Orbital and ocular perfusion in thyroid eye disease

Contrast-enhanced orbital MRI for activity assessment and treatment response prediction in thyroid eye disease

OBJECTIVE

To investigate the performance of contrast-enhanced orbital MRI (T1-weighted contrast-enhanced [T1CE] and dynamic contrast-enhanced MRI [DCE-MRI]) for activity assessment and prediction of treatment response to intravenous glucocorticoid (IVGC) treatment in thyroid eye disease (TED).

METHODS

A retrospective study of 59 active moderate-to-severe TED patients (36 responsive and 23 unresponsive) treated with IVGC, matched with 31 inactive TED patients were included. T1CE and DCE-MRI were collected from each subject. Univariate and multivariate logistic regression analyses, as well as receiver operating characteristic (ROC) curves (evaluated by area under the curve, AUC) were used to evaluate the diagnostic and predictive models.

RESULTS

Active patients showed a higher signal intensity ratio of lateral rectus (LR-SIR) on T1CE and a higher wash-in rate of inferior rectus (IR-WIR) on DCE-MRI compared to inactive patients (p < 0.05). The AUC for T1CE and DCE-MRI based models were 0.866, and 0.844, respectively. The combined model (LR-SIR and IR-WIR) significantly enhanced model performance (AUC = 0.914, 95 % CI: 0.858-0.970). Responsive patients demonstrated a longer time to peak of lateral rectus (LR-TTP) than unresponsive patients (p < 0.05). The cutoff value of prediction probability was 0.678, and the AUC based on this model was 0.739 (95 % CI: 0.608-0.807).

CONCLUSIONS

T1CE and DCE-MRI could effectively assist in TED activity assessment, and DCE-MRI could help predict IVGC treatment response. Specifically, LR-SIR and IR-WIR were indicators of TED activity, and IR-TTP was predictive of IVGC treatment response. Combining both contrast-enhanced sequences could further enhance the efficiency of TED activity assessment.

Alterations in blood flow at the optic nerve head in patients with thyroid eye disease using optic coherence tomography angiography

Introduction

This study aimed to evaluate changes in blood flow at the optic nerve head (ONH) in patients with thyroid eye disease (TED) using optical coherence tomography angiography (OCTA).

Methods

A total of 59 eyes from 59 patients with TED and 39 eyes from 39 healthy controls (HCs) were included. Patients with TED were categorized into the active and inactive groups based on clinical activity scores. All participants underwent ophthalmological and endocrinological tests. Peripapillary vessel density (VD) and retinal nerve fiber layer thickness (RNFLT) were measured using OCTA. All eyes underwent a 4.5*4.5-mm scan pattern centered on the ONH. The peripapillary region was divided into eight sectors: superior nasal (SN), nasal upper (NU), nasal lower (NL), inferior nasal (IN), inferior temporal (IT), temporal lower (TL), temporal upper (TU), and superior temporal (ST). A correlation analysis was used to explore the association between blood flow changes and relevant factors.

Results

Compared to the eyes of HCs, the eyes of patients in the inactive TED group demonstrated lower radial peripapillary capillary VD, with significant differences observed in the SN and ST sectors of the peripapillary region (p < 0.05). No differences were observed in the peripapillary RNFLT between the groups. Additionally, there was no significant correlation between the whole peripapillary VD and RNFLT or visual functional parameters. Moreover, visual acuity impairment was positively correlated with IN-VD, NU-VD, ST-VD, and NU-RNFLT in the peripapillary region. Intraocular pressure was positively correlated with IN-RNFLT.

Conclusion

OCTA can detect microvascular ONH changes in patients with TED.

Optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) for assessing thyroid-associated ophthalmopathy activity

PURPOSE

To explore the role of retinal and choroidal parameters obtained via optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) in predicting thyroid-associated ophthalmopathy (TAO) activity, providing a scientific basis for improved clinical diagnosis and treatment.

METHOD

This study included 90 active TAO patients (178 eyes), 69 inactive TAO patients (138 eyes), and 66 healthy individuals (132 eyes). It compared choroidal and retinal parameters and magnetic resonance imaging structural differences, analyzed correlations between these parameters, and developed a predictive model for TAO activity.

RESULTS

Compared to control and inactive groups, active group had thicker subfoveal choroidal thickness (SFCT) and reduced luminal area, stromal area, and total choroidal area. Active group showed reduced vessel density in the foveal and nasal regions versus inactive group, and in the foveal, superior, and nasal regions versus controls. Foveal avascular zone (FAZ) area was larger in active group than in both control and inactive groups. Active group also had larger inner diameters and signal intensity ratio (SIR) of the extraocular muscles than inactive group. SFCT correlated with proptosis, and FAZ correlated with proptosis, maximum extraocular muscle diameter, and SIR. The multivariate model achieved area under the curve values of 0.836 in overall TAO population and 0.855 in hyperlipidemia subgroup, outperforming the univariate model.

CONCLUSION

Retinal and choroidal parameters, obtained via OCT/OCTA, are keys to developing TAO activity predictive models, with enhanced accuracy in TAO patients with hyperlipidemia.

Effect of Cannabis Usage on Thyroid Eye Disease

PURPOSE

The purpose of this study is to investigate the association between cannabis usage and thyroid eye disease (TED) in patients with autoimmune hyperthyroidism. While the association between cigarette smoking and TED is well established, the effect of cannabis on TED is unclear.

METHODS

This cohort study examined data from TriNetX, an electronic health record platform, for patients with autoimmune hyperthyroidism between December 1, 2003, and December 1, 2023. Primary outcomes were TED presentation (exophthalmos, eyelid retraction, eyelid edema, orbital edema, strabismus, and optic neuropathy) and treatment (teprotumumab, methylprednisolone, tarsorrhaphy, and orbital decompression) in cannabis users, nicotine users, and control patients. Propensity matching was performed to control for characteristics such as age, sex, race, prior thyroidectomy, and/or radio ablation. Relative risk between cohorts was calculated for each outcome in 6-month, 1-year, and 2-year intervals following diagnosis of autoimmune hyperthyroidism.

RESULTS

Of 36,186 patients with autoimmune hyperthyroidism, 783 were cannabis users, 17,310 were nicotine users, and 18,093 were control patients without cannabis or nicotine usage. Compared with control patients, cannabis users were more likely to be younger, male, and Black/African American and have anxiety or depression. After propensity matching, cannabis users were 1.9 times more likely to develop exophthalmos ( p = 0.03) and 1.6 times more likely to develop any TED presentation ( p = 0.049) in the 1-year interval although these differences did not remain statistically significant in the 2-year interval.

CONCLUSIONS

Cannabis users had a significantly increased risk for TED outcomes in the 1-year interval. Further research is needed to inform TED management.

Retinal and Choroidal Alterations in Thyroid-Associated Ophthalmopathy: A Systematic Review

Thyroid-associated ophthalmopathy (TAO), or Graves' orbitopathy (GO), is a complex autoimmune disorder affecting orbital tissues, often leading to vision-threatening complications such as dysthyroid optic neuropathy (DON). In this systematic review, conducted following PRISMA guidelines, 22 studies were evaluated to investigate the role of optical coherence tomography (OCT) in assessing retinal and choroidal changes in TAO. Parameters such as the retinal nerve fiber layer (RNFL), ganglion cell complex (GCC), ganglion cell layer (GCL), and choroidal thickness were analyzed. RNFL changes varied by disease severity, with significant thinning in DON due to nerve fiber loss and thickening in early DON due to optic disk edema. Subfoveal choroidal thickness (SFCT) was consistently higher in active TAO, correlating positively with the clinical activity score (CAS) and proptosis, suggesting its role as a marker of disease activity. Subgroup analysis revealed that spectral-domain OCT (SD-OCT) was the most sensitive for detecting retinal changes. The findings highlight the effectiveness of OCT in detecting minor retinal and choroidal alterations in TAO. However, the variability of study designs, as well as the lack of longitudinal data, limits the ability to draw broad conclusions. Further standardized, long-term investigations are required to properly understand OCT's diagnostic and prognostic value in TAO.

Comprehensive Visualization of Choroidal Alterations in Thyroid Eye Disease With Ultra-Widefield OCT Angiography

Purpose

To evaluate choroidal and optic disc alterations in eyes with thyroid eye disease (TED) compared with healthy eyes by using TowardPi widefield optical coherence tomography angiography (OCTA).

Methods

This was a retrospective cross-sectional cohort study. A total of 112 participants (60 TED patients and 52 healthy controls) underwent TowardPi widefield OCTA, which provided detailed demographic and clinical data. Three-dimensional choroidal data, including thickness, vascular metrics, and optic disc measurements, were obtained from the built-in software.

Results

The study included 24 eyes with dysthyroid optic neuropathy (DON), 24 eyes with active non-DON TED, 71 eyes with inactive TED, and 104 healthy eyes. Choroidal thickness significantly decreased in the optic disc region during the DON phase (148.71 ± 78.98 µm) compared to normal eyes (182.35 ± 51.98 µm) and inactive TED eyes (191.34 ± 58.86 µm) (P = 0.030). In DON, choroidal stromal volume was reduced (34,183.81 ± 10,649.01 × 106 µm3) compared to normal (46,339.53 ± 16,711.99 × 106 µm3) (P = 0.002), whereas the choroidal vascular index increased (42.67% ± 3.41%) compared to normal (38.53% ± 6.35%) (P = 0.002). Optic disc area increased in DON (1.99 ± 1.24 mm2) compared to inactive TED (1.39 ± 0.38 mm2) (P < 0.001), along with reduced retinal nerve fiber layer blood-flow density in DON (45.09% ± 3.07%,) compared to normal (47.84% ± 1.41%) (P < 0.001).

Conclusions

This study highlights the critical role of choroidal and optic disc alterations in TED pathophysiology and underscore the utility of widefield OCTA in identifying these changes, particularly in DON-risk patients.

Association Between Breast Arterial Calcification on Mammography and Impaired Ocular Perfusion: A Novel Study Using Color Doppler Ultrasonography

OBJECTIVES

To investigate the relationship between the mammography-detected breast arterial calcification (BAC) and orbital color Doppler ultrasonography (CDUS) results.

METHODS

Our single-center study, included female patients who applied to our hospital between January and May 2022 and underwent mammography and orbital CDUS examinations. Two radiologists evaluated the mammograms, grouped the patients as BAC (+) and BAC (-), and performed orbital CDUS. Continuous variables obtained from CDUS were compared according to the presence of BAC. Also, receiver operating characteristics (ROC) analysis was used to determine the orbital CDUS threshold values for the presence of BAC.

RESULTS

A total of 119 women were included with a median age of 62 years, 57 (47.90%) had BAC. Orbital CDUS examination was performed on both eyes of 119 patients (238 eyes in total). Peak systolic velocity (PSV) and end-diastolic velocity (EDV) values of the ophthalmic artery (OA) (P < .001) and EDV of the central retinal artery (CRA) (P < .001) were significantly lower in patients with BAC. Pulsatile index (PI) and resistive index (RI) values of OA (P < .001) and CRA (P < .001) were higher in patients with BAC. In ROC analysis, the cut-off values for the presence of BAC were calculated as OA PI ≥1.415 and OA RI ≥0.755 (P < .001); CRA PI ≥1.135 and CRA RI ≥0.655 (P < .001).

CONCLUSIONS

Orbital perfusion disorders may be observed in patients with vascular calcification detected on routine mammography. Therefore, a more detailed evaluation of patients with BAC detected on mammography with orbital CDUS may enable early detection and treatment of ocular vascular problems.

Assessment of choroidal perfusion indices in thyroid eye disease by using optical coherence tomography

PURPOSE

To study choroidal vascularity changes in active and inactive TED orbits by using high-definition optical coherence tomography (HD-OCT) and correlate the changes with the duration and severity of TED and Barrets' index.

METHODS

A cross-sectional study wherein 37 TED orbits and 30 healthy control (HC) orbits were enrolled. Choroid was imaged using HD-OCT scans centered at the fovea, and subfoveal choroidal thickness (SFCT) was measured. The OCT images were analyzed using ImageJ software to calculate choroidal vascularity index (CVI) and associated choroidal perfusion indices.

RESULTS

The study included eight active, 13 non-inflammatory active (NIA), and 16 inactive TED orbits. The mean age was 39.73 ± 12.91 years, and the male: female ratio was 1.18:1. Intraocular pressure and CVI were higher, while SFCT was similar in TED on comparison to healthy orbits. CVI and SFCT were raised in active as compared to inactive TED. CVI and SFCT correlated positively with Barrets' index and negatively with the duration of thyroid disease. The area under curve of CVI (95% CI: 0.651-0.864, P < 0.001) helped in differentiating TED orbits from HC, while CVI (95% CI: 0.780-0.983, P < 0.001) had the maximum discriminatory power in predicting the activity of disease.

CONCLUSIONS

CVI has greater sensitivity than SFCT in differentiating healthy from TED orbits. The blood flow stagnation in active orbits, which improves during the course of TED and tends to worsen with increase in Barret's index, can lead to choroidal vascularity changes. CVI and SFCT can act as adjunct to existing modalities for monitoring the disease activity.

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

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

Macular blood flow changes in dysthyroid optic neuropathy after high-dose intravenous pulse methylprednisolone (IVMP)

OBJECTIVE

To investigate the changes in macular vessel density (VD) of the superficial layer of retina (SLR) and deep layer of retina (DLR) in dysthyroid optic neuropathy (DON) after high-dose intravenous pulse methylprednisolone (IVMP).

MATERIALS AND METHODS

Eighteen DON patients (29 eyes) who completed high-dose IVMP and 16 healthy individuals (32 eyes) were enrolled in this study. Optical coherence tomography angiography (OCTA) image analysis and comprehensive ophthalmic examinations were performed, including the SLR macular whole-image VD (SLR-mwiVD) and DLR-mwiVD, best-corrected visual acuity (BCVA), the mean deviation of visual field (VF-MD), pattern standard deviation of visual field (VF-PSD) and the other parameters.

RESULTS

The SLR-mwiVD (41.39 ± 4.71 vs. 48.13 ± 3.68, p < 0.001) and DLR-mwiVD (40.77 ± 5.85 vs. 49.14 ± 7.02, p < 0.001) were decreased in DON compared to control eyes. After IVMP, visual function parameters were improved, and SLR-mwiVD (49.41 ± 3.18, p < 0.001) and DLR-mwiVD (50.41 ± 4.04, p < 0.001) were increased in the DON group compared to pretreatment. The increased SLR-mwiVD and DLR-mwiVD were significantly correlated with improvements in BCVA (Log MAR: from 0.62 ± 0.49 to -0.01 ± 0.03, p < 0.001), VF-MD (from - 6.89 ± 2.89 dB to - 1.75 ± 1.29 dB, p < 0.001) and VF-PSD (from 4.38 ± 2.52 dB to 2.32 ± 1.64 dB, p < 0.001).

CONCLUSION

The increase in macular VD was significantly correlated with the improvement in visual function in DON after IVMP. Macular VD changes on OCTA may be a useful indicator for the response in DON after IVMP.

A Comparison of Observational Studies on Subfoveal Choroidal Thickness Measured with OCT according to the Level of Thyroid Eye Disease Activity-Systematic Review and Meta-Analysis

This study aims to systematise subfoveal choroidal thickness (SFCT) measured using optical coherence tomography (OCT) in patients with different severities of thyroid eye disease (TED) compared with healthy subjects. The PubMed, Web of Science and Scopus databases were searched for the following terms: ((Graves' ophthalmopathy) OR (thyroid eye disease) OR (Graves' orbitopathy) OR (thyroid-associated orbitopathy)) AND (choroidal thickness) AND ((optical coherence tomography) OR (OCT)). The pool of papers was narrowed down to articles published until 31 January 2023 (26, 26 and 96 papers, respectively). Twenty-five (25) articles were taken into consideration, which were original papers and included the choroidal thickness measurements among TED patients in their results. Finally, eight papers were included in the comparative analysis of the SFCT parameter in TED patients and a group of healthy controls, and seven papers in the comparative analysis of the same parameter between active and inactive TED patients. The mean value of the difference between the TED group and the healthy group was 38.79 μm, with a confidence interval (CI) from 0.09 to 77.49 μm (p = 0.0495). The mean difference between the active TED group and inactive TED group was 38.02 μm, with a CI from 8.62 to 67.42 μm (p = 0.0113). All the results were statistically significant.