Orbital radiotherapy for Graves' ophthalmopathy

Late orbital radiotherapy combined with intravenous methylprednisolone in the management of long-lasting active graves' orbitopathy: a case report and literature review

PURPOSE

To present a case and review the literature on Orbital Radiotherapy (OR) combined with intravenous methylprednisolone, focusing on its late application in patients with long-lasting active Graves' Orbitopathy (GO). Additionally, we suggest emerging perspective for future research in this context.

METHOD

Relevant literature (randomized controlled studies, retrospective studies and reviews) was explored on PubMed from January 1973 to January 2024, searching "orbital radiotherapy" & "Graves disease".

RESULTS

OR is a well-established second-line treatment for moderate-to-severe active GO, providing response rates comparable to glucocorticoids. Its anti-inflammatory effect makes OR particularly suitable for early active GO, and when combined with glucocorticoids, outcomes are synergistically improved. The emergence of the new Volumetric Modulated Arc Image-Guided Radiation Therapy (VMAT-IGRT) technique enables precise radiation delivery to the target, significantly reducing associated toxicity. This technological advancement enhances the feasibility of radiotherapy in benign diseases like GO. A retrospective study indicated that late OR in patients with long-lasting active GO may improve diplopia and visual acuity, decreasing disease activity. Our case report supports this conclusion.

CONCLUSIONS

This report and literature review underscores the importance of considering late OR combined with intravenous methylprednisolone as a viable treatment option for GO patients with prolonged disease activity, emphasizing the crucial role of personalized therapy in managing GO. However, further investigations are warranted to validate this approach in cases of long-lasting active GO.

Changes in therapeutic response, ocular manifestations of Graves' orbitopathy and quality of life during the first year after orbital radiotherapy

PURPOSE

The aim of our study was to assess the changes in the therapeutic response, ocular manifestations of GO and quality of life during the first year after OR.

METHODS

The study involved 26 consecutive patients with active moderate-to-severe GO indicated for OR, 18 females, mean age 57 ± 12.5. At baseline, all patients underwent comprehensive ocular examination and thyroid hormone and antibody testing. Then, OR was performed with a total dose of 20 Gy, divided into 10 sessions of 2 Gy each with concomitant oral intake of low-dose glucocorticoids. Therapeutic response and individual ocular manifestations were evaluated 1, 3, 6 and 12 months after OR, and QoL-at 3, 6 and 12 months by a disease-specific questionnaire.

RESULTS

One month after OR, 61.6% of patients had a therapeutic response (full or partial). During the follow-up, the proportion of full-responders gradually increased up to 57.5% at 12 months, while that of non-responders gradually decreased, reaching 11.5% at 12 months. All individual ocular manifestations improved significantly 1-3 months after OR. QoL related to visual functioning increased significantly at 6 months, whereas QoL related to appearance improved significantly at 12 months.

CONCLUSIONS

The vast majority of our patients with active moderate-to-severe GO exhibited full or partial therapeutic response after OR. The initial effect on the therapeutic response and individual ocular parameters was evident as soon as 1-3 months after the procedure. OR also has a beneficial effect on patients' QoL.

TRIAL REGISTRATION NUMBER

NCT05775185/07.03.2023, retrospectively registered.

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

Purpose

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

Observations

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

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

Conclusions and Importance

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

•

Teprotumumab is effective for the treatment of dysthyroid optic neuropathy.

•

Most patients demonstrated rapid objective improvement after 2 infusions.

•

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

•

Orbital imaging showed improvement of orbital apex crowding after treatment.

•

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

Updates on the understanding and management of thyroid eye disease

Thyroid eye disease (TED) is a complex disease associated with myriad clinical presentations, including facial disfigurement, vision loss, and decreased quality of life. Traditionally, steroid therapy and/or radiation therapy were commonly used in the treatment of active TED. While these therapies can help reduce inflammation, they often do not have a sustainable, significant long-term effect on disease outcomes, including proptosis and diplopia. Recent advances in our understanding of the pathophysiology of TED have shifted the focus of treatment toward targeted biologic therapies. Biologics have the advantage of precise immune modulation, which can have better safety profiles and greater efficacy compared to traditional approaches. For instance, the insulin-like growth factor-1 receptor (IGF-1R) has been found to be upregulated in TED patients and to colocalize with the thyroid-stimulating hormone receptor (TSHR), forming a signaling complex. Teprotumumab is an antibody targeted against IGF-1R. By inhibiting the IGF-1R/TSHR signaling pathway, teprotumumab may reduce the production of proinflammatory cytokines, hyaluronan secretion, and orbital fibroblast activation in patients with TED. Due to promising phase II and III clinical trial results, teprotumumab has become the first biologic US Food and Drug Administration (FDA)-approved for the treatment of TED. In addition, there are currently ongoing studies looking at the use of antibodies targeting the neonatal Fc receptor (FcRn) in various autoimmune diseases, including TED. FcRn functions to transport immunoglobulin G (IgG) and prevent their lysosomal degradation. By blocking the recycling of IgG, this approach may dampen the body's immune response, in particular the pathogenic IgG implicated in some autoimmune diseases. Advances in our understanding of the pathophysiology of TED, therefore, are leading to more targeted therapeutic options, and we are entering an exciting new phase in the management of TED. This review will cover recent insights into the understanding of TED pathophysiology and novel treatment options as well as ongoing studies of new potential treatment options for TED.

Current Knowledge on Graves' Orbitopathy

(1) Background: Graves' orbitopathy (GO) is an autoimmune inflammation of the orbital tissues and the most common extra-thyroid symptom of Graves' disease (GD). Mild cases of GO are often misdiagnosed, which prolongs the diagnostic and therapeutic process, leading to exacerbation of the disease. A severe course of GO may cause permanent vision loss. (2) Methods: The article presents an analysis of GO-its etiopathogenesis, diagnostics, current treatment and potential future therapeutic options based on a review of the currently available literature of the subject. (3) Results: Current treatment of the active GO consists predominantly in intravenous glucocorticoids (GCs) administration in combination with orbital radiotherapy. The growing knowledge on the pathogenesis of the disease has contributed to multiple trials of the use of immunosuppressive drugs and monoclonal antibodies which may be potentially effective in the treatment of GO. Immunosuppressive treatment is not effective in patients in whom a chronic inflammatory process has caused fibrous changes in the orbits. In such cases surgical treatment is performed-including orbital decompression, adipose tissue removal, oculomotor muscle surgery, eyelid alignment and blepharoplasty. (4) Conclusions: Management of GO is difficult and requires interdisciplinary cooperation in endocrinology; ophthalmology, radiation oncology and surgery. The possibilities of undertaking a reliable assessment and comparison of the efficacy and safety of the therapeutic strategies are limited due to the heterogeneity of the available studies conducted mostly on small group of patients, with no comparison with classic systemic steroid therapy. The registration by FDA of Teprotumumab, an IGF1-R antagonist, in January 2020 may be a milestone in future management of active GO. However, many clinical questions require to be investigated first.

Efficacy of orbital radiotherapy in moderate-to-severe active graves' orbitopathy including long-lasting disease: a retrospective analysis

Background

We aimed to explore the efficacy of orbital radiotherapy (RT) in patients with moderate-to-severe active Graves’ orbitopathy (GO), including long-lasting disease, and to determine the predictive factors associated with treatment response.

Methods

This was a retrospective study of 62 moderate-to-severe active GO patients treated with RT. Demographic data and ophthalmic findings prior to RT and at 3 and 6 months afterward were analyzed. Computed tomography was performed before and after RT to compare orbital volume change. We used logistic regression to determine the predictive factors for treatment response. Subjects were divided into early- and late-active phase groups based on GO duration of 24 months and treatment outcomes were compared with each other to observe the effects of RT timing on treatment response.

Results

Forty (64.5%) and forty-six (74.1%) patients experienced improvements in GO at 3 and 6 months after radiotherapy, respectively. Ocular parameters such as clinical activity score (CAS), proptosis, extraocular muscle (EOM) limitation, and compressive optic neuropathy (CON) were improved by RT. Volumes of EOM significantly decreased after RT. The enlargement of EOMs and EOM limitation were predictive factors for a good response to RT. At 6 months after RT, 22 (68.8%) patients of late-active phase group exhibited improvement in GO, which is comparable to the number of 24 (80.0%) patients of early-active phase group. In the late-active phase group, CAS, diplopia, and visual acuity were improved significantly, but there was no change in EOM limitation.

Conclusions

In moderate-to-severe active GO patients, orbital RT may help improve high CAS, proptosis, EOM limitation, and CON. The orbital RT in long-lasting active GO patients may be considered as treatments for the relief of symptoms including high CAS and poor visual acuity.

Exophthalmos and multinodular goitre, an unusual combination

Multinodular goitre is not associated with eye disease, unless in a rare case of Marine-Lenhart syndrome where it coexists with Grave's disease. Therefore, other causes of exophthalmos need to be ruled out when the eye disease is seen in a patient with multinodular goitre. Confusion can arise in patients with features suggestive of Graves' ophthalmopathy in the absence of thyroid-stimulating hormone receptor autoantibodies and no evidence of other causes of exophthalmos. We present a case of multinodular goitre in a patient with exophthalmos which flared up after iodine contrast-based study. A 61-year-old Australian presented with a pre-syncopal attack and was diagnosed with toxic multinodular goitre. At the same time of investigations, to diagnose the possible cause of the pre-syncopal attack, computerised tomographic (CT) coronary artery angiogram was requested by a cardiologist. A few days after the iodine contrast-based imaging test was performed, he developed severe eye symptoms, with signs suggestive of Graves' orbitopathy. MRI of the orbit revealed features of the disease. Although he had pre-existing eye symptoms, they were not classical of thyroid eye disease. He eventually had orbital decompressive surgery. This case poses a diagnostic dilemma of a possible Graves' orbitopathy in a patient with multinodular goitre. Learning points: Graves' orbitopathy can occur in a patient with normal autothyroid antibodies. The absence of the thyroid antibodies does not rule out the disease in all cases. Graves' orbitopathy can coexist with multinodular goitre. Iodine-based compounds, in any form, can trigger severe symptoms, on the background of Graves' eye disease.

Orbital Radiotherapy Plus Concomitant Steroids in Moderate-to-Severe Graves' Ophthalmopathy: Good Results After Long-Term Follow-Up

BACKGROUND

Orbital radiotherapy (RT) is an effective and consolidate treatment for steroid-refractory Graves' ophthalmopathy (GO); however, long term effects are not well known.

OBJECTIVES

The aim of this study was to evaluate the long term efficacy and toxicity of orbital RT plus concomitant systemic steroids in a population of patients with moderate-to-severe GO or with eyesight threatening symptoms refractory to steroids.

METHODS

Forty patients with moderate-to-severe GO or with eyesight threatening symptoms not responsive/resistant to steroids were treated with orbital RT at the dose of 20 Gy in 10 fractions plus concomitant steroids. Clinical activity score (CAS) and symptoms status were evaluated to determine response to the treatment.

RESULTS

We reported overall improvement of symptoms, in particular, a regression at 1-year of diplopia in 32.5% eye movement impairment in 42.5%, eyesight in 27.5% and a 2 point reduction in CAS. After a median time of 56 months 21.9% of the patients underwent orbital decompression for relapse of GO, 4.8% received surgical correction of strabismus, and 2.4% received eyelid lipectomy. Acute toxicity was mild; grade 1 - 2 keratitis occurred in 19.5% of the patients and grade 3 keratitis was observed in 2.4% of the patients. Cataract occurred in 7.4% of the patients after a median time of 24-month-follow-up. No secondary malignancies were reported.

CONCLUSIONS

Our results reported the long-term efficacy and the good tolerance of orbital RT. The combination of RT plus steroids in this setting may avoid or delay performing the surgery in some cases.

Tocilizumab for thyroid eye disease

BACKGROUND

Thyroid eye disease (TED) is an autoimmune disorder that constitutes a major clinical and therapeutic challenge. Current treatment options for moderate-to-severe TED include immunotherapy, orbital radiotherapy and decompression surgery. Limited drugs of proven efficacy are available for the treatment of people with TED. Given the role in the pathogenesis of TED of interleukin (IL)-6 expression in adipocytes, fibroblasts and macrophages, the proposed theory is that inhibition of IL-6 by tocilizumab may be an effective treatment in TED by directly reducing the inflammatory response. In addition, there is an unmet need for a new treatment that can modify the natural course of the disease and reduce the incidence of late complications that can occur as a result of fibrosis following inflammation.

OBJECTIVES

To investigate the efficacy and harms of tocilizumab for the treatment of people with TED.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); MEDLINE Ovid; Embase Ovid; LILACS BIREME; OpenGrey; the ISRCTN registry; ClinicalTrials.gov; the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and the EU Clinical Trials Register. The date of the search was 31 July 2018.

SELECTION CRITERIA

We searched for trials of tocilizumab administered by intravenous infusion using any dosage regimen, compared with placebo or intravenous glucocorticoid therapy for people with TED.

DATA COLLECTION AND ANALYSIS

We planned to use standard methods recommended by Cochrane. The primary outcome was change in TED score (as defined by investigators). Secondary outcomes included measurement of the following parameters: change in proptosis, change in extraocular motility, change in palpebral aperture measurements, number of relapses, development of optic neuropathy and change in quality of life score. We planned to measure these outcomes at three months (range two to six months) and 12 months (range six to 18 months) post-treatment. Adverse outcomes included any adverse effects identified in the trials at any time point.

MAIN RESULTS

No studies met the inclusion criteria of this review. We found one randomised, placebo-controlled, double masked study (NCT01297699). This study plans to evaluate the efficacy and harms of tocilizumab administration in people with moderate-to-severe or sight-threatening graves' ophthalmopathy (GO), that had not responded adequately to treatment with intravenous corticosteroid pulses. It was completed in December 2015 and will be assessed for inclusion in the review when data become available.

AUTHORS' CONCLUSIONS

There is currently no evidence from randomised controlled trials evaluating the efficacy and harms of tocilizumab for the treatment of people with TED.

A British Ophthalmological Surveillance Unit (BOSU) study into dysthyroid optic neuropathy in the United Kingdom

This prospective British Ophthalmological Surveillance Unit (BOSU) study on dysthyroid optic neuropathy (DON) determines the incidence, presenting features and management throughout the UK. New cases were identified through the BOSU yellow card and an initial questionnaire and a subsequent 9-month follow-up questionnaire were posted out. From August 2015 to August 2016 DON was reported in 49 patients with 71 eyes affected, 22 patients had bilateral DON. The most common presenting symptom was blurred vision (83%) and the most common examination finding was upgaze restriction (85%). 85% of patients were initially treated with 3 days of either 1 g or 500 mg intravenous methyl prednisolone. We received 25 follow-up questionnaires (51% of the initial cohort) with 38 eyes treated for DON and 13 bilateral cases. The average steroid dose over 9 months was 4.5 g and 47% of patients had a surgical orbital decompression. The mean visual acuity gain after 9 months of follow-up for all patients was 0.25 LogMAR. The mean visual acuity gain after just medical therapy was 0.25 LogMAR and after both medical therapy and orbital decompression it was 0.24 LogMAR. In conclusion, the incidence of DON in the UK from this study is 0.75 per million population per annum. The majority of patients are treated with initial medical therapy and almost half of all patients subsequently went on to have an orbital decompression. With either medical therapy or medical and surgical therapy, vision can improve in patients with DON.

The efficacy of intensity modulated radiation therapy in treating thyroid-associated ophthalmopathy and predictive factors for treatment response

The study evaluated clinical efficacy of intensity modulated radiation therapy (IMRT) in treating patients with thyroid-associated ophthalmopathy (TAO) and defined predictive factors that associated with treatment response. A total of 178 TAO patients were treated with retro-orbital IMRT with radiation dose of 20 Gy in 10 fractions. The immediate and long-term treatment response and complications were evaluated. Besides, logistic-regression analysis was conducted to identify possible predictive factors. TAO symptom score significantly fell from the initiation to 6-month post-treatment (P < 0.001). 134 patients (73.2%) had mild to significant response to IMRT, and 172 patients (96.6%) achieved stabilization of TAO without future progression. Current smoker (OR 2.88, 95% CI 1.32–6.29; P = 0.008) and symptom duration longer than 18 months (OR 3.33, 95% CI 1.24–8.93; P = 0.017) were identified as independent predictive factors for non-response of TAO to retro-orbital IMRT. Immediate complications were slight and self-limited, and long-term complications mainly included chronic xerophthalmias in12 patients (6.74%) and cataract formation in 4 patients (2.25%). The study suggested that IMRT was a viable option for treating TAO patients, with a satisfactory symptom control ability and acceptable post-treatment complications.

Clinical outcomes of graves' ophthalmopathy treated with intensity modulated radiation therapy

BACKGROUND

Radiation for Graves' ophthalmopathy (GO) has traditionally utilized lateral opposing fields (LOF) or three-dimensional conformal radiotherapy (3DCRT) technique. The current study was conducted to report clinical outcomes and therapeutic effects of intensity modulated radiation therapy (IMRT) in treating GO patients.

METHODS

One hundred sixteen patients with GO were treated with IMRT as initial local therapy between July 2010 and August 2013, with a median follow-up of 62 months (range 45-81 months). Radiotherapy dose was 20 Gy in 10 fractions within two to three weeks. The immediate and long-term response to IMRT was evaluated in GO severity score and in each category of symptoms. Acute and long-term complications were recorded to assess its safety.

RESULTS

Symptom severity score significantly fell from the start of treatment to 4- or 6- month post-IMRT (P < 0.01). In total, 85 patients (73.3%) experienced improvement of GO symptoms in the first half-year, and only 4 of them (4.7%) suffered recurrence of the GO symptoms during the subsequent follow-ups. Orbital pain, tearing and extraocular muscle dysfunction had the best treatment reaction to IMRT, while proptosis and blurred vision were the most refractory symptoms. Acute complications were slight and self-limited, mainly including intermittent eye redness in 9 patients (7.8%), sideburns hair loss in 19 patients (16.4%), increased milphosis or madarosis in 23 patients (19.8%) and pseudo-progression of GO symptoms in 15 patients (12.9%). For long-term complications, chronic xerophthalmias occurred in 7 patients (6.03%), cataract developed in 2 patients (1.72%), and all were well-managed by medical interventions. Radiation retinopathy and secondary malignancy was not presented in the cohort.

CONCLUSION

The study demonstrated that IMRT could serve as a viable option in treating GO patients, with a satisfactory symptom control ability, and relatively slight and acceptable post-radiotherapeutic complications.

Advances in the management of thyroid eye diseases: An overview

INTRODUCTION

Thyroid eye disease (TED) remains a notorious ailment for both patients and the treating ophthalmologists. Recent years have witnessed considerable research in the immunopathogenic mechanism of TED that has resulted in an expansion and modification of the available management options.

AIM

Purpose of this review is to summarise the advances in the management of thyroid ophthalmopathy.

MATERIAL AND METHOD

A thorough literature search and of the past 10 years web search with words Thyroid ophthalmopathy, recent, advances.

RESULTS

Recent VISA classification and new serum markers seem to have potential to give diagnostic as well as therapeutic guidance, gauge treatment response and even identify risk of disease progression. Majority of TED patients can be managed conservatively due to its self-limiting nature but if indicated, still steroids are the preferable medical therapy; however, there is an increasing consensus towards the use of parenteral form as compared to the oral one on account of greater efficacy with lesser side effects. Steroid sparing medications, for example, rituximab, infliximab, etanercept, adalimumab, teprotumumab, tocilizumab, tanshinone, are showing encouraging results and form an area of active research.

CONCLUSION

Radiation therapy remains as an adjunctive modality in active diseases as a nonmedical treatment for TED with some promising data. Surgical intervention may be required in vision threatening conditions or to counteract the sequel of inflammatory phase. Advances in surgical techniques like stereotactic image-guided balanced orbital decompression with endoscopic approach ensure meticulous dissection with minimal trauma.

Radiotherapy for the treatment of thyroid eye disease-a prospective comparison: Is orbital radiotherapy a suitable alternative to steroids?

BACKGROUND AND AIMS

To evaluate the efficacy of orbital radiotherapy (OR) for the treatment of thyroid eye disease (TED).

METHODS

Thirty-five consecutive patients with active TED with contraindications to steroid therapy received a course of OR. Bilateral retrobulbar irradiation was performed with a total dose of 20 Gy. 7-points clinical activity score (7-CAS), ocular motility, visual acuity (VA), exophthalmos and eyelid retraction were prospectively evaluated at 3, 6 and 12 months and compared with baseline data.

RESULTS

There was a statistically significant improvement in 7-CAS at 3, 6 and 12 months post-treatment (p < 0.05). Ocular motility disturbances improved at 6 and 12 months (p < 0.05). Visual acuity remained stable; there was no significant change in exophthalmos (mean 24 mm, SD 3 mm) or eyelid retraction (marginal reflex distance mean 6 mm, SD 1.5 mm) during the follow-up period. No side effects were registered.

CONCLUSIONS

This study suggests that OR might be effective in reducing 7-CAS and ocular motility disturbances. No significant improvement in proptosis or eyelid retraction should be expected from this treatment. OR might be considered a suitable alternative treatment in TED for patients who cannot tolerate steroids.

The Effect of Systemic Steroids and Orbital Radiation for Active Graves Orbitopathy on Postdecompression Extraocular Muscle Volume

PURPOSE

To evaluate the effect of orbital radiation prior to surgery on the clinical course and extraocular muscle (EOM) radiologic volume changes after decompression in Graves orbitopathy (GO).

DESIGN

Retrospective, interventional case series.

METHODS

The medical records of patients treated with orbital decompression for GO and who underwent postoperative orbital computed tomography were reviewed. Only patients who underwent rehabilitative decompression in the inactive phase and who received systemic corticosteroids alone (ST group) or combined orbital radiation and systemic corticosteroids (SRT group) in the active inflammatory phase of the disease were selected. The main outcome measure was the comparison of preoperative and postoperative EOM volumes. Secondary outcome measures were changes in proptosis and diplopia after decompression.

RESULTS

Thirty-seven of 114 patients were selected for this study. There were no differences between the ST group (n = 22, 42 eyes) and SRT group (n = 15, 30 eyes) in terms of demographics or predecompression characteristics. After decompression surgery, the total EOM volume significantly increased by 15% in the ST group, but radiated EOMs in the SRT group did not expand, resulting in decreased induction of postoperative diplopia. The percentages of patients showing increased diplopia after decompression differed significantly between the groups (ST group, 40.9% vs SRT group, 13.3%, P = .04). However, there was no difference in exophthalmos reduction after decompression between the 2 groups.

CONCLUSIONS

Orbital radiation prior to orbital decompression can reduce both the postoperative increase in EOM volume and deterioration in diplopia.

THERAPY OF ENDOCRINE DISEASE: Endocrine dilemma: management of Graves' orbitopathy

Management of Graves' orbitopathy (GO) must be based on the correct assessment of activity and severity of the disease. Activity is usually assessed with the Clinical Activity Score, whereas severity is classified according to a European Group On Graves' Orbitopathy (EUGOGO) consensus statement as mild, moderate-to-severe, and sight-threatening. Myopathic and chronic congestive forms are uncommon clinical presentations of GO. Restoration and maintenance of stable euthyroidism are recommended in the presence of GO.In moderate-to-severe disease, steroids have been widely employed and have shown to possess an anti-inflammatory activity, but about 20-30% of patients are not responsive and present recurrence. Some novel immunosuppressors have already been employed in clinical studies and have shown interesting results, although the lack of randomized and controlled trials suggests caution for their use in clinical practice. Potential targets for therapy in GO are the thyroid-stimulating hormone and the insulin-like growth factor 1 receptor on the fibroblasts, inflammatory cytokines, B and T cells, and the PIK3/mTORC1 signaling cascades for adipogenesis. A recent open study has shown that tocilizumab, an anti-sIL-6R antibody, inactivates GO. Consistent reports on the efficacy of rituximab have recently been challenged by randomized controlled trials.As the main goal of treatment is the well-being of the patient, the therapeutic strategy should be addressed to better suit the patient needs, more than improving one or more biological parameters. The increasing availability of new therapies will expand the therapeutic options for GO patients and allow the clinician to really personalize the treatment to better suit the patients' personal needs.

Orbital Radiation Therapy in Thyroid Eye Disease

PURPOSE

To review the current literature summarizing the state of knowledge on the use of orbital radiation therapy (ORT) in thyroid eye disease.

METHODS

A systematic review and analysis of the literature were performed. MEDLINE/PubMed, Cochrane Library databases, SCOPUS, and recent relevant journal articles were searched.

RESULTS

Thyroid eye disease is an autoimmune disorder that has the propensity to affect multiple orbital tissues and can cause permanent vision loss. In moderate to severe disease, treatment may be warranted and can include multiple therapeutic modalities. Orbital radiation therapy is frequently used in this setting and may act to break the inflammatory cycle of glycosaminoglycan production and deposition. There has been a wealth of data regarding the effectiveness of ORT in thyroid eye disease resulting in the publication of treatment algorithms and management guidelines; however, there continues to be a lack of conformity among experts on the exact role of ORT in thyroid eye disease.

CONCLUSION

The multiple different thyroid eye disease classification schemes and the concurrent use of other therapeutic modalities challenge the interpretation of studies evaluating the effectiveness of thyroid eye disease. Despite these limitations, the current literature indicates that ORT is generally safe and well tolerated. Orbital radiation therapy may have a modest effect on motility and proptosis early in the disease process. It is unclear whether ORT leads to improved quality of life. There are some data to support the use of ORT to prevent compressive optic neuropathy.

Relationship between magnetic resonance imaging signal intensity and volume of extraocular muscles in thyroid-associated ophthalmopathy with methylprednisolone pulse therapy

Purpose

To characterize the relationship between inflammation and swelling of extraocular muscles in thyroid-associated ophthalmopathy before and after methylprednisolone pulse therapy.

Methods

The signal intensities and volumes of the superior rectus (SR), inferior rectus (IR), lateral rectus (LR), medial rectus (MR), and superior oblique (SO) muscles were measured with magnetic resonance imaging in 25 eyes of 25 patients with thyroid-associated ophthalmopathy in the acute inflammatory phase before and after methylprednisolone pulse therapy. The signal intensity ratios (SIRs) of muscles and brain white matter were calculated.

Result

The mean SIRs before treatment were 2.28±0.74 in SR, 2.66±0.57 in IR, 2.03±0.42 in LR, 2.45±0.49 in MR, and 1.98±0.48 in SO muscles. The mean SIRs after treatment were 1.82±0.62, 1.84±0.52, 1.70±0.35, 1.95±0.46, and 1.60±0.36, respectively. The mean volumes (cm³) before treatment were 1.35±0.67 in SR, 1.21±0.39 in IR, 0.66±0.13 in LR, 0.94±0.31 in MR, and 0.58±0.14 in SO muscles. Those after treatment were 1.12±0.45, 0.91±0.31, 0.61±0.12, 0.85±0.28, and 0.49±0.11, respectively. The SIRs showed significantly positive correlations with volumes both before and after treatment in SR muscles (before, r=0.77; after, r=0.69), IR muscles (before, r=0.65; after, r=0.60), MR muscles (before, r=0.69; after, r=0.73), and SO muscles (before, r=0.52; after, r=0.50) (P<0.01 for all correlations).

Conclusion

Swelling reflected the inflammation in extraocular muscles of thyroid-associated ophthalmopathy both before and after treatment.

An overview of thyroid eye disease

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.

Treatment modalities of thyroid related orbitopathy

Aims:

The aim was to highlight recent advances in the treatment of thyroid eye disease.

Settings and Design:

Review article.

Materials and Methods:

Existing literature and the authors’ experience was reviewed.

Results:

Thyroid ophthalmopathy is a disfiguring and vision-threatening complication of autoimmune thyroid disease that may develop or persist even in the setting of well-controlled systemic thyroid status. Treatment response can be difficult to predict, and optimized algorithms for disease management do not exist. Thyroid ophthalmopathy should be graded for both severity and disease activity before choosing a treatment modality for each patient. The severity of the disease may not correlate directly with the activity; medical treatment is most effective in active disease, and surgery is usually reserved for quiescent disease with persistent proptosis and/or eyelid changes.

Conclusions:

Intravenous pulsed corticosteroids, orbital radiotherapy, and orbital surgical techniques form the mainstay of current management of thyroid ophthalmopathy. Immunosuppressive and biologic agents may have a role in treating active disease although additional safety and efficacy studies are needed.

Reduced risk of compressive optic neuropathy using orbital radiotherapy in patients with active thyroid eye disease

PURPOSE

To compare the risk of developing compressive optic neuropathy in patients with active thyroid eye disease (TED) treated with corticosteroids with or without orbital radiotherapy.

DESIGN

Retrospective single-center case-control study.

METHODS

The clinical charts of 351 patients with active TED who received corticosteroids with or without orbital radiotherapy between 1999 and 2010 were reviewed. Patients with compressive optic neuropathy at the time of presentation were excluded. Group 1 received corticosteroids only and Group 2 received corticosteroids as well as orbital radiotherapy. The primary outcome measure was the development of compressive optic neuropathy. Secondary outcome measures were changes in other parameters indicating the activity of TED, including soft tissue inflammation, diplopia, ocular motility restriction, and appearance.

RESULTS

There were 144 cases in Group 1 and 105 in Group 2. Both groups were matched for age, sex, and stability of thyroid function. The 2 groups differed only in the modality of treatment for active TED. The main indication for treatment in both groups was soft tissue inflammation. Corticosteroids were initiated an average of 2.6 months following symptom onset in Group 1 and 2.5 months in Group 2. Group 2 received orbital radiotherapy on average 4.2 months following the initiation of corticosteroid therapy and 8% (9/105) were intolerant to corticosteroids. At an average of 3.2 years follow-up, compressive optic neuropathy had developed in 17% (25/144) of Group 1 and 0% of Group 2 (P < .0001), on average 5.5 months following the initiation of corticosteroid therapy. Although both groups experienced a significant reduction in periocular inflammation, the radiotherapy-treated group demonstrated a significantly greater improvement in ocular motility.

CONCLUSION

The rate of compressive optic neuropathy was significantly lower and improvement in ocular motility greater in patients receiving orbital radiotherapy in addition to corticosteroids. Patients with active TED appear to have an effective and sustained response to orbital radiotherapy combined with corticosteroids that is protective against disease progression and the development of compressive optic neuropathy.

Methotrexate for the treatment of thyroid eye disease

Background/Aim. To evaluate the efficacy of methotrexate for the treatment of thyroid eye disease (TED). Methods. 36 consecutive patients with active TED, previously treated with corticosteroids but stopped due to the occurrence of side effects, were commenced on methotrexate therapy. Two different weekly doses were administered depending on the weight of the patient (7.5 mg or 10 mg). Clinical activity score (7-CAS), visual acuity (VA), ocular motility, exophthalmos, and eyelid position were retrospectively evaluated at 3, 6, and 12 months and compared with baseline data. Results. There was a statistically significant improvement in 7-CAS at 3, 6, and 12 months after treatment (P < 0.0001). There was no significant change in visual acuity. Ocular motility disturbances improved at 6 and 12 months (P < 0.001). There was no significant change in exophthalmos (mean 24 mm, SD 3 mm) or eyelid position (marginal reflex distance mean 6 mm, SD 1.5 mm) during the follow-up period. No side effects were registered. Conclusions. Methotrexate therapy is effective in reducing CAS and ocular motility disturbances. No significant improvement in proptosis or eyelid retraction should be expected from this treatment. Eventually, it might be considered a suitable alternative treatment in TED for patients who cannot tolerate steroids.

Graves' orbitopathy: imperfect treatments for a rare disease

Graves' orbitopathy (GO) is the most frequent and invalidating extrathyroidal expression of Graves' disease. Its incidence and prevalence are, however, low. About three quarters of Graves' patients have no GO at diagnosis, and moderate-to-severe and severe forms represent no more that 5-6% of cases. Progression to severe forms occurs rarely, but it may be caused by risk factors, the most important being smoking and poor control of thyroid dysfunction. Lot of progress has been recently achieved in the understanding of GO pathogenesis, while the disease remains a therapeutic challenge and dilemma. Common treatments for moderate-to-severe and active forms of GO (glucocorticoids and orbital radiotherapy) frequently provide incomplete responses and may be followed by relapse or progression of GO. After the disease has been inactivated by medical treatment, many patients need rehabilitative surgery for residual manifestations (orbital decompression for exophthalmos, squint surgery for extraocular muscle dysfunction, eyelid surgery for eyelid malposition). Novel pharmacological treatments are on the horizon and might target pathogenetic mechanisms of the disease better than glucocorticoids. Clinical evidence concerning their efficacy and safety is presently lacking.

Acute thyroid eye disease (TED): principles of medical and surgical management

The active inflammatory phase of thyroid eye disease (TED) is mediated by the innate immune system, and management is aimed at aborting this self-limited period of autoimmune activity. In most patients with TED, ocular and adnexal changes are mild and management involves controlling thyroid dysfunction, cessation of smoking, and addressing ocular surface inflammation and exposure. In patients with acute moderate disease, this being sufficient to impair orbital functions, immunosuppression reduces the long-term sequelae of acute inflammation, and adjunctive fractionated low-dose orbital radiotherapy is used as a steroid-sparing measure. Elective surgery is often required following moderate TED, be it for proptosis, diplopia, lid retraction, or to debulk the eyelid, and this should be delayed until the disease is quiescent, with the patient stable and weaned off all immunosuppression. Thus, surgical intervention during the active phase of moderate disease is rarely indicated, although clinical experience suggests that, where there is significant orbital congestion, early orbital decompression can limit progression to more severe disease. Acute severe TED poses a major risk of irreversible loss of vision due to marked exposure keratopathy, 'hydraulic' orbital congestion, or compressive optic neuropathy. If performed promptly, retractor recession with or without a suture tarsorrhaphy protects the ocular surface from severe exposure and, in patients not responding to high-dose corticosteroid treatment, decompression of the deep medial orbital wall and floor can rapidly relieve compressive optic neuropathy, as well as alleviate the inflammatory and congestive features of raised orbital pressure.

Clinical outcomes of radiotherapy as initial local therapy for Graves' ophthalmopathy and predictors of the need for post-radiotherapy decompressive surgery

Background

The optimal initial local treatment for patients with Graves’ ophthalmopathy (GO) is not fully characterized. The purpose of this retrospective study is to describe the clinical outcomes of RT as initial local therapy for GO and define predictors of the need for post-RT salvage bony decompressive surgery.

Methods

91 patients with active GO and without prior surgery were treated with RT as initial local therapy between 01/1999 and 12/2010, with a median follow-up period of 18.3 months (range 3.7 - 142 months). RT dose was 24 Gy in 12 fractions. 44 patients (48.4%) had prior use of steroids, with 31 (34.1%) being on steroids at the initiation of RT. The most common presenting symptoms were diplopia (79%), proptosis (71%) and soft tissue signs (62%).

Results

84 patients (92.3%) experienced stabilization or improvement of GO symptoms. 58 patients (64%) experienced improvement in their symptoms. 19 patients (20.9%) underwent salvage post-RT bony decompressive surgery. Smoking status and total symptom score at 4 months were independent predictors of post-RT bony decompression with odds ratios of 3.23 (95% CI 1.03 – 10.2) and 1.59 (95% CI 1.06 – 2.4), respectively. Persistent objective vision loss at 4 months post-RT was the most important symptom type in predicting salvage decompression. Chronic dry eye occurred in 9 patients (9.9%) and cataracts developed in 4 patients (4.4%).

Conclusions

RT is effective and well tolerated as initial local therapy for active GO, with only 21% of patients requiring decompressive surgery post RT. Most patients experience stabilization or improvement of GO symptoms, but moderate to significant response occurs in the minority of patients. Smoking status and total symptom severity at 4 months, primarily persistent objective vision loss, are the primary determinants of the need for post-RT salvage bony decompression. Patients who smoke or present with predominantly vision loss symptoms should be advised as to their lower likelihood of symptomatic response to RT and their increased likelihood of requiring post-RT decompressive surgery.

Thyroid-associated orbitopathy

Thyroid-associated orbitopathy (TAO) is usually diagnosed clinically. Early presentation of TAO such as ocular irritation, lid puffiness, and mild retraction may be overlooked and misdiagnosed. Careful clinical evaluation, laboratory investigations, and orbital imaging studies are needed for diagnosing early TAO. Knowing the pathogenesis will open the door for obtaining directed and effective treatment for the inflammatory process in TAO. Most patients with mild to moderate active TAO are treated with observation alone as the available treatment modalities effective in controlling the disease have many potential side effects. Severe active TAO, compressive optic neuropathy, and severe exposure keratopathy are the main indications for treatment with immunosuppressant agents, orbital radiotherapy, or orbital decompression. Surgery remains the final rehabilitation in TAO, which should be done during cicatricial (inactive) TAO when reliable and stable results can be obtained.

Outcome of thyroid associated ophthalmopathy treated by radiation therapy

Thyroid associated orbitopathy is a common manifestation of Graves disease. Many options can be considered for treatment. In this case series, we reviewed the medical records of 17 patients who received radiation therapy (RT) for GO in a tertiary care center between 1997 and 2007. All patients received 20 Gy to both orbits and 12 of them (71%) had already received one or more trials of steroid therapy prior to RT. After a median follow-up of 2 years, a subjective improvement in exophthalmos and vision was reported by all patients at the end of RT but only 3 patients reported a decrease in their diplopia immediately after therapy. Symptoms continued to improve with time in many patients: 22% had complete reversal of their symptoms and signs, and the remaining 78% had partial improvement. Two patients developed recurrent signs and symptoms, both of them were smokers who continued to smoke after treatment. About 60-65% of patients responded favorably to RT alone which increased to 87-97% when RT is combined with steroids. No patients developed late toxicity during the follow-up period. We conclude that RT is an effective treatment option in GO even in patients who failed previous treatment with steroids or surgical decompression. Based on our own clinical experiences and the literature data, the combination of RT and intravenous corticosteroid administration may improve the response rate.

Treatment of thyroid-associated orbitopathy with rituximab--a novel therapy for an old disease: case report and literature review

OBJECTIVE

To report the use of rituximab to treat thyroid-associated orbitopathy (TAO) in a patient with a concomitant B-cell organ-specific autoimmune disorder-the stiff person syndrome (SPS).

METHODS

We present a case report and a review of the related literature.

RESULTS

A 62-year-old man with SPS, latent autoimmune diabetes of the adult, and Graves-Basedow disease was referred to our medical center because of bilateral TAO. An ophthalmologic examination documented asymmetric bilateral NOSPECS (N = no signs or symptoms; O = only signs, no symptoms; S = soft tissue involvement; P = proptosis; E = extraocular muscle involvement; C = corneal involvement; and S = sight loss) class IV TAO (left eye>right eye) with a clinical activity score of 5 on a scale of 7. Magnetic resonance imaging of the orbits documented bilateral exophthalmos (left eye>right eye) due to retrobulbar fibroadipose infiltration, bilateral increase of extrinsic ocular muscle thickness, and enhancement of the left inferior rectus muscle on T2-weighted sequences. Because of concomitant incapacitating SPS and diet-controlled latent autoimmune diabetes of the adult, we excluded long-term corticosteroid therapy as an option and considered the use of rituximab, a mouse-human chimeric monoclonal antibody targeting the CD20 protein on pre-B and mature B lymphocytes. Rituximab was administered in accordance with the protocol for rheumatoid arthritis. During the subsequent 4 months, clinical signs and symptoms of TAO dramatically resolved (clinical activity score = 0 of 7) with a sustained improvement of the spastic paraparesis. The glutamic acid decarboxylase antibody titer remained high, and glycemic control and first-phase insulin secretion did not change.

CONCLUSION

Treatment of active TAO with rituximab should be considered when standard intravenous pulse glucocorticoid treatment is contraindicated or ineffective and when SPS or other organ-specific autoimmune disorders with involvement of humoral autoimmunity are present, inasmuch as more than 1 disease may benefit from the use of this chimeric monoclonal antibody.

Medical management of thyroid eye disease

Thyroid eye disease (TED) is the most common cause of orbital disease in adults. The immunologic pathogenesis of TED has been an area of active research and considerable progress has resulted in an expansion of therapeutic options. Although surgical intervention may be required, a majority of TED patients can be managed with medical therapies. Of medical therapies, glucocorticoids remain the agent of choice in the control of TED activity. The objective of this review is to discuss the paradigm and options in medical management of TED.

Update on the medical treatment of Graves' ophthalmopathy

PURPOSE

To review recent advances in the understanding of Graves' ophthalmopathy (GO) pathogenesis as well as discuss current and future medical management strategies.

DESIGN

Interpretive essay.

METHODS

Literature review and interpretation.

RESULTS

Medical treatment of GO has slowly evolved during the past few decades and has been hampered by a poor understanding of the disease at a cellular and molecular level. Current treatment recommendations and guidelines therefore focus on nonspecific immuno-suppression. Newer classes of treatment agents hold promise to more selectively target underlying cellular and molecular alterations in GO.

CONCLUSION

Cooperation between individual patients, physicians and between differing medical centers, together with a refined understanding of the pathogenesis of GO, will lead to newer more-effective treatments for the disease and improve patient quality of life.

A retrospective study on the efficacy of total absorbed orbital doses of 12, 16 and 20 Gy combined with systemic steroid treatment in patients with Graves' orbitopathy

BACKGROUND

Graves' disease (GD) is an autoimmune disease that typically affects the thyroid gland. Thirty to sixty percent of patients also suffer from orbital inflammation. Retrobulbar radiotherapy for Graves' orbitopathy (GO) has been used for decades, though there is no direct evidence for the influence of dose and fractionation schedules on various signs and symptoms. Indeed, optimal fractionation schedules and recommended total irradiation doses are still a matter of discussion. Our aim was to investigate treatment efficacy of retrobulbar irradiation for GO at different total absorbed doses and fractionation schedules.

METHODS

A retrospective evaluation of 129 patients who were examined before, as well as 6-8 months after irradiation with different treatment schedules at eight radiotherapeutic departments. Total absorbed doses were 12, 16, or 20 Gy. All patients were additionally treated with systemic application of corticosteroids. Treatment efficacy was evaluated through assessment of proptosis, horizontal and vertical ocular motility and of clinical activity (CAS). Overall group and individual responses were evaluated. Treatment response was defined as inactivation of GO, reduction of proptosis by at least 2 mm, improvement of motility by > or = 8 degrees or unchanged normal parameters.

RESULTS

Prior to irradiation, neither age, disease duration, gender distribution, smoking behavior or serologic parameters, nor clinical activity or severity stages varied significantly between groups. Neither did outcome measures, except proptosis, differ significantly. Retrobulbar irradiation led to inactivity of GO in approximately 80% of patients, with no significant group difference. After irradiation with 16 and 20 Gy, vertical motility improved in a significantly higher percentage of patients than after irradiation with 12 Gy. Median improvement of vertical motility in responding patients was excellent in all groups (15 degrees at 12 Gy, 10 degrees at 16 Gy, 10 degrees at 20 Gy). Horizontal motility did not change significantly.

CONCLUSION

If the aim of retrobulbar irradiation is primarily to reduce soft-tissue signs, lower doses are sufficient. If a patient also suffers from dysmotility, doses exceeding 12 Gy may be more effective.

Radiotherapy in the treatment of Graves ophthalmopathy-to do it or not?

To the objective of this study is to evaluate the role and toxicity of radiotherapy in the treatment of Graves ophthalmopathy. In the years 2000-2003, 121 patients with malignant exophthalmos were treated with radiotherapy of the retrobulbar area to the total dose of 20 Gy in ten fractions with a 6 MeV photon beam. The treatment was performed by the team of the Clinic of Oncology of the Jagiellonian University Medical College in Cracow. The radiotherapy was preceded by intravenous steroid therapy: methylprednisolone acetate administered at the dose of 2 g/week for four consecutive weeks. The highest efficacy, expressed as improvement of all ocular symptoms, was observed for the combined treatment. Female and non-diabetic patients responded positively to the combined treatment. Radiotherapy combined with steroid therapy in the treatment of Graves ophthalmopathy seems to be an effective treatment for strictly defined indications. In the treatment of Graves-Basedow disease, radiotherapy is a well-tolerated treatment modality. Diabetes is a factor that worsens prognosis in Graves ophthalmopathy and female sex is a favourable factor for this condition.

Protocol for the combined immunosuppression & radiotherapy in thyroid eye disease (CIRTED) trial: a multi-centre, double-masked, factorial randomised controlled trial

BACKGROUND

Medical management of thyroid eye disease remains controversial due to a paucity of high quality evidence on long-term treatment outcomes. Glucocorticoids are known to be effective initially but have significant side-effects with long-term use and recrudescence can occur on cessation. Current evidence is conflicting on the efficacy of radiotherapy and non-steroid systemic immunosuppression, and the majority of previous studies have been retrospective, uncontrolled, small or poorly designed.The Combined Immunosuppression and Radiotherapy in Thyroid Eye Disease (CIRTED) trial was designed to investigate the efficacy of radiotherapy and azathioprine in combination with a standard course of oral prednisolone in patients with active thyroid eye disease.

METHODS/DESIGN

Patients with active thyroid eye disease will be randomised to receive (i) azathioprine or oral placebo and (ii) radiotherapy or sham-radiotherapy in this multi-centre, factorial randomised control trial. The primary outcome is improvement in disease severity (assessed using a composite binary measure) at 12 months and secondary end-points include quality of life scores and health economic measures.

DISCUSSION

The CIRTED trial is the first study to evaluate the role of radiotherapy and azathioprine as part of a long-term, combination immunosuppressive treatment regime for Thyroid Eye Disease. It will provide evidence for the role of radiotherapy and prolonged immunosuppression in the management of this condition, as well as pilot data on their use in combination. We have paid particular attention in the trial design to establishing (a) robust placebo controls and masking protocols which are effective and safe for both radiotherapy and the systemic administration of an antiproliferative drug; (b) constructing effective inclusion and exclusion criteria to select for active disease; and (c) selecting pragmatic outcome measures.

TRIAL REGISTRATION

Current controlled trials ISRCTN22471573.

An update on medical management of Graves' ophthalmopathy

Graves' ophthalmopathy (GO), the most frequent extrathyroidal manifestation of Graves' disease, is a disorder of autoimmune origin, the pathogenic mechanisms of which are still incompletely understood. Although GO is severe in only 3-5% of affected individuals, quality of life is severely impaired even in patients with mild GO. Management of severe GO can be either medical or surgical (orbital decompression, eye muscle or lid surgery). Medical management relies on the use of high-dose systemic glucocorticoids or orbital radiotherapy, either alone or in combination. Studies carried out in the last 5 yr have shown that glucocorticoids are more effective through the i.v. route than through the oral route. However, particular attention should be paid to possible liver toxicity of i.v. glucocorticoids. Recent randomized clinical trials have, with one exception, confirmed that orbital radiotherapy is an effective and safe therapeutic procedure for GO. At variance with previous encouraging data, recent randomized clinical trials have shown that currently available SS analogs are not very effective in the management of GO. Antioxidants might have a role, at least in mild forms of GO. Particular attention should be paid to correction of risk factors (cigarette smoking, thyroid dysfunction, radioiodine therapy) involved in GO progression.

Autoimmune hepatitis during intravenous glucocorticoid pulse therapy for Graves' ophthalmopathy treated successfully with glucocorticoids themselves

We report a case of acute hepatitis of autoimmune origin which occurred in a 43-yr-old woman during iv glucocorticoid (GC) pulse therapy for Graves' ophthalmopathy (GO). Prior to therapy, liver function tests were normal with no previous history of liver disorders or conditions predisposing to GC-associated liver damage. After the administration of a 4.7-g cumulative dose of methylprednisolone acetate, there was a marked increase of liver enzymes, prompting immediate discontinuation of iv GC. Nevertheless, liver enzymes increased further, reaching a peak 45 days later, with values 30- to 50-fold greater than those prior to therapy, associated with evidence of impaired liver function. Liver biopsy showed a marked lymphocytic infiltration, likely indicating an autoimmune hepatitis. Based on the assumption that following GC-induced immune suppression, autoimmune hepatitis might have been precipitated by sudden re-activation of the immune system during interpulse periods, we treated the patient with im and then oral GC, in order to re-induce immune suppression. Within three days from re-institution of GC therapy, there was a marked reduction of liver enzymes and amelioration of liver function. Complete normalization was achieved two months later, while the patient was still receiving a low maintenance dose of oral prednisone.

[The role of radiotherapy in Graves' ophthalmopathy]

Radiotherapy is a well-established method of treatment for Graves' ophthalmopathy. The main rationale is its anti-inflammatory effect and the high radiosensitivity of T lymphocytes and orbital fibroblasts, which are important effectors in the immune reactions characterizing this disorder. Most centers use a dose of 20 Gy, ten daily doses of 2 Gy given over a period of 2 weeks. Overall favorable responses have been reported in 60% of cases. The best responses were noted for inflammatory signs and recent onset of extraocular muscle involvement. Radiotherapy is well tolerated and safe. A careful selection of patients is necessary. New randomized studies will have to evaluate new radiotherapy protocols with or without corticosteroids or medical immunosuppression.

Thyroid-associated orbitopathy: a clinicopathologic and therapeutic review

PURPOSE OF REVIEW

To review the literature related to thyroid-associated orbitopathy and to emphasize recent developments in its pathophysiology, diagnosis, and therapy. Current therapeutic trends and controversies are discussed.

RECENT FINDINGS

Expression of thyroid stimulating hormone receptor is highest in the fat and connective tissue of patients with thyroid-associated orbitopathy, where fibroblasts have the potential for adipogenesis. Electrophysiology can now detect subclinical optic neuropathy, and somatostatin-receptor scintigraphy can help justify immunomodulation. Other than steroids, radiotherapy can control inflammation, but its use is controversial. Current trends in orbital decompression are to camouflage incisions and to limit strabismus with balanced decompression, deep lateral wall techniques, fat removal, and onlay implants. Proptosis reductions of 0.9 to 12.5mm are possible by the use of various algorithms. Before or after decompression, botulinum toxin can correct strabismus, intraocular pressure elevation, and retraction. The latter is now also treated with full-thickness blepharotomy.

SUMMARY

As knowledge of the pathophysiology of thyroid-associated orbitopathy grows, there is a slow movement from nonspecific and invasive measures to more directed treatments causing less morbidity.

Transcaruncular orbital decompression for management of compressive optic neuropathy in thyroid-related orbitopathy

This study was conducted to assess the outcome of transcaruncular orbital decompression to treat compressive optic neuropathy in thyroid-related orbitopathy. It involved a retrospective, noncomparative case series of 18 eyes of 10 consecutive patients with documented vision loss secondary to thyroid-related orbitopathy. Bony decompression of the orbital apex was performed via a transcaruncular approach. Main outcome measures were visual acuity, color vision, presence of diplopia, and reduction of exophthalmos. Of 18 eyes, 16 (89 percent) had improved visual acuity after the operation. One eye had no improvement and one had worsening of vision in the setting of diabetic retinopathy. Color vision was improved in 12 eyes (67 percent). Five of the patients did not have diplopia before the operation; none of these patients developed double vision after intervention. Exophthalmos was decreased by an average of 2.6 mm. The authors conclude that transcaruncular orbital decompression for compressive optic neuropathy in thyroid-related orbitopathy is successful in restoring visual function. Compared with other approaches used for decompression surgery, the transcaruncular approach offers direct access to the medial wall and orbital apex without a cutaneous incision or disruption of the medial canthus. In addition, this approach allows a controlled, graded removal of the ethmoidal air cells and reduced recovery time.

Effect of steroid pulse therapy with and without orbital radiotherapy on Graves' ophthalmopathy

PURPOSE

To report the effect of high-dose intravenous corticosteroid pulse therapy with and without orbital radiotherapy on Graves' ophthalmopathy.

DESIGN

Nonrandomized clinical trial.

METHODS

We selected 39 Japanese patients (age range, 22-64 years; mean, 48 years; 31 women, 8 men) who had active Graves' ophthalmopathy among 195 consecutive patients. In the first 20 patients, high-dose intravenous methylprednisolone pulse therapy (1 g per day for 3 successive days, repeated 3 times within 3 weeks) followed by 24-Gy orbital radiotherapy was performed. In the other 19 of the 39 patients, high-dose intravenous methylprednisolone pulse therapy without orbital radiotherapy was performed. Coronal computed tomography (CT) of the orbit and exophthalmometry were performed before the corticosteroid pulse therapy, and 1 and 6 months after the corticosteroid pulse therapy. The maximum coronal section area of the most hypertrophic rectus muscle in each eye was measured based on orbital CT imaging.

RESULTS

Clinical findings at study entry were not significantly different between the two groups. No significant difference was found in the maximum coronal section area of the most hypertrophic rectus muscle and the results of exophthalmometry measurements in both groups before the therapy. Extraocular muscle hypertrophy was significantly reduced 1 month and 6 months after the therapy (P < .01) in both groups. However, no beneficial therapeutic effect on proptosis was observed in either group at 1 month and 6 months after the therapy. No significant difference in the therapeutic effect on extraocular muscle hypertrophy and proptosis was found between the two groups.

CONCLUSIONS

Orbital irradiation after corticosteroid pulse therapy had no beneficial therapeutic effects on rectus muscle hypertrophy or proptosis of active Graves' ophthalmopathy during the 6-month follow-up period.

Orbital radiotherapy for Graves' ophthalmopathy: useful or useless? Safe or dangerous?

Treatment of Graves' ophthalmopathy does not always provide favorable results. After several decades of efforts, glucocorticoids, orbital radiotherapy (OR) and surgery (orbital decompression) remain the milestones in the management of this disease. OR produce favorable results in about 55-60% of patients. Its effectiveness is increased by the association with systemic glucocorticoids. Recent studies have cast some doubts on its real effectiveness and this is discussed by participants in this Forum. Selection of patients is particularly important to assess treatment outcome, because OR is unlikely to provide beneficial effects in patients with longstanding and inactive eye disease. OR is a safe procedure, with very limited side-effects. It should be used in patients older than 35 years of age. It is recommended that a large, multi-center, prospective, randomized and controlled study with well defined inclusion criteria be carried out to draw sound conclusions on the role of OR in the management of Graves' ophthalmopathy.