplopia score in patients with baseline diplopia) following treatment. Adverse events and risk factors for recalcitrant disease were also evaluated. RESULTS Sixty-six patients were included in this study, 46 females and 20 males. Average age was 59.3 years (range 29-93). The mean duration of disease from TED diagnosis to first infusion was 57.8 months. The proptosis, CAS, and diplopia responses in this recalcitrant patient population were 85.9%, 93.8%, and 69.1%, respectively. Patients experienced a mean reduction in proptosis of 3.1 ± 2.4 mm and a mean improvement in CAS of 3.8 ± 1.6. Patients who underwent prior decompression surgery experienced a statistically significant decrease in diplopia response (46.7% vs. 77.5%, p = 0.014) and proptosis response (75.0% vs. 90.9%, p = 0.045) when compared with nondecompression patients. Additionally, there were no significant differences in proptosis, CAS, and diplopia responses between patients with acute (defined as disease duration <1 year) versus chronic (disease duration ≥1 year) TED. While most adverse events were mild to moderate, 4 patients reported serious adverse events related to persistent hearing loss. CONCLUSIONS Patients with recalcitrant TED demonstrated a significant improvement after teprotumumab in each of the primary study outcomes. The degree of proptosis reduction, diplopia response, and CAS improvement in the recalcitrant group were similar to those of treatment-naïve patients from the pivotal clinical trials. Patients with a prior history of orbital decompression, however, demonstrated poor improvement in diplopia and less reduction in proptosis than surgery naïve patients. These results indicate that teprotumumab is a treatment option for the treatment of patients with TED recalcitrant to prior medical therapies.
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Affiliation(s)
- Clara J Men
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Linus Amarikwa
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Brandon Pham
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, U.S.A
| | - Connie Sears
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Kevin Clauss
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, U.S.A
| | - Bradford W Lee
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, U.S.A
- Department of Surgery, Ophthalmology Division, University of Hawai'i John A. Burns School of Medicine, Honolulu, Hawaii, U.S.A
| | - Wendy W Lee
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, U.S.A
| | - Joshua Pasol
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, U.S.A
| | - Shoaib Ugradar
- Private Practice, Beverly Hills, Los Angeles, California, U.S.A
| | - Roman Shinder
- Department of Ophthalmology, SUNY Downstate Medical, Brooklyn, New York, U.S.A
| | - Kimberly Cockerham
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, U.S.A
- Private Practice, San Diego, California, U.S.A
| | - Sara Wester
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, U.S.A
| | - Raymond Douglas
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Andrea L Kossler
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, U.S.A
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Lee C, Park JW, Kim YD, Woo KI. Efficacy of tocilizumab in patients with moderate-to-severe corticosteroid-resistant thyroid eye disease: a prospective study. Int Ophthalmol 2024; 44:179. [PMID: 38622479 DOI: 10.1007/s10792-024-03117-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 03/24/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE To evaluate the clinical outcomes of intravenous tocilizumab (TCZ) injection in patients with moderate-to-severe active thyroid eye disease (TED). METHODS Patients with active and moderate-to-severe TED who did not respond to conventional therapies were treated with TCZ from June 2019 to January 2021. The medical records of the patients were evaluated before the treatment. We analyzed patient demographics, including the duration of Graves' disease and TED, and assessed subjective symptoms, such as diplopia and ocular movement, clinical activity score (CAS), modified NOSPECS score, and exophthalmos before treatment and at 4, 8, 12, and 16 weeks after the first drug injection. Blood tests, including TSH Rc Ab and TS Ab, were performed before treatment and 24 weeks after the first injection. And orbital computed tomography (CT) was performed and Barrett's Index was calculated at baseline and after completion of all injections. RESULTS Nineteen completed the scheduled treatment. There were no significant side effects, other than herpes zoster in one case and headache and dermatitis in another. Clinical symptoms before and 16 weeks after the treatment showed mean CAS decreased by 2.4 points, mean modified NOSPECS score decreased by 3.7 points, and mean exophthalmos decreased by 0.4 mm. Diplopia and extraocular muscle limitation improved in ten and remained stationary in five of the 15 patients, who presented with extraocular motility abnormalities. Six of 11 patients who underwent orbit CT showed improvement in muscle size. The mean TSH Rc Ab decreased by 7.5 IU/L and TS-Ab decreased by 162.9%. CONCLUSION TCZ can treat active moderate-to-severe TED, showing high drug compliance and reasonable response to inflammation and extraocular motility abnormality.
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Affiliation(s)
- Chaeyeon Lee
- Department of Ophthalmology, Samsung Medical Center, SungkyunkwanUniversitySchool of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Ji Woong Park
- Department of Ophthalmology, Seoul Eye Clinic, Anyang, South Korea
| | - Yoon-Duck Kim
- Department of Ophthalmology, Nune Eye Hospital, Seoul, South Korea
| | - Kyung In Woo
- Department of Ophthalmology, Samsung Medical Center, SungkyunkwanUniversitySchool of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
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North VS, Dolman PJ, Garrity JA, Kazim M. Disease Modulation Versus Modification: A Call for Revised Outcome Metrics in the Treatment of Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg 2024; 40:156-160. [PMID: 38285956 DOI: 10.1097/iop.0000000000002591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
PURPOSE This perspective introduces the concepts of disease-modulating and -modifying therapy for thyroid eye disease and offers novel metrics for therapeutic outcomes. METHODS A focused literature review was performed. RESULTS Modulators are treatments that suppress disease symptoms whereas modifiers alter the natural history of a disease. Though many drugs are capable of exhibiting both effects, consideration of a drug's primary effect is useful when considering therapeutic options. For thyroid eye disease, corticosteroids and teprotumumab are effective at modulating many signs and symptoms of the disease, particularly those related to soft tissue inflammation. Orbital radiotherapy and rituximab have demonstrated effectiveness at durably modifying the natural history of thyroid eye disease. CONCLUSIONS Outcome metrics should reflect the unique therapeutic objectives associated with disease modulation and modification. This conceptual framework should guide treatment of thyroid eye disease.
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Affiliation(s)
- Victoria S North
- Department of Ophthalmology, Orbit and Oculoplastic Surgery, Tufts Medical Center, Tufts University, Boston, Massachusetts, U.S.A
| | - Peter J Dolman
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - James A Garrity
- Department of Ophthalmology, Oculoplastic Surgery, Lake Region Medical Group, Fergus Falls, Minnesota, U.S.A
| | - Michael Kazim
- Department of Ophthalmology, Oculoplastic and Orbital Surgery, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York City, New York, U.S.A
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Zhang H, Liu Y, Xia D, Jiang M, Li Y, Sun J, Guan H, Zhu L, Song X, Wang J, Fan X, Zhou H. The insular cortex is not insular in thyroid eye disease: neuroimaging revelations of central-peripheral system interaction. J Neuroinflammation 2024; 21:51. [PMID: 38368427 PMCID: PMC10874024 DOI: 10.1186/s12974-024-03044-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 02/13/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Thyroid eye disease (TED) is highly correlated with dysregulated immunoendocrine status. The insular cortex was found to regulate peripheral inflammation and immunomodulation in mice. This study aimed to explore whether the insular cortex in patients with TED played a modulatory role including the aberrant brain functional alteration and its association with immunoendocrine status. METHODS This study included 34 active patients (AP), 30 inactive patients (IP) with TED, and 45 healthy controls (HC) matched for age, sex, and educational level. Comprehensive clinical details (especially immunoendocrine markers) and resting-state functional magnetic resonance imaging data were collected from each participant. The amplitude of low-frequency fluctuation (ALFF) was used to probe the aberrant alterations of local neural activity. The seed-based functional connectivity (FC) analysis was used to explore the relationship between the insular cortex and each voxel throughout the whole brain. The correlation analysis was conducted to assess the association between insular neurobiomarkers and immunoendocrine parameters. RESULTS When compared with the IP and HC groups, the AP group displayed significantly higher ALFF values in the right insular cortex (INS.R) and lower FC values between the INS.R and the bilateral cerebellum. None of the neurobiomarkers differed between the IP and HC groups. Besides, correlations between insular neurobiomarkers and immunoendocrine markers (free thyroxine, the proportion of T cells, and natural killer cells) were identified in both AP and IP groups. CONCLUSIONS This study was novel in reporting that the dysregulation of the insular cortex activity in TED was associated with abnormal peripheral immunoendocrine status. The insular cortex might play a key role in central-peripheral system interaction in TED. Further research is crucial to enhance our understanding of the central-peripheral system interaction mechanisms involved in autoimmune diseases.
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Affiliation(s)
- Haiyang Zhang
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Yuting Liu
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Duojin Xia
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Mengda Jiang
- Department of Radiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yinwei Li
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Jing Sun
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Haixia Guan
- Department of Endocrinology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Ling Zhu
- Department of Radiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuefei Song
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Jue Wang
- Institute of Sports Medicine and Health, Chengdu Sport University, Chengdu, China.
| | - Xianqun Fan
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China.
| | - Huifang Zhou
- Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China.
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Wang Y, Liu Y, Cai J, Zong T, Zhang Z, Xie T, Mu T, Wu M, Yang Q, Wang Y, Wang X, Yao Y. Differentially expressed genes in orbital adipose/connective tissue of thyroid-associated orbitopathy. PeerJ 2023; 11:e16569. [PMID: 38130930 PMCID: PMC10734407 DOI: 10.7717/peerj.16569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/13/2023] [Indexed: 12/23/2023] Open
Abstract
Background Thyroid-associated orbitopathy (TAO) is a disease associated with autoimmune thyroid disorders and it can lead to proptosis, diplopia, and vision-threatening compressive optic neuropathy. To comprehensively understand the molecular mechanisms underlying orbital adipogenesis in TAO, we characterize the intrinsic molecular properties of orbital adipose/connective tissue from patients with TAO and control individuals. Methods RNA sequencing analysis (RNA-seq) was performed to measure the gene expression of orbital adipose/connective tissues of TAO patients. Differentially expressed genes (DEGs) were detected and analyzed through Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis, and Gene Set Enrichment Analysis (GSEA). The protein-protein interaction (PPI) network was constructed using the STRING database, and hub genes were identified by the Cytoscape plug-in, cytoHubba. We validated several top DEGs through quantitative real-time polymerase chain reaction (qRT-PCR). Results We identified 183 DEGs in adipose tissue between TAO patients (n = 3) and control patients (n = 3) through RNA sequencing, including 114 upregulated genes and 69 downregulated genes. The PPI network of these DEGs had 202 nodes and 743 edges. PCR-based validation results of orbital adipose tissue showed multiple top-ranked genes in TAO patients (n = 4) are immune and inflammatory response genes compared with the control individual (n = 4). They include ceruloplasmin isoform x3 (CP), alkaline tissue-nonspecific isozyme isoform x1 (ALPL), and angiotensinogen (AGT), which were overrepresented by 2.27- to 6.40-fold. Meanwhile, protein mab-21-like 1 (MAB21L1), phosphoinositide 3-kinase gamma-subunit (PIK3C2G), and clavesin-2 (CLVS2) decreased by 2.6% to 32.8%. R-spondin 1 (RSPO1), which is related to oogonia differentiation and developmental angiogenesis, was significantly downregulated in the orbital muscle tissues of patients with TAO compared with the control groups (P = 0.024). Conclusions Our results suggest that there are genetic differences in orbital adipose-connective tissues derived from TAO patients. The upregulation of the inflammatory response in orbital fat of TAO may be consistent with the clinical phenotype like eyelid edema, exophthalmos, and excess tearing. Downregulation of MAB21L1, PIK3C2G, and CLVS2 in TAO tissue demonstrates dysregulation of differentiation, oxidative stress, and developmental pathways.
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Affiliation(s)
- Yan Wang
- Department of Ophthalmology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Yanqiu Liu
- Department of Ophthalmology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Jiping Cai
- Department of Ophthalmology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Tianyi Zong
- Department of Ophthalmology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Ziyin Zhang
- Department of Ophthalmology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Tianhua Xie
- Department of Ophthalmology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Tong Mu
- Department of Ophthalmology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Meili Wu
- Center of Clinical Research, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Qian Yang
- Department of Ophthalmology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
- Center of Clinical Research, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Yangningzhi Wang
- Department of Ophthalmology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Xiaolu Wang
- Center of Clinical Research, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Yong Yao
- Department of Ophthalmology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
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Spadaro JZ, Kohli AA. Pathogenesis of Thyroid Eye Disease. Int Ophthalmol Clin 2023; 63:65-80. [PMID: 36963828 DOI: 10.1097/iio.0000000000000464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
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Goel R, Shah S, Sundar G, Arora R, Gupta S, Khullar T. Orbital and ocular perfusion in thyroid eye disease. Surv Ophthalmol 2023; 68:481-506. [PMID: 36681278 DOI: 10.1016/j.survophthal.2023.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/20/2022] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
Thyroid eye disease (TED) is characterized by enlargement of extraocular muscles, an increase in retrobulbar fat, orbital fibrosis, and fluctuations in plasma thyroid hormone levels in most patients, often associated with raised autoantibody titers. The occurrence of orbital space conflict compromises the orbital perfusion, unchecked progression of which results in irreversible loss of visual acuity and visual fields. The quantitative assessment of orbital perfusion can be done by measurement of blood flow velocities in the superior ophthalmic vein (SOV), ophthalmic artery (OA), central retinal artery (CRA), and posterior ciliary artery by color Doppler imaging. The retinal and choroidal microvasculature is studied by optical coherence tomography and optical coherence tomography angiography. The orbital and ocular perfusion fluctuates during the course of TED. Orbital congestion is reflected by the reduction or reversal of SOV flow and an increase in subfoveal choroidal thickness. The active phase is characterized by high blood flow velocities of the OA and CRA. The onset of dysthyroid optic neuropathy is associated with reduced arterial perfusion and reduction in parafoveal and peripapillary vascular density. Orbital decompression improves the SOV flow and decreases the resistivity index of CRA. Sequential evaluation of orbital hemodynamic changes can thus supplement the clinical scoring systems for monitoring and planning intervention in TED.
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Affiliation(s)
- Ruchi Goel
- Department of Ophthalmology, Maulana Azad Medical College, New Delhi, India.
| | - Shalin Shah
- Department of Ophthalmology, Maulana Azad Medical College, New Delhi, India
| | - Gangadhara Sundar
- Department of Ophthalmology, National University Hospital, Kent Ridge, Singapore
| | - Ritu Arora
- Department of Ophthalmology, Maulana Azad Medical College, New Delhi, India
| | - Swati Gupta
- Department of Radiology, Maulana Azad Medical College, New Delhi, India
| | - Tamanna Khullar
- Department of Radiology, Maulana Azad Medical College, New Delhi, India
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Park J, Kim J, Ryu D, Choi HY. Factors related to steroid treatment responsiveness in thyroid eye disease patients and application of SHAP for feature analysis with XGBoost. Front Endocrinol (Lausanne) 2023; 14:1079628. [PMID: 36817584 PMCID: PMC9928572 DOI: 10.3389/fendo.2023.1079628] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/12/2023] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION The primary treatment for active thyroid eye disease (TED) is immunosuppressive therapy with intravenous steroids. In this study, we attempted to predict responsiveness to steroid treatment in TED patients using eXtreme Gradient Boosting (XGBoost). Factors associated with steroid responsiveness were also statistically evaluated. METHODS Clinical characteristics and laboratory results of 89 patients with TED who received steroid treatment were retrospectively reviewed. XGBoost was used to explore responsiveness to steroid treatment, and the diagnostic performance was evaluated. Factors contributing to the model output were investigated using the SHapley Additive exPlanation (SHAP), and the treatment response was investigated statistically using SPSS software. RESULTS The eXtra Gradient Boost model showed high performance, with an excellent accuracy of 0.861. Thyroid-stimulating hormone, thyroid-stimulating immunoglobulin (TSI), and low-density lipoprotein (LDL) cholesterol had the highest impact on the model. Multivariate logistic regression analysis showed that less extraocular muscle limitation and high TSI levels were associated with a high risk of poor intravenous methylprednisolone treatment response. As a result of analysis through SHAP, TSH, TSI, and LDL had the highest impact on the XGBoost model. CONCLUSION TSI, extraocular muscle limitation, and LDL cholesterol levels may be useful in predicting steroid treatment response in patients with TED. In terms of machine learning, XGBoost showed relatively robust and reliable results for small datasets. The machine-learning model can assist in decision-making for further treatment of patients with TED.
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Affiliation(s)
- Jungyul Park
- Department of Ophthalmology, Pusan National University Hospital, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jaehyun Kim
- Department of Ophthalmology, Pusan National University Hospital, Busan, Republic of Korea
| | - Dongman Ryu
- Medical Research Institute, Pusan National University, Busan, Republic of Korea
| | - Hee-young Choi
- Department of Ophthalmology, Pusan National University Hospital, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- Department of Ophthalmology, School of Medicine, Pusan National University, Busan, Republic of Korea
- *Correspondence: Hee-young Choi,
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Park HY, Chae MK, Ko J, Kikkawa DO, Jang SY, Yoon JS. Therapeutic effect of ibrutinib, a selective Bruton's tyrosine kinase inhibitor, in orbital fibroblasts from patients with Graves' orbitopathy. PLoS One 2022; 17:e0279060. [PMID: 36521376 PMCID: PMC9754806 DOI: 10.1371/journal.pone.0279060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Bruton's tyrosine kinase (BTK) is an essential protein in B-cell antigen receptor (BCR) signaling pathway and is known to be related to pathogenetic effect on B-cell related malignancies and various autoimmune diseases. In this study, we investigated the therapeutic effect of ibrutinib, an orally bioavailable BTK inhibitor in the pathogenesis of Graves' orbitopathy (GO) in in vitro model. METHODS Expression of BTK in orbital tissues from GO and normal control subjects were evaluated by real-time polymerase chain reaction (PCR). Primary cultured orbital fibroblasts from each subject were exposed to ibrutinib and stimulated with interleukin (IL)-1β or insulin like growth factor (IGF)-1. Production of inflammatory cytokines was evaluated by real time PCR and enzyme-linked immunosorbent assays (ELISA). The downstream transcription factors were also determined by western blot assays. RESULTS The expression of BTK in GO tissues were significantly higher than in healthy controls. After stimulation of GO orbital fibroblasts with IL-1β or IGF-1, BTK mRNA and phosphorylated (p)- BTK protein expression was also enhanced. Ibrutinib reduced the expression of BTK mRNA and proteins of p-BTK, and inhibited the IL-1β- and IGF-1-induced production of proinflammatory cytokines including IL-6, IL-8 and COX-2 in both GO and normal cells. Ibrutinib also significantly attenuated phosphorylation of Akt, p38, c-Jun N-terminal kinase (JNK), extracellular signal-regulated kinase (ERK), and nuclear factor kappa-light-chain-enhancer of activated B-cells (NF-κB) in IL-1β stimulated GO cells and Akt, JNK, and NF-κB in IL-1ß stimulated normal cells. CONCLUSIONS BTK expression is enhanced in GO tissue and orbital fibroblasts. Ibrutinib, a BTK inhibitor suppresses proinflammatory cytokine production as well as phosphorylation of Akt and NF-κB protein. Our results suggest the potential role of BTK in GO inflammatory pathogenesis and possibility of a novel therapeutic target of GO.
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Affiliation(s)
- Hyun Young Park
- Department of Ophthalmology, Severance Hospital, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Republic of Korea
- Siloam Eye Hospital, Seoul, Republic of Korea
| | - Min Kyung Chae
- Department of Ophthalmology, Severance Hospital, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - JaeSang Ko
- Department of Ophthalmology, Severance Hospital, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Don O. Kikkawa
- Division of Oculofacial Plastic and Reconstructive Surgery, Department of Ophthalmology, University of California San Diego, La Jolla, California, United States of America
| | - Sun Young Jang
- Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jin Sook Yoon
- Department of Ophthalmology, Severance Hospital, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Republic of Korea
- * E-mail:
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Supronik J, Szelachowska M, Kretowski A, Siewko K. Rituximab in the treatment of Graves' orbitopathy: latest updates and perspectives. Endocr Connect 2022; 11:e220303. [PMID: 36219838 PMCID: PMC9716394 DOI: 10.1530/ec-22-0303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/11/2022] [Indexed: 11/08/2022]
Abstract
Graves' orbitopathy (GO) is a potentially sight-threatening and disfiguring, extrathyroidal manifestation of Graves' disease. It often impairs patients' quality of life, causing severe social and psychological sequelae. Intravenous glucocorticosteroids is currently the mainstay of therapy, but the efficacy is often underwhelming and recurrence rate is high. For many years, clinicians have been searching for new methods of treatment. Rituximab (RTX) is a chimeric monoclonal antibody targeted against CD20 which is a surface antigen present on B cells. It is frequently used to treat non-Hodgkin's lymphoma, chronic lymphocytic leukemia, rheumatoid arthritis, or various types of vasculitis. Numerous clinical trials employing RTX in the treatment of GO have shown promising results. RTX is currently considered to be a valid second-line treatment option in patients unresponsive to previous interventions or in disease reactivation. This review summarizes the available literature on this topic, including two largest, randomized, controlled studies. Potential benefits, as well as the limitations of RTX therapy, are discussed.
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Affiliation(s)
- Jakub Supronik
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Małgorzata Szelachowska
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Adam Kretowski
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
- Clinical Research Centre, Medical University of Bialystok, Bialystok, Poland
| | - Katarzyna Siewko
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
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Moi L, Hamedani M, Ribi C. Long-term outcomes in corticosteroid-refractory Graves' orbitopathy treated with tocilizumab. Clin Endocrinol (Oxf) 2022; 97:363-370. [PMID: 34908176 PMCID: PMC9545295 DOI: 10.1111/cen.14655] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/15/2021] [Accepted: 12/03/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Up to 20% of patients with moderate to severe Graves' orbitopathy (GO) do not respond to high-dose glucocorticoids (GC). A few studies, including a randomized trial, have demonstrated the efficacy of interleukin-6 (IL-6) blockade with tocilizumab (TCZ) in GC-refractory GO. However, data on predictors of response to TCZ and long-term outcomes are lacking. METHODS Observational single-center study on ten consecutive patients treated with TCZ for GC-refractory GO, between 2016 and 2020. Median (interquartile range) follow-up was 24 (12-36) months. RESULTS Inflammation and exophthalmos improved dramatically in all patients within months after starting TCZ. Mean Clinical Activity Score decreased from 4.80 ± 1.13 to 0.70 ± 0.82 points at 6 months (mean change: -4.10 ± 1.52; p < .0001). Proptosis improved from 23.2 ± 2.1 to 20.6 ± 2.0 mm at 6 months (mean change: -2.9 ± 1.4 mm; p < .0001). Diplopia resolved in 7 patients. Thyroid receptor antibodies decreased markedly during TCZ treatment. Baseline serum IL-6 levels did not predict clinical response. TCZ was well-tolerated. During follow-up, 3 patients were diagnosed with cancer (breast cancer in 2 and urothelial cancer in 1). CONCLUSIONS TCZ was rapidly effective and well-tolerated in our patients with GC-refractory GO. Four patients experienced mild/moderate adverse events as neutropenia, hyperlipidemia, and infections; nearly a third developed cancer during the follow-up. The increased incidence observed could be explained by the high prevalence of smokers, that are at higher risk for Graves' orbitopathy and solid malignancies as breast cancer. Thus, regular cancer screening could be proposed to this vulnerable population receiving high doses of immunosuppressants.
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Affiliation(s)
- Laura Moi
- Division of Immunology and Allergy, Department of Medicine, Lausanne University HospitalLausanne UniversityLausanneSwitzerland
| | - Mehrad Hamedani
- Department of Oculoplasty, Jules‐Gonin Eye HospitalLausanne UniversityLausanneSwitzerland
| | - Camillo Ribi
- Division of Immunology and Allergy, Department of Medicine, Lausanne University HospitalLausanne UniversityLausanneSwitzerland
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12
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Kossler AL, Douglas R, Dosiou C. Teprotumumab and the Evolving Therapeutic Landscape in Thyroid Eye Disease. J Clin Endocrinol Metab 2022; 107:S36-S46. [PMID: 36346685 PMCID: PMC9359446 DOI: 10.1210/clinem/dgac168] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Indexed: 02/13/2023]
Abstract
CONTEXT Thyroid eye disease (TED) is a sight-threatening and debilitating autoimmune condition, with limited therapies available, that often poses diagnostic and therapeutic challenges. In recent years, the treatment landscape has shifted to early intervention with targeted therapy. METHODS A PubMed review of the literature was conducted for the period between 1979 and 2021. Search terms included thyroid eye disease, teprotumumab, targeted therapy, Graves disease, Graves ophthalmopathy, dysthyroid optic neuropathy, and related terms in different combinations. Novel biologic therapies for TED have emerged as alternatives to traditional steroid regimens in recent years. New insights into TED pathophysiology have uncovered the role of the insulin-like growth factor 1 receptor (IGF-1R) and led to the development of teprotumumab, an IGF-1R-inhibiting monoclonal antibody. RESULTS Randomized clinical trials demonstrating the efficacy of teprotumumab for TED led to Food and Drug Administration approval. Teprotumumab is gradually replacing immunosuppressive agents as first-line therapy in the United States for active moderate-to-severe TED, while emerging reports also show its use in other stages of the disease. Recent data highlight risk factors for adverse events and screening protocols to maximize patient safety. Personalized therapeutic plans developed through effective partnership between endocrinologists and ophthalmologists aim to enhance the safety and outcomes of TED treatments and improve care for this complex disease. CONCLUSION TED management is shifting to an era of targeted therapy with multidisciplinary care. Teprotumumab has demonstrated superior efficacy to conventional treatments and has transformed our therapeutic and surgical algorithms. Clinical guidelines and additional studies are needed to further guide and refine therapy.
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Affiliation(s)
- Andrea Lora Kossler
- Correspondence: Andrea Lora Kossler, MD, Department of Ophthalmology, Stanford University School of Medicine, 2452 Watson Ct, Palo Alto, CA 94303, USA.
| | - Raymond Douglas
- Cedars–Sinai Medical Center, Los Angeles, California 90048, USA
| | - Chrysoula Dosiou
- Division of Endocrinology, Stanford University School of Medicine, Palo Alto, California 94305, USA
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13
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Lee J, Seo W, Park J, Lim WS, Oh JY, Moon NJ, Lee JK. Neural network-based method for diagnosis and severity assessment of Graves' orbitopathy using orbital computed tomography. Sci Rep 2022; 12:12071. [PMID: 35840769 PMCID: PMC9287334 DOI: 10.1038/s41598-022-16217-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 07/06/2022] [Indexed: 11/09/2022] Open
Abstract
Computed tomography (CT) has been widely used to diagnose Graves' orbitopathy, and the utility is gradually increasing. To develop a neural network (NN)-based method for diagnosis and severity assessment of Graves' orbitopathy (GO) using orbital CT, a specific type of NN optimized for diagnosing GO was developed and trained using 288 orbital CT scans obtained from patients with mild and moderate-to-severe GO and normal controls. The developed NN was compared with three conventional NNs [GoogleNet Inception v1 (GoogLeNet), 50-layer Deep Residual Learning (ResNet-50), and 16-layer Very Deep Convolutional Network from Visual Geometry group (VGG-16)]. The diagnostic performance was also compared with that of three oculoplastic specialists. The developed NN had an area under receiver operating curve (AUC) of 0.979 for diagnosing patients with moderate-to-severe GO. Receiver operating curve (ROC) analysis yielded AUCs of 0.827 for GoogLeNet, 0.611 for ResNet-50, 0.540 for VGG-16, and 0.975 for the oculoplastic specialists for diagnosing moderate-to-severe GO. For the diagnosis of mild GO, the developed NN yielded an AUC of 0.895, which is better than the performances of the other NNs and oculoplastic specialists. This study may contribute to NN-based interpretation of orbital CTs for diagnosing various orbital diseases.
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Affiliation(s)
- Jaesung Lee
- School of Computer Science and Engineering, Chung-Ang University, Seoul, Korea
| | - Wangduk Seo
- School of Computer Science and Engineering, Chung-Ang University, Seoul, Korea
| | - Jaegyun Park
- School of Computer Science and Engineering, Chung-Ang University, Seoul, Korea
| | - Won-Seon Lim
- School of Computer Science and Engineering, Chung-Ang University, Seoul, Korea
| | - Ja Young Oh
- Department of Ophthalmology, Chung-Ang University College of Medicine, Chung-Ang University Hospital, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, Korea
| | - Nam Ju Moon
- Department of Ophthalmology, Chung-Ang University College of Medicine, Chung-Ang University Hospital, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, Korea
| | - Jeong Kyu Lee
- Department of Ophthalmology, Chung-Ang University College of Medicine, Chung-Ang University Hospital, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, Korea.
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14
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Yu CY, Ford RL, Wester ST, Shriver EM. Update on thyroid eye disease: Regional variations in prevalence, diagnosis, and management. Indian J Ophthalmol 2022; 70:2335-2345. [PMID: 35791115 PMCID: PMC9426067 DOI: 10.4103/ijo.ijo_3217_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Caroline Y Yu
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, IA, USA
| | - Rebecca L Ford
- Department of Ophthalmology, Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Sara T Wester
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Erin M Shriver
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, IA, USA
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15
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Ko J, Kook KH, Yoon JS, Woo KI, Yang JW. Longitudinal association of thyroid-stimulating immunoglobulin levels with clinical characteristics in thyroid eye disease. BMJ Open 2022; 12:e050337. [PMID: 35728893 PMCID: PMC9214404 DOI: 10.1136/bmjopen-2021-050337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The clinical course of thyroid eye disease (TED) is heterogeneous and predicting patients who may develop the severe sequelae of the disease is difficult. In this study, we evaluated the longitudinal association between changes in serum thyroid-stimulating hormone (TSH) receptor antibody (TRAb) levels and course of disease activity and severity over time. DESIGN This was a multicentre, prospective, observational study. SETTING Fifteen tertiary care oculoplastic service centres in Korea. PARTICIPANTS Seventy-six patients with newly diagnosed TED were included and followed up for 12 months. METHODS We evaluated clinical characteristics and serum TRAb levels at baseline, 6 and 12 months of TED diagnosis. Additionally, we analysed longitudinal associations between the serum TRAb levels and clinical activity score (CAS), no signs or symptoms, only signs, soft tissue involvement, proptosis, extraocular muscle involvement, corneal involvement, sight loss (NOSPECS) score and proptosis. RESULTS Thyroid-stimulating immunoglobulin (TSI) and TSH-binding inhibitory immunoglobulin (TBII) levels decreased during the 1-year follow-up, whereas disease activity measured using CAS decreased mainly in the first 6 months. Disease severity measured using NOSPECS score and proptosis remained unchanged. Moreover, inter-person differences in TBII levels were associated with CAS, NOSPECS score and proptosis over time, whereas inter-person differences in TSI levels were associated with NOSPECS score. Subgroup analysis of patients with a baseline CAS≥4 demonstrated that within-person changes in TSI levels affected the CAS and NOSPECS score. CONCLUSIONS Follow-up measurement of serum TSI and TBII levels may help evaluate TED prognosis and enable accurate clinical decision-making.
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Affiliation(s)
- JaeSang Ko
- Department of Ophthalmology, Severance Hospital, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Koung Hoon Kook
- Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea (the Republic of)
- Nune Eye Hospital, Seoul, Korea (the Republic of)
| | - Jin Sook Yoon
- Department of Ophthalmology, Severance Hospital, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Kyung In Woo
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of)
| | - Jae Wook Yang
- Department of Ophthalmology, Inje University College of Medicine, Inje University Busan Paik Hospital, Busan, Korea (the Republic of)
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16
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FitzPatrick AM. Is Estrogen a Missing Culprit in Thyroid Eye Disease? Sex Steroid Hormone Homeostasis Is Key to Other Fibrogenic Autoimmune Diseases - Why Not This One? Front Immunol 2022; 13:898138. [PMID: 35784325 PMCID: PMC9248759 DOI: 10.3389/fimmu.2022.898138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Sex bias in autoimmune disease (AID) prevalence is known, but the role of estrogen in disease progression is more complex. Estrogen can even be protective in some AIDs; but in systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and systemic sclerosis (SSc), estrogen, its metabolites, and its receptors have been demonstrated to play critical, localized inflammatory roles. Estrogen is instrumental to the fibrosis seen in RA, SLE, SSc and other disease states, including breast cancer and uterine leiomyomas. Fibrotic diseases tend to share a common pattern in which lymphocyte-monocyte interactions generate cytokines which stimulate the deposition of fibrogenic connective tissue. RA, SLE, SSc and thyroid eye disease (TED) have very similar inflammatory and fibrotic patterns-from pathways to tissue type. The thorough investigations that demonstrated estrogen's role in the pathology of RA, SLE, and SSc could, and possibly should, be carried out in TED. One might even expect to find an even greater role for estrogen, and sex steroid homeostasis in TED, given that TED is typically sequalae to Graves' disease (GD), or Hashimoto's disease (HD), and these are endocrine disorders that can create considerable sex steroid hormone dysregulation. This paper highlights the pathophysiology similarities in 4 AIDs, examines the evidence of sex steroid mediated pathology across 3 AIDs and offers a case study and speculation on how this may be germane to TED.
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17
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Albrashdi S, Alsharqi H, Habroosh F, Eatamadi H. Tocilizumab use in pediatric thyroid eye disease: First documented case. Am J Ophthalmol Case Rep 2022; 25:101387. [PMID: 35198812 PMCID: PMC8851154 DOI: 10.1016/j.ajoc.2022.101387] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 01/25/2022] [Accepted: 01/28/2022] [Indexed: 11/27/2022] Open
Abstract
Purpose To report the first case of Tocilizumab treatment for progressive pediatric thyroid eye disease (TED) in a 9-year-old female. Observations A 9-year-old female with a history of hyperthyroidism for 4 months presented with bilateral proptosis (more in the right eye) associated with retrobulbar pain, tearing, and conjunctival and caruncular redness. The exophthalmometry reading on presentation was 21mm OD and 17 mm OS. The patient was managed with observation and control of hyperthyroidism in the beginning. However, on a subsequent visit 3 months later it was observed that the symptoms and clinical findings were rapidly worsening. The exophthalmometry reading upon subsequent follow-up was 22 OD and 22 OS. After multidisciplinary team (MDT) discussions it was decided to treat the patient with four doses of 8mg/kg Tocilizumab injection on monthly basis. Notable improvement of proptosis and resolution of pain, conjunctival and caruncular redness was observed. The exophthalmometry reading 4 months after treatment was 20 OD and 19 OS. Conclusion and importance This case report opens an important gateway for the use of Tocilizumab in progressive TED in pediatric age groups.
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Affiliation(s)
- Safiya Albrashdi
- Sheikh Khalifa Medical City (SKMC), Al Karamah St - Al TibbiyaW13-01, Abu Dhabi, United Arab Emirates
| | - Hessah Alsharqi
- Sheikh Khalifa Medical City (SKMC), Al Karamah St - Al TibbiyaW13-01, Abu Dhabi, United Arab Emirates
| | - Fatima Habroosh
- Sheikh Khalifa Medical City (SKMC), Al Karamah St - Al TibbiyaW13-01, Abu Dhabi, United Arab Emirates
| | - Habibullah Eatamadi
- Sheikh Shakhbout Medical City (SSMC), Ghweifat International Highway, Abu Dhabi, United Arab Emirates
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18
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Lun AY, Le Bras M, Scharbarg E, Morcel P, Hadjadj S, Lebranchu P, Drui D. L’orbitopathie basedowienne: diagnostic, épidémiologie et principes de traitement. Rev Med Interne 2022; 43:242-251. [DOI: 10.1016/j.revmed.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 01/04/2022] [Accepted: 01/30/2022] [Indexed: 10/19/2022]
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19
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Couch SM. Teprotumumab (Tepezza) for Thyroid Eye Disease. MISSOURI MEDICINE 2022; 119:36-41. [PMID: 36033157 PMCID: PMC9312457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Thyroid eye disease (TED) is an immune mediated infiltration and inflammation of the orbital and periorbital soft tissues leading to facial disfigurement. Classically broken into two "phases," active inflammatory and quiescent, disease modifying therapy and surgical intervention are used to improve a number of clinical aspects of TED. Many medical modalities have been utilized to halt the inflammatory phase of the disease including steroids, orbital radiation, and targeted steroid-sparing chemotherapy. Teprotumumab is currently the only Federal Drug Administration approved therapy for the treatment of TED. Significant improvements in proptosis, diplopia and quality of life are noted following its 24-week course of therapy.
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Affiliation(s)
- Steven M Couch
- John F. Hardesty MD Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri
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20
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Diniz SB, Cohen LM, Roelofs KA, Rootman DB. Early Experience With the Clinical Use of Teprotumumab in a Heterogenous Thyroid Eye Disease Population. Ophthalmic Plast Reconstr Surg 2021; 37:583-591. [PMID: 33710036 DOI: 10.1097/iop.0000000000001959] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the clinical course in a heterogeneous series of subjects with thyroid eye disease (TED) treated with teprotumumab. METHODS Cross-sectional cohort study including patients with clinical diagnosis of TED who was treated with teprotumumab. The entire cohort was analyzed together and subsequently in clinical subgroups based on stage and grade of disease. Primary outcome measure was change in proptosis ≥2 mm. Secondary outcome measures included change in clinical activity score (CAS), ductions, strabismic deviation, MRD1, and MRD2. Bivariate and multivariate statistics were performed. RESULTS The study included 21 patients. Mean ± SD age was 61.5 ± 12.6 years and 71.4% were female. Reduction in proptosis ≥2 mm was achieved in 71.4% of the sample. Stage and grade were not significant predictors of outcome. Treatment with teprotumumab resulted in a 2.5 ± 1.8 mm reduction of proptosis (P < 0.001), 2.2 ± 1.4 reduction in CAS (P < 0.001), and 16.9 ± 19.3 degree improvement in extraocular motility (P < 0.001). There were no significant differences for change in CAS, proptosis, ductions, or MRD2 between different grades and stages of disease. Total strabismus and MRD1 improvement were greater in the active stage of disease (P < 0.05). Three cases of dysthyroid optic neuropathy, refractory to methylprednisolone therapy improved after initiation of teprotumumab. CONCLUSIONS Treatment of TED with teprotumumab in a heterogeneous patient population is associated with improvement in proptosis, extraocular motility, and CAS. Patients beyond those defined in the clinical trials, including those affected by stable stage, milder grade, and vision-threatening TED may benefit from this therapy. There are, however, limits on the overall efficacy of this medication in the management of certain physical characteristics in TED including eyelid position and strabismus.
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Affiliation(s)
- Stefania B Diniz
- Division of Orbital and Ophthalmic Plastic Surgery, Jules Stein Eye Institute, University of California, Los Angeles, California, U.S.A
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21
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Abstract
PURPOSE To evaluate extraocular muscle response to teprotumumab using orbital echography in thyroid eye disease. METHODS This retrospective study included adult thyroid eye disease patients with pre- and post-teprotumumab orbital echography. Data collected included: age, Hertel measurements, clinical activity score, Gorman diplopia scores, ocular motility, and recti muscle diameters measured by echography. The patient's more proptotic eye before treatment initiation was designated as the study orbit. Ocular motility was assessed by totaling the ductions in all 4 cardinal directions. Orbital echography was obtained pre- and post-treatment to assess response of extraocular muscle diameters. RESULTS Six patients with a mean age of 67 years were included. There was a mean improvement in proptosis of 4.3 mm in the study eye with 11/12 orbits showing improvement in globe position (p < 0.05). All patients had a decrease in clinical activity score with a mean reduction of 2.5. Four patients had an improvement in Gorman diplopia score. Ocular motility in the study orbits improved by a total mean of 26.9° (p < 0.05). Mean total extraocular muscle diameter was reduced from 27.4 to 23.4 mm (p < 0.001). On average, superior recti were largest pre- and post-treatment, followed by inferior, medial, then lateral recti. However, inferior recti showed the greatest reduction of 23% (p < 0.02). CONCLUSIONS Orbital echography demonstrated extraocular muscle reduction in all patients after teprotumumab, correlating with improved clinical activity score, ocular motility, and proptosis. Orbital echography is a safe and cost-effective imaging alternative to monitor therapeutic response to teprotumumab.
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22
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Gupta R, Thomas R, Almukhtar F, Kiran A. Visual morbidity in thyroid eye disease in Asian Indian patients. Indian J Ophthalmol 2021; 68:1622-1627. [PMID: 32709792 PMCID: PMC7640861 DOI: 10.4103/ijo.ijo_2284_19] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose: To describe visual morbidity in thyroid orbitopathy in Asian Indians and the factors influencing its onset. Methods: A retrospective chart review was performed for patients with thyroid related orbitopathy seen between May 2014 and April 2019. Three hundred and one patients were included in the study. Relevant history, clinical findings, investigations, and treatment were documented. Results: Nineteen percent of patients had at least 1 visual morbidity feature such as compressive optic neuropathy, exposure keratopathy or diplopia, requiring intravenous glucocorticoid. Male gender, older age, and diabetes were the significant risk factors for high visual morbidity (all P < 0.05). Systemic thyroid status, degree of proptosis, and duration of disease were not significant. Average dose of intravenous glucocorticoid needed was 3.8 g; 24 (7.9%) patients required orbital decompression, and 13 (4.3%) needed eyelid surgery. At the last follow-up, 97% of patients had vision 6/12 or better in both eyes. Conclusion: There is significant visual morbidity found in Indian patients with TED, even with moderate proptosis and systemic control of thyroid status. This is the first set of data on the subject.
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Affiliation(s)
- Roshmi Gupta
- Orbit and Oculoplasty Services, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Rwituja Thomas
- Orbit and Oculoplasty Services, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Fatema Almukhtar
- Orbit and Oculoplasty Services, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Anjali Kiran
- Orbit and Oculoplasty Services, Narayana Nethralaya, Bengaluru, Karnataka, India
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23
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Winn BJ, Kersten RC. Teprotumumab: Interpreting the Clinical Trials in the Context of Thyroid Eye Disease Pathogenesis and Current Therapies. Ophthalmology 2021; 128:1627-1651. [PMID: 33930408 DOI: 10.1016/j.ophtha.2021.04.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 11/16/2022] Open
Abstract
Teprotumumab, a monoclonal antibody targeted against the insulin-like growth factor 1 (IGF-1) receptor, was recently approved by the United States Food and Drug Administration for the treatment of thyroid eye disease (TED). Phase 1 studies of teprotumumab for the treatment of malignancies demonstrated an acceptable safety profile but limited effectiveness. Basic research implicating the IGF-1 receptor on the CD-34+ orbital fibrocyte in the pathogenesis of TED renewed interest in the drug. Two multicenter, randomized, double-masked, clinical trials (phase 2 and 3) evaluated the efficacy of 8 infusions of teprotumumab every 3 weeks versus placebo in 170 patients with recent-onset active TED, as defined by a clinical activity score (CAS) of at least 4. Teprotumumab was superior to placebo for the primary efficacy end points in both studies: overall responder rate as defined by a reduction of 2 or more CAS points and a reduction of 2 mm or more in proptosis (69% vs. 20%; P < 0.001; phase 2 study) and proptosis responder rate as defined by a reduction of 2 mm or more in proptosis (83% vs. 10%; P < 0.001; phase 3 study). In both studies, treatment with teprotumumab compared with placebo achieved a significant mean reduction of proptosis (-3.0 mm vs. -0.3 mm, phase 2 study; -3.32 mm vs. -0.53 mm, phase 3 study) and CAS (-4.0 vs. -2.5, phase 2 study; -3.7 vs. -2.0, phase 3 study). Teprotumumab also resulted in a greater proportion of patients with a final CAS of 0 or 1, higher diplopia responder rate, and a larger improvement in the Graves' Ophthalmopathy Quality of Life overall score. More than half of patients (62%, phase 2 trial; 56%, phase 3 trial) who were primary end point responders maintained this response at 51 weeks after the last dose of therapy. The most common adverse events reported with teprotumumab included muscle spasms (25%), nausea (17%), alopecia (13%), diarrhea (13%), fatigue (10%), hearing impairment (10%), and hyperglycemia (8%). Teprotumumab is contraindicated for those with inflammatory bowel disease and who are pregnant. Although the current dosing regimen has proven effective for TED, dose-ranging studies including variable concentrations, infusion frequencies, and durations of teprotumumab therapy in the setting of TED have not been performed.
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Affiliation(s)
- Bryan J Winn
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California; Ophthalmology Section, Surgical Service, San Francisco Veterans Affairs Medical Center, San Francisco, California.
| | - Robert C Kersten
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
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25
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Yoo HK, Park H, Hwang HS, Kim HJ, Choi YH, Kook KH. Ganglioside GT1b increases hyaluronic acid synthase 2 via PI3K activation with TLR2 dependence in orbital fibroblasts from thyroid eye disease patients. BMB Rep 2021. [PMID: 33407998 PMCID: PMC7907747 DOI: 10.5483/bmbrep.2021.54.2.178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Thyroid eye disease (TED) is a complex autoimmune disease with a spectrum of signs. we previously reported that trisialoganglioside (GT)1b is significantly overexpressed in the orbital tissue of TED patients, and that exogenous GT1b strongly induced HA synthesis in orbital fibroblasts. However, the signaling pathway in GT1b-induced hyaluronic acid synthase (HAS) expression in orbital fibroblasts from TED patients have rarely been investigated. Here, we demonstrated that GT1b induced phosphorylation of Akt/mTOR in a dose-dependent manner in orbital fibroblasts from TED patients. Both co-treatment with a specific inhibitor for PI3K and siRNA knockdown of TLR2 attenuated GT1b-induced Akt phosphorylation. GT1b significantly induced HAS2 expression at both the transcriptional and translational level, which was suppressed by specific inhibitors of PI3K or Akt/mTOR, and by siRNA knockdown of TLR2. In conclusion, GT1b induced HAS2 in orbital fibroblasts from TED patients via activation of the PI3K-related signaling pathway, dependent on TLR2.
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Affiliation(s)
- Hyun Kyu Yoo
- Department of Ophthalmology, Ajou University School of Medicine, Suwon 16499, Korea
| | - Hyunju Park
- Department of Physiology, Inflammation-Cancer Microenvironment Research Center, Ewha Womans University School of Medicine, Seoul 07804, Korea
| | - Hye Suk Hwang
- Department of Ophthalmology, Ajou University School of Medicine, Suwon 16499, Korea
| | - Hee Ja Kim
- Department of Physiology, Inflammation-Cancer Microenvironment Research Center, Ewha Womans University School of Medicine, Seoul 07804, Korea
| | - Youn-Hee Choi
- Department of Physiology, Inflammation-Cancer Microenvironment Research Center, Ewha Womans University School of Medicine, Seoul 07804, Korea
| | - Koung Hoon Kook
- Department of Ophthalmology, Ajou University School of Medicine, Suwon 16499, Korea
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Ugradar S, Wang Y, Mester T, Kahaly GJ, Douglas R. Improvement of asymmetric thyroid eye disease with teprotumumab. Br J Ophthalmol 2021; 106:755-759. [PMID: 33579690 PMCID: PMC9132868 DOI: 10.1136/bjophthalmol-2020-318314] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/29/2020] [Accepted: 01/07/2021] [Indexed: 11/28/2022]
Abstract
Purpose Teprotumumab, a specific blocking antibody to the insulin like growth factor 1 receptor, significantly reduced proptosis in patients with thyroid eye disease (TED) in recent clinical trials. Given its specificity, we expect it to demonstrate greater efficacy on the worse affected orbit, in patients with asymmetric TED. Herein, we investigate the differential impact of teprotumumab on the orbits of such patients. Methods In this pooled analysis of patients who were enrolled in the recent phase 2 (NCT01868997) and phase 3 (NCT03298867) trials, all patients with asymmetric TED (difference in exophthalmometry of ≥3 mm) were screened for eligibility. The primary outcomes of the trials, proptosis, diplopia and Clinical Activity Score (CAS) response, were evaluated in both orbits of patients who had received treatment or placebo, to examine the differential response from baseline to week 24. Results From a pooled group of 84 patients randomised to receive teprotumumab and 87 randomised to placebo, 10 (12%) and 12 (14%), respectively, met the inclusion criteria. The teprotumumab-treated patients demonstrated significant reductions in proptosis, CAS and diplopia in both orbits of each patient and this was not seen with placebo. The reduction in proptosis and CAS was significantly greater in the worse affected orbit, improving symmetry. In the placebo arm, while the mean CAS in the study eye reduced over time, proptosis and diplopia did not change in either orbit. Conclusion The findings in this study suggest the differential impact of teprotumumab on orbits that are clinically more affected by TED, suggesting that teprotumumab reduces asymmetry.
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Affiliation(s)
- Shoaib Ugradar
- Orbital and Ophthalmic Plastic Surgery, Jules Stein Eye Institute, Los Angeles, California, USA
| | - Yao Wang
- Oculoplastics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Tunde Mester
- Oculoplastics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - George J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Raymond Douglas
- Ophthalmology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Nabi T, Rafiq N, Dar I. Risk factors for thyroid-associated orbitopathy due to Graves' disease. JOURNAL OF CLINICAL OPHTHALMOLOGY AND RESEARCH 2021. [DOI: 10.4103/jcor.jcor_67_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Park JW, Kim YC, Lee DC. Effects of Thyroid-stimulating Hormone Receptor Autoantibody on Retinal and Choroidal Vessels in Thyroid Eye Disease. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2020. [DOI: 10.3341/jkos.2020.61.10.1121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Demographic and clinical profile of 1000 patients with thyroid eye disease presenting to a Tertiary Eye Care Institute in India. Int Ophthalmol 2020; 41:231-236. [PMID: 32844239 DOI: 10.1007/s10792-020-01571-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To assess the demographic and clinical profile of thyroid eye disease (TED) presenting to a Tertiary Eye Care Institute in India. METHODS All patients who were diagnosed to have TED between the year 2007 and 2017 at the Ophthalmic Plastic Surgery Service, LV Prasad Eye Institute, were included in this retrospective observational study. The demographic details of parameters such as age, gender and laterality, presenting signs and symptoms, clinical activity at presentation, and systemic thyroid status were assessed. RESULTS A total of 1000 consecutive patients of TED were evaluated in the 10-year period. Average age at presentation was 44.9 years (range 8-89). Of the 1000, 529 (53%) were males, and 358 (36%) had unilateral TED. At presentation, the TED was active (time since onset ≤ 12 months) in 476 (48%) cases and 71 (7%) had dysthyroid optic neuropathy. Of the 913 patients where systemic thyroid status was available at the time of presentation, 342 (37%) were euthyroid at presentation. Of the patients who were active at presentation (n = 476), 349 (70.3%) were 'Silent presenters' (Active as per timeline, but CAS ≤ 3). A prominent eye was the most common presenting symptom in 563 (64%) patients. Presenting signs in order of frequency were proptosis in 582 (58%), lower lid retraction (49%), upper lid retraction (48%), strabismus (6%), ptosis (5.5%), and corneal ulcer (1.3%). CONCLUSIONS TED in India presents to the tertiary eye center with slight male preponderance. One-third (37%) are euthyroid and half (48%) are active at presentation. One-third (35%) are silent presenters, with minimal clinical activity during the active phase of TED.
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Abstract
Thyroid eye disease (TED) is an autoimmune inflammatory disease of the orbit and the most common extrathyroidal manifestation of Graves disease. The release of pro-inflammatory cytokines is associated with inflammation of the ocular surface and lacrimal gland along with periorbital skin erythema and edema. Resultant tissue remodeling, fibrosis, and fat deposition can impart permanent physical changes to the ocular adnexa with effects on function and cosmesis. These changes occur in the active phase of disease, and it is during this time that steroids are often relied on to help alleviate symptoms. Due to the common and predictable side effects of long-term and high-dose steroid use, there has been a continuous effort to find alternative steroid-sparing medical management options for TED. This review highlights the various research studies that support the use of these medications.
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Affiliation(s)
- Victor D Liou
- Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear , Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School , Boston, MA, USA
| | - Michael K Yoon
- Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear , Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School , Boston, MA, USA
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Nabi T, Rafiq N. Factors associated with severity of orbitopathy in patients with Graves' disease. Taiwan J Ophthalmol 2020; 10:197-202. [PMID: 33110751 PMCID: PMC7585466 DOI: 10.4103/tjo.tjo_10_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 02/10/2020] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Graves' orbitopathy (GO) is one of the most frequent orbital disorders and is the most common cause of proptosis in adults. GO is described as chronic inflammation of orbital and periorbital tissues. This study aimed to evaluate the risk factors for severe GO in patients with Graves' disease (GD). MATERIALS AND METHODS This was a prospective cross-sectional study done on 52 newly diagnosed patients of GD with GO documented by thyroid 99mTechnetium-pertechnetate scan at our center between May 2016 and May 2019. All patients underwent a comprehensive ophthalmological examination and laboratory and hormonal analysis. Clinical Activity Score (CAS) and severity were estimated as per the European Group on Graves Orbitopathy. Thirty-four patients with mild GO were compared with 18 patients with moderate-to-severe GO (severe) for baseline risk parameters. RESULTS Majority of the patients had mild orbitopathy (34 [65.4%]) followed by moderate to severe (18 [34.6%]). CAS was active in 13.5% of the study group. There was a statistically significant male preponderance in severe GO. Current smoking increased the risk of severe GO (P = 0.003). Duration of GD symptoms at presentation was statistically significantly longer in severe GO patients than mild GO (P = 0.004). Thyrotropin receptor antibody (TRAb) titer significantly increased in severe GO group (6.2 ± 2.4 IU/L) when compared to mild GO (3.2 ± 1.6 IU/L) (P < 0.001). TRAb positivity was similar between groups. Braley's sign, i.e., the differential intraocular pressure (IOP) of >6 mmHg, was statistically significantly higher in severe GO (P < 0.001). Male gender, current smoking, TRAb >2 upper limit of normal (ULN), and differential IOP >6 mmHg were found to be associated with severe GO. CONCLUSION Approximately 35% of the patients with GO have severe disease, with a higher risk in men. This study identified male gender, current smoking, TRAb >2 ULN, and differential IOP >6 mmHg to be associated with severe GO.
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Affiliation(s)
- Tauseef Nabi
- Department of Endocrinology, MMSSH, Ambala, Haryana, India
| | - Nadeema Rafiq
- Department of Physiology, Government Medical College, Baramulla, Jammu and Kashmir, India
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Abstract
PURPOSE To quantify changes to the bony orbital volume (BOV) in patients with thyroid eye disease (TED) relative to normal controls. METHODS In this case-control study, all patients affected with TED seen over a 2-year period were screened for study entry. Eligible participants were adults with clinical evidence of TED and CT scans of their orbits obtained during the course of their routine care. Exclusion criteria included the history of decompression surgery and/or medical or other ophthalmic conditions that could alter the orbital anatomy. The primary outcome was the measurement of the BOV. Secondary outcome measures included the relationships between BOV and muscle volume, fat volume, Hertel measurements, duration of the disease, and the occurrence of dysthyroid optic neuropathy in patients with TED. Three-dimensional reconstructions of the orbits were created to measure BOV, muscle volume, and fat volume. RESULTS A total of 100 participants were included in the study, contributing 200 orbits. This sample was comprised of 50 patients with TED (37 female, 13 male) and 50 controls (37 female and 13 male). There were no differences between the control and patient groups in age or sex. Of the patients with TED, 14 were diagnosed with dysthyroid optic neuropathy (15 orbits, 1 case was bilateral). The mean (standard deviation [SD]) clinical activity score for males was 4.1 (2.29) and 4.35 (2.63) for females. The mean (SD) BOV for males in the TED group was 28.62 ml (3.47), while that of the control group was 24.59 ml (2.19). This difference was significant (p < 0.01). The mean (SD) BOV for females with TED was 24.33 ml (2.39), while that of the female control group was 20.97 ml (1.84). This was again significant (p < 0.01). There was a significant relationship between the BOV and fat volume (p <0.05). There were no significant relationships between BOV and: muscle volume, duration of disease (p = 0.705), Hertel measurements (p = 0.212), age (p = 0.9), and dysthyroid optic neuropathy (p = 0.12). CONCLUSIONS This study found that the BOV is significantly greater in patients with TED, suggesting that TED is associated with widespread bony remodeling of the orbit.
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Current Understanding of the Progression and Management of Thyroid Associated Orbitopathy: A Systematic Review. Ophthalmol Ther 2019; 9:21-33. [PMID: 31823232 PMCID: PMC7054489 DOI: 10.1007/s40123-019-00226-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Indexed: 12/20/2022] Open
Abstract
Thyroid associated orbitopathy (TAO) is a common diagnosis encountered by ophthalmologists and oculoplastic surgeons. TAO has a varying clinical presentation that can include upper eyelid retraction, restrictive strabismus, proptosis, exposure keratopathy, and optic neuropathy. In this review, we discuss the most recent literature on and the current understanding of the pathophysiology of TAO. We also review available and potential future treatment options for the management of TAO.
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Kim M, Chang JH, Lee NK. Quantitative analysis of extraocular muscle volume and exophthalmos reduction after radiation therapy to treat Graves' ophthalmopathy: A pilot study. Eur J Ophthalmol 2019; 31:340-345. [PMID: 31496266 DOI: 10.1177/1120672119873841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The aim of this study was to provide radiological information on the inherent response of Graves' ophthalmopathy after radiation therapy. METHODS Quantitative analysis of extraocular muscle volume was performed on 96 involved extraocular muscles in a total of 16 patients. A total of 48 computed tomography images were analyzed. Exophthalmos was also measured. The percentage reductions in extraocular muscle volume and exophthalmos length were determined and compared to the pre-radiation therapy values at 6-, 12-, and 24-month follow-up. RESULTS The median follow-up time was 21.5 months (range: 7.2-29.4 months). The mean reduction in relative tumor volume compared to the pre-radiation therapy extraocular muscle volume was 46.1% (range: 33.3%-58.8%). The mean relative extraocular muscle volumes were 71.5% at 6 months, 59.2% at 12 months, and 54.3% at 24 months after radiation therapy. The volume of the involved extraocular muscles decreased rapidly within the first 12 months of follow-up. The mean pre-radiation therapy length of exophthalmos was 21.7 mm (range: 17.6-26.1 mm). The mean percentages of exophthalmos length by comparison with the pre-radiation therapy length were 96.7% at 6 months, 92.3% at 12 months, and 88.5% at 24 months after radiation therapy. Exophthalmos decreased slowly and steadily during the follow-up period. CONCLUSION Quantitative volumetric analysis of the pattern of extraocular muscle volume reduction and exophthalmos length reduction in response to radiation therapy will allow clinicians to better understand the effect of radiotherapy on Graves' ophthalmopathy.
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Affiliation(s)
- Myungsoo Kim
- Department of Radiation Oncology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea.,Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea
| | - Nam Kwon Lee
- Department of Radiation Oncology, Korea University Medical Center, Korea University College of Medicine, Seoul, South Korea
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Ugradar S, Rootman DB. Orbital fat expansion in thyroid eye disease is related to age. Eur J Ophthalmol 2019; 30:1004-1007. [DOI: 10.1177/1120672119852322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Purpose: To objectively measure the differential expansion of orbital fat and muscle volume in patients with thyroid eye disease. Methods: In this retrospective study, eligible participants were adults with clinical evidence of thyroid eye disease and high-resolution computed tomography scans of their orbits. Patients with a history of decompression surgery and/or medical or other conditions that could alter the orbital anatomy were excluded. Three dimensional reconstructions of the orbits allowed the calculation of the fat volume, muscle volume and bony orbital volume using the MIMICS imaging analysis tool. Both orbits from each patient were included without bias through the use of the generalized estimating equation. The primary outcome was the measurement of fat volume. Secondary outcome measures included the correlation of the muscle volume, bony orbital volume and exophthalmometry with age. Results: Fifty patients with thyroid eye disease who were included contributed 100 orbits. The sample included 29 females (age 57, standard deviation = 14.8) and 21 males (age 52, standard deviation = 18.14). Mean (standard deviation) exophthalmometry measurement was 21.58 (4.01). Fat volume and exophthalmometry were negatively correlated with age (p = 0.00001 and p = 0.00001, respectively). Muscle volume (p = 0.985) and bony orbital volume (p = 0.484) did not correlate with age. Conclusion: Older patients with thyroid eye disease have less expansion of fat volume compared with younger patients. There are no associations between age and the bony orbital volume or muscle volume. These results support the growing body of evidence which suggests that the pathophysiology of TED is different in older patient.
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Affiliation(s)
- Shoaib Ugradar
- Stein Eye Institute, Division of Orbital and Ophthalmic Plastic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Daniel B Rootman
- Doheny Eye Institute, Division of Orbital and Ophthalmic Plastic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
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Lai FHP, Iao TWU, Ng DSC, Young AL, Leung J, Au A, Ko STC, Chong KKL. Choroidal thickness in thyroid-associated orbitopathy. Clin Exp Ophthalmol 2019; 47:918-924. [PMID: 31034694 DOI: 10.1111/ceo.13525] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 03/25/2019] [Accepted: 04/22/2019] [Indexed: 12/14/2022]
Abstract
IMPORTANCE To investigate the choroidal thickness (CT) in patients with thyroid-associated orbitopathy (TAO). BACKGROUND To compare CT of TAO patients and healthy subjects. DESIGN Prospective cross-sectional study in a public hospital. PARTICIPANTS One hundred and four eyes of 52 TAO patients and 52 eyes of 26 healthy subjects. METHODS CT was measured with enhanced-depth imaging optical coherence tomography (EDI-OCT) at the subfoveal, macular and peripapillary regions. Multivariate linear regression was used to evaluate the associations of subfoveal CT with systemic and ocular variables among TAO eyes. MAIN OUTCOME MEASURES CT of both groups. RESULTS CT of eyes with TAO was significantly increased at the subfoveal region, 1 and 2 mm from the fovea nasally, temporally and superiorly, and 1 mm inferior to the fovea (all P < .05). No significant difference was found in CT at 2 mm inferior to the fovea (P = .094) and all four quadrants of the peripapillary region (superior, P = .096; nasal, P = .732; inferior, P = .179; temporal, P = .052). Among TAO eyes, thinner subfoveal choroid was associated with worsening exophthalmos (P = .043), poorer visual acuity (P = .017), increasing age (P = .040) and axial length (P < .001). There was no association between CT and clinical activity score (P = .239). CONCLUSIONS AND RELEVANCE TAO patients showed thicker choroid than controls over the macula, but not the peripapillary regions. Thinner subfoveal choroid was associated with worsening exophthalmos and poorer vision. EDI-OCT can monitor choroidal vascular changes associated with TAO and its complications.
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Affiliation(s)
- Frank H P Lai
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong.,Department of Ophthalmology and Visual Sciences, Prince of Wales Hospital, Hong Kong
| | - Tiara W U Iao
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Danny S C Ng
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong.,Department of Ophthalmology, Hong Kong Eye Hospital, Hong Kong
| | - Alvin L Young
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong.,Department of Ophthalmology and Visual Sciences, Prince of Wales Hospital, Hong Kong
| | - Joy Leung
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong
| | - Alvin Au
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong
| | - Simon T C Ko
- Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong
| | - Kelvin K L Chong
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong.,Department of Ophthalmology and Visual Sciences, Prince of Wales Hospital, Hong Kong
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Lee BW, Kumar VB, Biswas P, Ko AC, Alameddine RM, Granet DB, Ayyagari R, Kikkawa DO, Korn BS. Transcriptome Analysis of Orbital Adipose Tissue in Active Thyroid Eye Disease Using Next Generation RNA Sequencing Technology. Open Ophthalmol J 2018; 12:41-52. [PMID: 29760827 PMCID: PMC5906971 DOI: 10.2174/1874364101812010041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 01/09/2018] [Accepted: 03/03/2018] [Indexed: 11/30/2022] Open
Abstract
Objective: This study utilized Next Generation Sequencing (NGS) to identify differentially expressed transcripts in orbital adipose tissue from patients with active Thyroid Eye Disease (TED) versus healthy controls. Method: This prospective, case-control study enrolled three patients with severe, active thyroid eye disease undergoing orbital decompression, and three healthy controls undergoing routine eyelid surgery with removal of orbital fat. RNA Sequencing (RNA-Seq) was performed on freshly obtained orbital adipose tissue from study patients to analyze the transcriptome. Bioinformatics analysis was performed to determine pathways and processes enriched for the differential expression profile. Quantitative Reverse Transcriptase-Polymerase Chain Reaction (qRT-PCR) was performed to validate the differential expression of selected genes identified by RNA-Seq. Results: RNA-Seq identified 328 differentially expressed genes associated with active thyroid eye disease, many of which were responsible for mediating inflammation, cytokine signaling, adipogenesis, IGF-1 signaling, and glycosaminoglycan binding. The IL-5 and chemokine signaling pathways were highly enriched, and very-low-density-lipoprotein receptor activity and statin medications were implicated as having a potential role in TED. Conclusion: This study is the first to use RNA-Seq technology to elucidate differential gene expression associated with active, severe TED. This study suggests a transcriptional basis for the role of statins in modulating differentially expressed genes that mediate the pathogenesis of thyroid eye disease. Furthermore, the identification of genes with altered levels of expression in active, severe TED may inform the molecular pathways central to this clinical phenotype and guide the development of novel therapeutic agents.
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Affiliation(s)
- Bradford W Lee
- Department of Ophthalmology, Division of Ophthalmic Plastic and Reconstructive Surgery, University of California, San Diego, La Jolla, CA.,Department of Ophthalmology, University of California, San Diego, La Jolla, CA.,Division of Oculofacial Plastic and Reconstructive Surgery, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Virender B Kumar
- Department of Ophthalmology, University of California, San Diego, La Jolla, CA
| | - Pooja Biswas
- Department of Ophthalmology, University of California, San Diego, La Jolla, CA
| | - Audrey C Ko
- Department of Ophthalmology, Division of Ophthalmic Plastic and Reconstructive Surgery, University of California, San Diego, La Jolla, CA.,Department of Ophthalmology, University of California, San Diego, La Jolla, CA
| | - Ramzi M Alameddine
- Department of Ophthalmology, Division of Ophthalmic Plastic and Reconstructive Surgery, University of California, San Diego, La Jolla, CA.,Department of Ophthalmology, University of California, San Diego, La Jolla, CA
| | - David B Granet
- Department of Ophthalmology, University of California, San Diego, La Jolla, CA
| | - Radha Ayyagari
- Department of Ophthalmology, University of California, San Diego, La Jolla, CA
| | - Don O Kikkawa
- Department of Ophthalmology, Division of Ophthalmic Plastic and Reconstructive Surgery, University of California, San Diego, La Jolla, CA.,Department of Ophthalmology, University of California, San Diego, La Jolla, CA.,Division of Plastic Surgery, Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Bobby S Korn
- Department of Ophthalmology, Division of Ophthalmic Plastic and Reconstructive Surgery, University of California, San Diego, La Jolla, CA.,Department of Ophthalmology, University of California, San Diego, La Jolla, CA.,Division of Plastic Surgery, Department of Surgery, University of California, San Diego, La Jolla, CA
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Xu L, Li L, Xie C, Guan M, Xue Y. Thickness of Extraocular Muscle and Orbital Fat in MRI Predicts Response to Glucocorticoid Therapy in Graves' Ophthalmopathy. Int J Endocrinol 2017; 2017:3196059. [PMID: 28845157 PMCID: PMC5563423 DOI: 10.1155/2017/3196059] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/27/2017] [Accepted: 07/17/2017] [Indexed: 12/16/2022] Open
Abstract
33 patients with active, moderate-severe Graves' ophthalmopathy (GO) received 4.5 g methylprednisolone for 12 weeks and were divided by efficacy into two groups (responsive and unresponsive). All patients and 10 controls underwent orbital MRI examination at baseline. No significant difference was seen in baseline clinical characteristics between the two GO groups. The values of exophthalmos were higher in both GO groups than in the control and were higher in the responsive group versus the unresponsive group. Compared to the unresponsive group, the responsive group had a thicker inferior rectus as well as thinner orbital fat. The inferior rectus/fat ratio was significantly higher in the responsive group versus the unresponsive group. Multivariate logistic regression analysis showed that the exophthalmos value and inferior rectus/fat ratio were significantly associated with the response to glucocorticoid (GC). ROC analysis revealed that the cut-off points of the inferior rectus/fat ratio combined with the exophthalmos value to indicate efficacy were 1.42 and 20.78. For moderate-severe GO patients with CAS > 3, the combined inferior rectus/fat ratio and exophthalmos value in MRI may be a valuable indicator to predict the response to GC therapy.
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Affiliation(s)
- Lingling Xu
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Linna Li
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Cuihua Xie
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Meiping Guan
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Yaoming Xue
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
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Li Q, Ye H, Ding Y, Chen G, Liu Z, Xu J, Chen R, Yang H. Clinical characteristics of moderate-to-severe thyroid associated ophthalmopathy in 354 Chinese cases. PLoS One 2017; 12:e0176064. [PMID: 28472149 PMCID: PMC5417486 DOI: 10.1371/journal.pone.0176064] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 04/05/2017] [Indexed: 12/13/2022] Open
Abstract
Thyroid associated ophthalmopathy (TAO) is an autoimmune inflammatory disorder which disfigures appearance, threatens vision, and results in a pronounced loss of quality of life. The diversity and ethnic difference of the disease manifestations have made it difficult to tailor therapies for each patient. Few studies have analyzed its characteristics in Chinese populations. We therefore enrolled 354 patients with moderate-to-severe TAO from February 2015 to July 2016. A single ophthalmologist consistently performed detailed ophthalmic examinations. Orbital computed tomography or magnetic resonance imaging scans were performed to verify enlarged extraocular muscles. Multiple linear regression was used to analyze the association between sex, age, smoking, family history of thyroid diseases, degree of proptosis and disease severity. The mean age of males (46.56±11.08 years) was significantly higher than that of females (41.39±years), with a female-to-male ratio of 1.09. The females and males between 31~40 and 41~50 years, respectively, had the highest incidence of TAO. 81.48% of the patients suffered hyperthyroidism. TAO was diagnosed either after (47.17%) or simultaneously with thyroid dysfunction (27.68%). Proptosis (91.24%), eyelid retraction (83.33%), together with eyelid swelling (79.38%) and extraocular muscle enlargement (75.42%), were the most common clinical sign. 19.77% of patients manifested lower eyelid retraction. The mean values of exophthalmos and asymmetry on proptosis were 19.94±3.45mm and 2.18±2.06mm, respectively in males, 18.58±3.31mm and 1.61±1.53mm, respectively in females. The severity of disease was significantly associated with male, older age, smoking, family history of thyroid diseases and degree of proptosis. We found several differences in Chinese compared with White. The female-to-male ratio and mean value of exophthalmos were significantly lower than the data of White. Inferior and superior rectus became the most common extraocular muscles. Lower eyelid retraction should be included in diagnostic criteria in Asian patients. Understanding these differences, may allow better identification and treatment for TAO in China.
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Affiliation(s)
- Qian Li
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Huijing Ye
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Yungang Ding
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Qingdao Ludong Eye Hospital, Qingdao, Shandong, P.R. China
| | - Guo Chen
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Zhichang Liu
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Jianan Xu
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Rongxin Chen
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Huasheng Yang
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
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99Tc m-octreotide scintigraphy and serum eye muscle antibodies in evaluation of active thyroid-associated ophthalmopathy. Eye (Lond) 2017; 31:668-676. [PMID: 28387769 DOI: 10.1038/eye.2017.42] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 01/18/2017] [Indexed: 01/21/2023] Open
Abstract
PurposeAs an autoimmune inflammatory disorder, active thyroid-associated ophthalmopathy (TAO) is managed optimally by immunosuppression. In this study, we aimed to evaluate octreotide scintigraphy and the level of serum extraocular muscle antibodies in TAO activity.Patients and methodsThis prospective study comprised 304 patients with active TAO (the clinical activity score; CAS≥3), 73 with inactive TAO (CAS<3), 128 with Graves' disease (GD) without ophthalmopathy, and 100 healthy subjects. Moderate-to-severe active TAO patients (CAS≥5) received intravenous injection of methylprednisolone; mild active patients (3≤CAS≤4) received periocular injection of triamcinolone acetonide. 99Tcm-octreotide scintigraphy and serum levels of calsequestrin, uveal auto-antigen with coiled-coil domains and ankyrin repeats (UACA) and G2s antibodies were detected before and after treatment.Results99Tcm-octreotide scintigraphy was positive in active TAO patients (97%) with elevated uptake ratio (UR) (P<0.05), and showed a significant correlation with CAS (r=0.816, P<0.01). After treatment both UR and CAS decreased significantly (P<0.05). The receiving operator characteristic curve (ROC) showed that the best UR threshold for discriminating active and inactive TAO was 1.34 (sensitivity, 100%; specificity, 89.4%). The level of serum calsequestrin antibody was higher in active TAO (P<0.05), showed a significant correlation with CAS (r=0.738, P<0.05), and also decreased after treatment (P<0.05). The best serum calsequestrin antibody threshold of the ROC curve was 138 ng/l (sensitivity, 88.4%; specificity, 89.2%). The UACA antibody was elevated in both TAO and GD patients (P<0.05), with no significant difference (P>0.05). As to G2s, no significant difference was found between all groups (P>0.05). Moreover, six GD patients (4.69%) with elevated calsequestrin developed active TAO 12 weeks later.Conclusion99Tcm-octreotide scintigraphy played a critical role in the evaluation of the clinical activity and therapeutic efficacy of TAO. Autoimmunity against calsequestrin in the pathogenesis of the eye muscle components may provide further objective evidence of myopathy in active TAO. Furthermore, calsequestrin antibody may predict myopathy in active TAO.
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Braun TL, Bhadkamkar MA, Jubbal KT, Weber AC, Marx DP. Orbital Decompression for Thyroid Eye Disease. Semin Plast Surg 2017; 31:40-45. [PMID: 28255288 DOI: 10.1055/s-0037-1598192] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Although most cases of thyroid eye disease (TED) can be managed medically, some refractory or severe cases are treated surgically with orbital decompression. Due to a lack of randomized controlled trials comparing surgical techniques for orbital decompression, none have been deemed superior. Thus, each case of TED is managed based on patient characteristics and surgeon experience. Surgical considerations include the extent of bony wall removal, the surgical approach, the choice of incision, and the use of fat decompression. Outcomes vary based on surgical indications and techniques; hence, vision can improve or worsen after the surgery.
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Affiliation(s)
- Tara L Braun
- Division of Ophthalmology, Baylor College of Medicine, Houston, Texas
| | | | - Kevin T Jubbal
- Division of Ophthalmology, Baylor College of Medicine, Houston, Texas
| | - Adam C Weber
- Division of Ophthalmology, Baylor College of Medicine, Houston, Texas
| | - Douglas P Marx
- Division of Ophthalmology, Baylor College of Medicine, Houston, Texas
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Tirakunwichcha S, Lerdchanapornchai V, Reinprayoon U, Saonanon P, Snabboon T. Prevalence of dry eye disease in autoimmune thyroid disease and the association of dry eye with clinical signs of thyroid associated ophthalmopathy: observational, noncomparative, cross-sectional study. ASIAN BIOMED 2017. [DOI: 10.5372/1905-7415.1002.474] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Autoimmune thyroid disease (AITD) is a risk factor for dry eye disease. The prevalence of dry eye in AITD is not definitely known.
Objectives
To determine the prevalence of dry eye in AITD and its association with clinical signs of thyroid associated ophthalmopathy (TAO).
Methods
We enrolled a cross-section of 92 patients with AITD between May 1 and August 31, 2013. All were examined to establish thyroid eye signs, and severity was classified as none, mild, and moderate-severe according to the European Group on Graves’ orbitopathy. Dry eye disease was verified using an Ocular Surface Disease Index (OSDI) questionnaire, tear break-up time (TBUT), Schirmer test, and ocular surface fluorescein staining. Features of meibomian glands were inspected. This observational study was registered at www.clinicaltrials.in.th, No. TCTR20130713001.
Results
The prevalence of dry eye in AITD was 27% by OSDI questionnaire (95% confidence interval (CI), 16%-34%); 96% (95% CI, 93%-99%) by TBUT; 69% (95% CI, 62%-75%) by ocular surface staining; and 18% (95% CI, 12%-23%) using a Schirmer test, which associated dry eye and proptosis with an odds ratio (OR) of 9.3 (95% CI, 1.2-70.6, P = 0.031), and lagophthalmos by ocular surface staining with an OR of 5.8 (95% CI, 1.2-27.7, P = 0.026). Dry eye in patients with or without clinical signs of TAO was not significantly different.
Conclusions
The prevalence of dry eye varied by criteria, but was not different in AITD patients with or without TAO. Proptosis and lagophthalmos were associated more strongly with dry eye disease in AITD with TAO, than without.
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Affiliation(s)
- Suppapong Tirakunwichcha
- Department of Ophthalmology , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
| | - Vipavee Lerdchanapornchai
- Department of Ophthalmology , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
| | - Usanee Reinprayoon
- Department of Ophthalmology , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
| | - Preamjit Saonanon
- Department of Ophthalmology , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
| | - Thiti Snabboon
- Department of Medicine , Faculty of Medicine , Chulalongkorn University and King Chulalongkorn Memorial Hospital , Thai Red Cross Society , Bangkok 10330 , Thailand
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Şimşek T, Yıldırım N, Efe B, Kebapçı N. Rituximab Treatment in a Patient with Active Graves' Orbitopathy and Psoriasis. Turk J Ophthalmol 2017; 47:42-46. [PMID: 28182165 PMCID: PMC5282540 DOI: 10.4274/tjo.26780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 03/30/2015] [Indexed: 12/01/2022] Open
Abstract
Management of Graves’ orbitopathy remains an important therapeutic challenge. Current therapeutic modalities are unsatisfactory in about one third of patients. Rituximab is a monoclonal antibody against CD20 antigen that is expressed in mature and immature B cells. Early experience with rituximab suggests that it is a promising alternative therapy for Graves’ orbitopathy. Here we report a case of a 49-year-old woman with Graves’ orbitopathy and psoriasis. The patient received 2 infusions of 1 g rituximab 2 weeks apart. Although there was improvement in inflammatory signs of the disease, proptosis did not change after the treatment.
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Affiliation(s)
- Tülay Şimşek
- Eskişehir Osmangazi University Faculty of Medicine, Department of Ophthalmology, Eskişehir, Turkey
| | - Nilgün Yıldırım
- Eskişehir Osmangazi University Faculty of Medicine, Department of Ophthalmology, Eskişehir, Turkey
| | - Belgin Efe
- Eskişehir Osmangazi University Faculty of Medicine, Department of Internal Medicine, Division of Endocrinology, Eskişehir, Turkey
| | - Nur Kebapçı
- Eskişehir Osmangazi University Faculty of Medicine, Department of Internal Medicine, Division of Endocrinology, Eskişehir, Turkey
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Abstract
Thyroid eye disease (TED) can affect the eye in myriad ways: proptosis, strabismus, eyelid retraction, optic neuropathy, soft tissue changes around the eye and an unstable ocular surface. TED consists of two phases: active, and inactive. The active phase of TED is limited to a period of 12–18 months and is mainly managed medically with immunosuppression. The residual structural changes due to the resultant fibrosis are usually addressed with surgery, the mainstay of which is orbital decompression. These surgeries are performed during the inactive phase. The surgical rehabilitation of TED has evolved over the years: not only the surgical techniques, but also the concepts, and the surgical tools available. The indications for decompression surgery have also expanded in the recent past. This article discusses the technological and conceptual advances of minimally invasive surgery for TED that decrease complications and speed up recovery. Current surgical techniques offer predictable, consistent results with better esthetics.
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Affiliation(s)
- Milind Neilkant Naik
- Department of Ophthalmic Plastic Surgery, L. V. Prasad Eye Institute, Hyderabad, Telangana, India
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Novaes P, Diniz Grisolia AB, Smith TJ. Update on thyroid-associated Ophthalmopathy with a special emphasis on the ocular surface. Clin Diabetes Endocrinol 2016; 2:19. [PMID: 28702253 PMCID: PMC5471935 DOI: 10.1186/s40842-016-0037-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 11/10/2016] [Indexed: 01/08/2023] Open
Abstract
Thyroid-associated ophthalmopathy (TAO) is a condition associated with a wide spectrum of ocular changes, usually in the context of the autoimmune syndrome, Graves’ disease. In this topical review, we attempted to provide a roadmap of the recent advances in current understanding the pathogenesis of TAO, important aspects of its clinical presentation, its impact on the ocular surface, describe the tissue abnormalities frequently encountered, and describe how TAO is managed today. We also briefly review how increased understanding of the disease should culminate in improved therapies for patients with this vexing condition.
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Affiliation(s)
- Priscila Novaes
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI 48105 USA
| | - Ana Beatriz Diniz Grisolia
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI 48105 USA
| | - Terry J Smith
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI 48105 USA.,Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48105 USA.,Department of Ophthalmology and Visual Sciences, Brehm Tower, Room 7112, 1000 Wall Street, Ann Arbor, MI 48105 USA
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Ogun OA, Adeleye JO. Severe Ophthalmological Complications of Thyroid Disease are Rare in Ibadan, Southwestern Nigeria: Results of a Pilot Study. OPHTHALMOLOGY AND EYE DISEASES 2016; 8:5-9. [PMID: 27042149 PMCID: PMC4811264 DOI: 10.4137/oed.s32169] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 01/20/2016] [Accepted: 01/25/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Ocular manifestations of thyroid dysfunction constitute a wide clinical spectrum ranging from minor ocular discomfort, lid retraction, lid lag and ocular injection, to sight threatening eyeball protusion and optic nerve compression. Thyroid-related eye disorders are most commonly associated with Graves’ disease, and this most frequently occurs in the setting of hyperthyroidism. However, in 10% of cases, typical eye signs have also been reported in euthyroid and hypothyroid states. The severity of thyroid eye disease has been linked to cigarette smoking. There is very little data specifically reporting the ocular manifestations of thyroid disease among black African patients and there is no known report from Nigeria. This pilot study therefore focused on documenting the ocular signs accompanying thyroid dysfunction in a black African population. AIM To evaluate the pattern of ocular complications, among patients treated for thyroid disorders, in a major Nigerian teaching hospital. RESULTS A total of 75 patients with thyroid dysfunction, were evaluated, comprising 63 females and 12 males. There was a very low prevalence of smoking among patients (<5%). Graves’ disease was the commonest thyroid disorder, representing 70% of cases. Seventy-eight percent of patients were hyperthyroid, 11.8% were euthyroid and only 9.8% of patients were hypothyroid. Commonest systemic symptoms were neck swelling (68.6%), weight loss (63.8%), tremors (60.9%) and palpitations (59.4%). Two-thirds of patients reported ocular symptoms consisting mainly of painless eye swelling (66.7%) and ocular irritation (58%). Conjunctival injection, lid lag and lid retraction were the commonest ocular signs. Chemosis, severe proptosis and ocular motility disorder were very rare. Optic neuropathy was found in 4 patients but was related to pre-existing glaucoma. Majority of patients required only ocular emollients and tear supplements. CONCLUSION Severe ocular complications of thyroid disorders were uncommon in this cross-section of Nigerian patients. This may be linked to the very low prevalence of cigarette smoking among Nigerians or genetic and environmental factors linked to their African heritage.
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Affiliation(s)
- Olufunmilola A Ogun
- Department of Ophthalmology, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | - Jokotade O Adeleye
- Department of Medicine, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
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Kozdon K, Fitchett C, Rose GE, Ezra DG, Bailly M. Mesenchymal Stem Cell-Like Properties of Orbital Fibroblasts in Graves' Orbitopathy. Invest Ophthalmol Vis Sci 2015; 56:5743-50. [PMID: 26325413 DOI: 10.1167/iovs.15-16580] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Graves' orbitopathy (GO) is a sight-threatening autoimmune disorder causing extraocular muscle fibrosis, upper lid retraction and eye bulging due to orbital fat expansion. These clinical features are mediated by aspects of orbital fibroblasts differentiation, including adipogenesis and fibrosis. Our previous work suggested that this dual phenotype might be a manifestation of mixed cell populations, partially linked to the expression of mesenchymal stem cell (MSC) marker CD90. Thus, we set out to determine whether GO orbital fibroblasts displayed MSC properties. METHODS Control and GO orbital fibroblasts previously characterized for CD90 and CD45 expression were analyzed by flow cytometry for classical MSC positive (CD73, CD105) and negative (CD14, CD19, HLA-DR, and CD34) markers. Graves' orbitopathy fibroblasts were tested further for their ability to undergo lineage specific differentiation following standard protocols. RESULTS Control and GO fibroblasts strongly expressed CD73 and CD105, with a higher percentage of positive cells and stronger expression levels in GO. Neither cell type expresses CD14, CD19, and HLA-DR. Protein CD34 was expressed at low levels by 45% to 70% of the cells, with its expression significantly lower in GO cells. Graves' orbitopathy fibroblasts displayed features of osteogenesis (calcium deposits, and osteocalcin [BGLAP] and osteonectin [SPARC] expression), chondrogenesis (glycosaminoglycan production; SOX9 and aggrecan [ACAN] expression), myogenesis (α-smooth muscle actin expression), and neurogenesis (β-III tubulin expression) upon differentiation. CONCLUSIONS Our findings suggest that orbital fibroblasts contain a population of cells that fulfil the criteria defining MSC. This subpopulation may be increased in GO, possibly underlying the complex differentiation phenotype of the disease.
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Affiliation(s)
- Katarzyna Kozdon
- Department of Cell Biology UCL Institute of Ophthalmology, London, United Kingdom
| | - Caroline Fitchett
- Department of Cell Biology UCL Institute of Ophthalmology, London, United Kingdom
| | - Geoffrey E Rose
- Orbital clinic, Moorfields Eye Hospital and the National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Daniel G Ezra
- Department of Cell Biology UCL Institute of Ophthalmology, London, United Kingdom 2Orbital clinic, Moorfields Eye Hospital and the National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and
| | - Maryse Bailly
- Department of Cell Biology UCL Institute of Ophthalmology, London, United Kingdom
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Stein JD, Childers D, Gupta S, Talwar N, Nan B, Lee BJ, Smith TJ, Douglas R. Risk factors for developing thyroid-associated ophthalmopathy among individuals with Graves disease. JAMA Ophthalmol 2015; 133:290-6. [PMID: 25502604 DOI: 10.1001/jamaophthalmol.2014.5103] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Thyroid-associated ophthalmopathy (TAO) is a common and debilitating manifestation of Graves disease (GD). Presently little is known about factors that may increase the risk of developing TAO among patients with GD. OBJECTIVE To identify risk factors associated with the development of TAO among individuals with newly diagnosed GD. DESIGN, SETTING, AND PARTICIPANTS In this longitudinal cohort study, all beneficiaries 18 years of age or older with newly diagnosed GD who were continuously enrolled in a large nationwide US managed care network and who visited an eye care professional 1 or more times from 2001 to 2009 were identified. International Classification of Diseases, Ninth Revision, Clinical Modification billing codes were used to identify those who developed manifestations of TAO. Multivariable Cox regression was used to determine the hazard of developing TAO among persons with newly diagnosed GD, with adjustment for sociodemographic factors, systemic medical conditions, thyrotropin levels, and medical and surgical interventions for management of hyperthyroidism. MAIN OUTCOMES AND MEASURES Manifestations of TAO measured by hazard ratios (HRs) with 95% CIs. RESULTS Of 8404 patients with GD who met the inclusion criteria, 740 (8.8%) developed TAO (mean follow-up, 374 days since initial GD diagnosis). After adjustment for potential confounders, surgical thyroidectomy, alone or in combination with medical therapy, was associated with a 74% decreased hazard for TAO (adjusted HR, 0.26 [95% CI, 0.12-0.51]) compared with radioactive iodine therapy alone. Statin use (for ≥60 days in the past year vs <60 days or nonuse) was associated with a 40% decreased hazard (adjusted HR, 0.60 [CI, 0.37-0.93]). No significant association was found for the use of nonstatin cholesterol-lowering medications or cyclooxygenase 2 inhibitors and the development of TAO. CONCLUSIONS AND RELEVANCE If prospective studies can confirm our finding that a thyroidectomy and statin use are associated with substantially reduced hazards for TAO among patients with GD, preventive measures for this burdensome manifestation of GD may become a reality.
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Affiliation(s)
- Joshua D Stein
- Department of Ophthalmology and Visual Sciences, School of Medicine, University of Michigan, Ann Arbor
| | - David Childers
- Department of Ophthalmology and Visual Sciences, School of Medicine, University of Michigan, Ann Arbor
| | - Shivani Gupta
- Department of Ophthalmology and Visual Sciences, School of Medicine, University of Michigan, Ann Arbor
| | - Nidhi Talwar
- Department of Ophthalmology and Visual Sciences, School of Medicine, University of Michigan, Ann Arbor
| | - Bin Nan
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
| | - Brian J Lee
- Department of Ophthalmology and Visual Sciences, School of Medicine, University of Michigan, Ann Arbor
| | - Terry J Smith
- Department of Ophthalmology and Visual Sciences, School of Medicine, University of Michigan, Ann Arbor3Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor
| | - Raymond Douglas
- Department of Ophthalmology and Visual Sciences, School of Medicine, University of Michigan, Ann Arbor4Veterans Administration Medical Center, Ann Arbor, Michigan
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McAlinden C. An overview of thyroid eye disease. EYE AND VISION 2014; 1:9. [PMID: 26605355 PMCID: PMC4655452 DOI: 10.1186/s40662-014-0009-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 10/28/2014] [Indexed: 12/26/2022]
Abstract
Thyroid eye disease (also known as Graves’ ophthalmopathy) is a complex orbital inflammatory disease, which can be sight threatening, debilitating and disfiguring. This overview discusses the epidemiology, risk factors, pathogenesis, presentation, ophthalmic clinical features, investigations and treatment of thyroid eye disease.
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