Management of Graves' ophthalmopathy: reality and perspectives

Therapeutic effect of nintedanib in orbital fibroblasts in patients with Graves' orbitopathy

BACKGROUND

Nintedanib is a potent antifibrotic angiokinase inhibitor approved for various fibrotic lung diseases. Potential therapeutic efficacy of nintedanib in various inflammatory diseases is under investigation. In this study, we investigated the therapeutic effect of nintedanib on adipogenesis and fibrosis in orbital fibroblasts in patients with Graves' orbitopathy (GO).

METHODS

Primary orbital fibroblasts were cultured from orbital connective tissue of patients with GO and healthy controls. The cells were pretreated with nintedanib before stimulation with either interleukin (IL)-1β, transforming growth factor (TGF)-β, insulin-like growth factor-1, or IL-11. Fibrosis-related and intracellular signaling protein expressions were assessed using western blotting. Hyaluronan and procollagen concentrations were quantified using enzyme-linked immunosorbent assay. Adipogenesis was quantified by Oil Red O staining and the levels of adipogenic transcription factors were determined by Western blot.

RESULTS

TGF-β-induced fibronectin and collagen 1/3 protein expression was abrogated by nintedanib treatment. Nintedanib decreased the phosphorylation of signal transducer and activator of transcription 3, SMAD 2/3, Akt, c-Jun N-terminal kinase, and extracellular regulated protein kinase. Exposure to nintedanib hindered adipocyte differentiation and expression of adipogenic transcription factors, including peroxisome proliferator-activated receptor γ, CCAAT/enhancer-binding protein α/β, adipocyte protein 2, adiponectin, and leptin. Additionally, nintedanib reduced hyaluronan and procollagen secretion.

CONCLUSIONS

Nintedanib suppressed profibrotic protein production, adipogenesis, and hyaluronan production in in vitro. These findings indicate the potential therapeutic efficacy of nintedanib in GO management.

Regional Differences in the Management of Thyroid Eye Disease: Results from an International Clinical Practice Survey of Endocrinologists

Background: Over the past several decades, there have been indications of potential shifts in the diagnostic strategies and treatment of patients with Graves' disease (GD) and thyroid eye disease (TED). The objective of this study was to evaluate current practices in managing GD when complicated by moderate-to-severe TED worldwide. Methods: We recently reported results from a global online survey of endocrinologists comparing the management of GD in different scenarios. The current analysis focuses on regional differences in the diagnosis and treatment of GD when complicated by TED. Results: A total of 1252 respondents from 85 countries completed the survey. Regarding the initial diagnostic and treatment measures, there were no differences among the various geographical regions. Regarding the treatment of moderate-to-severe TED, the use of sodium selenite was higher in Europe (66.5%) and Oceania (60%) compared to other regions (p < 0.001). North American respondents were more likely to recommend teprotumumab and less likely to use glucocorticoids (p < 0.001). When comparing the treatment options for GD in patients with TED, although prolonged use of antithyroid drugs (ATD) remained the first choice in all regions, respondents from Europe, North America, and Oceania were more likely to recommend thyroidectomy than those from other regions (p < 0.001). Ophthalmologists, rather than endocrinologists, would more often be responsible for prescribing advanced medical therapy for TED in North America, Oceania, and Africa, while endocrinologists would have primary responsibility in other regions of the globe. Conclusions: Although there are regional differences, respondents generally employ the recommended diagnostic tools, treatments, and a multidisciplinary approach suggested by current clinical practice guidelines. However, there were examples of deviations from current guidance from professional societies.

Teprotumumab Use in Thyroid Eye Disease: Clinical Outcomes in the United Arab Emirates- a First Regional Case Series

BACKGROUND

Thyroid eye disease (TED), an autoimmune disorder frequently associated with Graves' disease, manifests as orbital inflammation, proptosis, diplopia, and vision impairment, significantly diminishing quality of life. Traditional treatments, such as corticosteroids and rituximab, exhibit variable efficacy, while targeted therapies like teprotumumab, an insulin-like growth factor-1 receptor (IGF-1 R) inhibitor, have shown promise, particularly in the United States. However, data from the Middle East, including the United Arab Emirates (UAE), remain scarce, highlighting the need for regional studies.

OBJECTIVE

To evaluate the clinical efficacy and safety of teprotumumab in TED patients in the UAE, presenting the first case series from the Gulf region.

METHODS

This retrospective case series analysed 14 patients (25 eyes) with moderate-to-severe TED who completed eight teprotumumab cycles. Outcomes-proptosis reduction (primary), Clinical Activity Score (CAS), double vision, quality of life (TED-QOL), stability, and adverse effects-were assessed at 24 weeks and 6 months post-treatment using standardized measures.

RESULTS

Teprotumumab reduced proptosis by 2.64 mm at 24 weeks (p < .0001) and 2.32 mm at 6 months (p < .0001), with 68% of eyes achieving ≥ 2 mm reduction. CAS dropped from 5.21 to 0.35 (p < .0001), double vision improved in 85.7% of cases, and QoL enhanced across all domains (p < .001). Stability persisted at 6 months, with tolerable adverse effects.

CONCLUSION

Teprotumumab is effective and safe for TED in the Gulf region, offering sustained benefits. Larger, longer-term studies are needed to confirm efficacy, recurrence, and safety.

Development and validation of a surgical robot system for orbital decompression surgery

PURPOSE

Orbital decompression surgery, which expands the volume of the orbit by removing sections of the orbital walls with a drill and saw, is an important treatment option for thyroid-associated ophthalmopathy. However, it is often limited by physical factors such as a narrow operating space and instability of the manual holding of surgical instruments, which constrains doctors from accurately executing surgical planning.

METHODS

To overcome these limitations, we designed a surgical robot comprising position adjustment, remote center of motion, and end-effector with a rapid surgical instrument assembly mechanisms. Additionally, to guide surgical robots in precisely performing preoperative surgical planning, we constructed a surgical navigation system comprising preoperative surgical planning and intraoperative optical navigation subsystems. An internally complementary orbital surgical robot system in which the navigation system, optical tracker, and surgical robot and its motion control system serve as the decision-making, perception, and execution layers of the system, respectively, was developed.

RESULTS

The results of precision measurement experiments revealed that the absolute and repeated pose accuracies of the surgical robot satisfied the design requirements. As verified by animal experiments, the precision of osteotomy and bone drilling operation of orbital surgical robot system can meet the clinical technical indicators.

CONCLUSION

The developed orbital surgical robotic system for orbital decompression surgery could perform routine operations such as drilling and sawing on the orbital bone with assistance and supervision from surgeons. The feasibility and reliability of the orbital surgical robot system were comprehensively verified through accuracy measurements and animal experiments.

Neural network-based automated proptosis measurement using computed tomography images for patients with thyroid-associated orbitopathy

The purpose of this study was to evaluate the clinical feasibility and reliability of a neural network (NN)-based automated proptosis measurement system using computed tomography (CT) images. An automated proptosis measurement system was developed using the CT images of 200 eyes from 100 patients diagnosed with thyroid-associated orbitopathy. We compared the proptosis value obtained from the proposed automated system with the values obtained from the Hertel exophthalmometer and manual measurements of CT slices. The average measurement values were 17.77 ± 2.47 mm with the Hertel exophthalmometer, 18.87 ± 2.68 mm with the manual measurement of CT slices, and 19.30 ± 2.76 mm with the proposed automated system. There was no significant difference in the proptosis values measured using the manual and automated NN-based methods (p = 0.241). The values obtained from manual measurement and automated measurement using CT images showed excellent agreement with an intraclass correlation coefficient of 0.95. Based on the Bland-Altman plots, the 95% limits of agreement between manual CT and NN-based measurements were much smaller than those between Hertel exophthalmometer measurement and manual and NN-based measurements. In conclusion, automated NN-based measurements could provide a straightforward and efficient method for measuring proptosis using CT images.

Emergency Endoscopic Endonasal Optic Nerve Decompression for Graves' Orbitopathy

Graves' orbitopathy (GO) is a rare autoimmune disease that affects patients in their fourth to sixth decade, resulting in retro-orbital inflammation and hypertrophy of extraocular muscles and orbital fat. It is the most common disease affecting the orbit globally, and treatment options vary depending on the severity and activity status of the affection, ranging from local measures such as lubricating eye drops and patching, glucocorticoid eye drops, mydriatics, nonsteroid anti-inflammatory medications to systemic glucocorticoids, and emergency orbital decompression surgery. Immunotherapy and orbital radiation may as well be used as a treatment option even though their efficiency remains controversial. This paper presents the cases of two patients with GO who underwent endoscopic endonasal decompressive surgery. These patients' medical records, including symptoms and duration, clinical examination, imaging results, preoperative preparation, surgery steps, and postoperative course and outcomes, were collected from various specialties, including ophthalmologists and endocrinologists. We highlight the importance of a multidisciplinary approach to managing GO and its complications, with endoscopic endonasal techniques emerging as a minimally invasive and effective way to treat compressive optic nerve forms of the disease. However, the timing of decompression remains crucial, and early intervention is recommended to avoid sight-threatening ophthalmopathy when medical therapies are ineffective.

A retrospective study on the effectiveness of intensity modulated radiation therapy for thyroid associated ophthalmopathy at a single institute

Thyroid-associated ophthalmopathy (TAO) is a hallmark autoimmune condition, and the treatment of TAO requires a multidisciplinary approach. Radiation therapy (RT) is a viable treatment option for active TAO, IMRT is a more precise technology in radiation oncology. This study aims to evaluate the efficacy, feasibility, and safety of orbital intensity-modulated radiation therapy (IMRT) in the treatment of TAO. A single-center retrospective analysis was conducted, including patients diagnosed with moderate to severe active TAO at the Department of Radiation Oncology, Peking University Third Hospital, from October 2020 to October 2023, who had poor responses to corticosteroid treatment. These patients subsequently received IMRT treatment, followed by a period of follow-up and retrospective analysis. The study focused on the outcomes of treatment efficacy, safety, and acute toxic reactions induced by radiation therapy. Improvements in clinical activity score (CAS) at 4 and 12 months were considered as primary and secondary study endpoints, respectively, along with the incidence rate of adverse events. The median follow-up period was 12 months. The median follow-up time after radiation therapy was 12 months. There was no statistically significant difference in CAS between before and 4 months after radiation therapy (CAS: 5.53 ± 2.07 vs.4.68 ± 2.62; R squared: 0.21; 95% CI: - 1.01-0.02; P = 0.054). However, there was a significant reduction in CAS 12 months post-treatment compared to pre-treatment (CAS: 5.53 ± 2.07 vs. 3.06 ± 2.38; R squared: 0.66; 95% CI: 3.42 - 1.52; P < 0.001). The CAS showed a progressively decreasing trend at both 4 months and 12 months post-treatment. In the combined radiotherapy with glucocorticoid treatment group, a statistically significant difference was found between the CAS before treatment and 12 months after radiotherapy (CAS: 6.38 ± 2.00 vs. 3.88 ± 2.85; R squared: 0.66; 95% CI - 4.11 to 0.89; P = 0.008). In the radiotherapy alone group, a statistically significant difference was found between the CAS before treatment and 12 months after radiotherapy (CAS: 4.78 ± 1.92 vs. 2.33 ± 1.73; R squared: 0.66; 95% CI - 3.89 to 1.00; P = 0.005). A few patients experienced Grade I periorbital edema, conjunctival congestion, and dry eye syndrome, but no adverse events such as cataracts, radiation retinopathy, or radiation-induced optic neuropathy were observed by the end of the follow-up period. Orbital IMRT is an effective treatment modality for moderate to severe active TAO, demonstrating significant efficacy even in patients who had not achieved success with previous treatments such as corticosteroids. This retrospective study was approved by the Ethics Committee of Peking University Third Hospital. The permit number was M2024220 and data of registration was April I, 2024.

Thyroid-associated ophthalmopathy: the role of oxidative stress

Thyroid-associated ophthalmopathy (TAO) is an autoimmune condition affecting the eyes, characterized by proptosis, extraocular muscle involvement, and in severe cases, vision impairment including diplopia, optic neuropathy, and potential blindness. The exact etiology of TAO remains elusive; however, increased oxidative stress and decreased antioxidant capacity are pivotal in its pathogenesis. Elevated oxidative stress not only directly damages orbital tissues but also influences thyroid function and autoimmune responses, exacerbating tissue destruction. This review explores the role of oxidative stress in TAO, elucidates its mechanisms, and evaluates the efficacy and limitations of antioxidant therapies in managing TAO. The findings aim to enhance understanding of oxidative stress mechanisms in TAO and propose potential antioxidant strategies for future therapeutic development.

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.

Potential involvement of the bone marrow in experimental Graves' disease and thyroid eye disease

Introduction

Graves' disease is an autoimmune disorder caused by auto-antibodies against the thyroid stimulating hormone receptor (TSHR). Overstimulation of the TSHR induces hyperthyroidism and thyroid eye disease (TED) as the most common extra thyroidal manifestation of Graves' disease. In TED, the TSHR cross talks with the insulin-like growth factor 1 receptor (IGF-1R) in orbital fibroblasts leading to inflammation, deposition of hyaluronan and adipogenesis. The bone marrow may play an important role in autoimmune diseases, but its role in Graves' disease and TED is unknown. Here, we investigated whether induction of experimental Graves' disease and accompanying TED involves bone marrow activation and whether interference with IGF-1R signaling prevents this activation.

Results

Immunization of mice with TSHR resulted in an increase the numbers of CD4-positive T-lymphocytes (p ≤0.0001), which was normalized by linsitinib (p = 0.0029), an increase of CD19-positive B-lymphocytes (p= 0.0018), which was unaffected by linsitinib and a decrease of GR1-positive cells (p= 0.0038), which was prevented by linsitinib (p= 0.0027). In addition, we observed an increase of Sca-1 positive hematopietic stem cells (p= 0.0007) and of stromal cell-derived factor 1 (SDF-1) (p ≤0.0001) after immunization with TSHR which was prevented by linsitinib (Sca-1: p= 0.0008, SDF-1: p ≤0.0001). TSHR-immunization also resulted in upregulation of CCL-5, IL-6 and osteopontin (all p ≤0.0001) and a concomitant decrease of the immune-inhibitory cytokines IL-10 (p= 0.0064) and PGE2 (p ≤0.0001) in the bone marrow (all p≤ 0.0001). Treatment with the IGF-1R antagonist linsitinib blocked these events (all p ≤0.0001). We further demonstrate a down-regulation of arginase-1 expression (p= 0.0005) in the bone marrow in TSHR immunized mice, with a concomitant increase of local arginine (p ≤0.0001). Linsitinib induces an upregulation of arginase-1 resulting in low arginase levels in the bone marrow. Reconstitution of arginine in bone marrow cells in vitro prevented immune-inhibition by linsitinib.

Conclusion

Collectively, these data indicate that the bone marrow is activated in experimental Graves' disease and TED, which is prevented by linsitinib. Linsitinib-mediated immune-inhibition is mediated, at least in part, by arginase-1 up-regulation, consumption of arginine and thereby immune inhibition.

Clinical significance of the detection of serum IgG4 and IgG4/IgG ratio in patients with thyroid-associated ophthalmopathy

To evaluate the clinical significance of detecting serum IgG4 and the IgG4/IgG ratio in patients with thyroid-associated ophthalmopathy (TAO) and to explore whether high serum IgG4 levels and the IgG4/IgG ratio are associated with the severity and activity of TAO, we retrospectively assessed the records of 78 TAO patients and 32 controls collected in our hospital from July 2020 to July 2022. The TAO patients were divided into TAO inactive and TAO active phase groups according to the clinical activity score (CAS), and we evaluated the association between the serum IgG4 levels, the IgG4/IgG ratio, and the clinical data of the participants. The levels of IgG4 significantly increased in the TAO active group compared to those in the inactive and control groups (P < 0.05). Additionally, the number of patients with increased IgG4 levels (≥135 mg/dL) in the TAO active group was markedly higher than that in the inactive and control groups (P < 0.05). The IgG4/IgG ratio was also significantly enhanced in the TAO active group compared to the inactive and control groups (P < 0.05). CAS was identified as an independent factor influencing IgG4 levels in patients with TAO. The levels of serum IgG4, as well as the IgG4/IgG ratio, were significantly increased in some patients with active TAO, and they were related to the CAS, suggesting that the pathogenesis of TAO may be heterogeneous.

Linsitinib, an IGF-1R inhibitor, attenuates disease development and progression in a model of thyroid eye disease

Introduction

Graves' disease (GD) is an autoimmune disorder caused by autoantibodies against the thyroid stimulating hormone receptor (TSHR) leading to overstimulation of the thyroid gland. Thyroid eye disease (TED) is the most common extra thyroidal manifestation of GD. Therapeutic options to treat TED are very limited and novel treatments need to be developed. In the present study we investigated the effect of linsitinib, a dual small-molecule kinase inhibitor of the insulin-like growth factor 1 receptor (IGF-1R) and the Insulin receptor (IR) on the disease outcome of GD and TED.

Methods

Linsitinib was administered orally for four weeks with therapy initiating in either the early ("active") or the late ("chronic") phases of the disease. In the thyroid and the orbit, autoimmune hyperthyroidism and orbitopathy were analyzed serologically (total anti-TSHR binding antibodies, stimulating anti TSHR antibodies, total T4 levels), immunohistochemically (H&E-, CD3-, TNFa- and Sirius red staining) and with immunofluorescence (F4/80 staining). An MRI was performed to quantify in vivo tissue remodeling inside the orbit.

Results

Linsitinib prevented autoimmune hyperthyroidism in the early state of the disease, by reducing morphological changes indicative for hyperthyroidism and blocking T-cell infiltration, visualized by CD3 staining. In the late state of the disease linsitinib had its main effect in the orbit. Linsitinib reduced immune infiltration of T-cells (CD3 staining) and macrophages (F4/80 and TNFa staining) in the orbita in experimental GD suggesting an additional, direct effect of linsitinib on the autoimmune response. In addition, treatment with linsitinib normalized the amount of brown adipose tissue in both the early and late group. An in vivo MRI of the late group was performed and revealed a marked decrease of inflammation, visualized by ¹⁹F MR imaging, significant reduction of existing muscle edema and formation of brown adipose tissue.

Conclusion

Here, we demonstrate that linsitinib effectively prevents development and progression of thyroid eye disease in an experimental murine model for Graves' disease. Linsitinib improved the total disease outcome, indicating the clinical significance of the findings and providing a path to therapeutic intervention of Graves' Disease. Our data support the use of linsitinib as a novel treatment for thyroid eye disease.

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

Backgrounds

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

Methods

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

Results

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

Conclusions

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

Systematic Review Registration

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

Influence of biological sex, age and smoking on Graves’ orbitopathy – a ten-year tertiary referral center analysis

Purpose

Severity of Graves’ orbitopathy (GO) shows wide individual differences. For optimal treatment, it is important to be able to predict the natural course of the disease as accurate as possible to counteract with anti-inflammatory and surgical treatment. Therefore, we aimed to further elucidate the impact of sex, age and smoking on GO.

Methods

We collected the clinical and demographic data of all patients of our tertiary referral center from January 2008 till December 2018 and analyzed it with descriptive statistics. Only patients with a complete data set were included in the further analysis. Odds ratio’s for moderate-to-severe and sight-threatening GO in relation to age, sex and smoking were calculated by means of multivariate logistic regression models.

Results

We evaluated the data of 4260 patient with GO and complete data sets. Most of these were women (83%). There were no significant differences between male and female patients regarding smoking habits and thyroid treatment. Men were significantly older at initial manifestation of TED (51.8 vs. 49.9y, p&lt;0.01) and showed significant more often severe stages (61% vs. 53%, p&lt;0.0001). Therefore, they needed significantly more intense treatment with steroids, irradiation, orbital decompression and muscle surgery. In multivariate logistic regression analyses age (OR 0.97, 95% CI:0.97-0.98, p&lt;0.0001), male sex (OR 1.64, 95% CI:1.38-1.9, p&lt;0.0001), smoking (OR 1.19, 95% CI:1.04-1.36, p=0.01), Grave’s disease (OR 1.55, 95% CI:1.26-1.90, p&lt;0.0001) and history of radioiodine treatment (RAI) (OR 2.44, 95% CI:2.10-2.86, p&lt;0.0001) showed an significant association with severe stages of GO.

Discussion

Our retrospective analysis showed once more that women are more often afflicted by GO. In contrast, men seem to be more severely afflicted and in need of anti-inflammatory and surgical treatments. This might be due to a different approach to the health system and resilience to GO specific symptoms, as well as previously described worse thyroid control. Estrogen mediated effects might also play a role as in other autoimmune diseases and should be subject of further trials. Besides the biological sex, smoking could again be confirmed as serious risk factor for severe GO. Of note, RAI was associated with more severe stages of GO, which should be subject to further investigation.

Optical coherence tomography and optical coherence tomography — angiography used in endocrine ophthalmopathy

The literature review presents the results of optical coherence tomography and optical coherence tomography — angiography used for Graves’ orbitopathy. The data on the thickness of the inner layers of the retina, microcirculation in the peripapillary and macular regions, parameters of the choroid, lamina cribrosa and extraocular muscles were analyzed as possible diagnostic criteria of the condition.

Update on the surgical management of Graves' orbitopathy

Graves' orbitopathy (GO) is a complex autoimmune disorder of the orbit that causes the eye to appear disfigured. GO is typically associated with Graves' disease, an inflammatory autoimmune condition that is caused by thyrotropin receptor autoantibodies. Although our knowledge of the pathophysiology of GO has improved, its exact pathogenesis remains unclear. Some patients suffer from disfigurement, double vision, and even vision loss rather than hyperthyroidism. The disease severity and activity prompt different treatments, as the signs of GO are heterogeneous, so their management can be very complex. Despite medical advances, the first-line treatment for moderate-to-severe active GO is still glucocorticoids, while surgery can be critical for the treatment of chronic inactive GO. Surgery is sometimes required in the acute phase of the disease when there is an immediate risk to vision, such as in dysthyroid optic neuropathy. Most surgeries for GO are rehabilitative and subdivided into three categories: decompression, strabismus repair, and lid surgery. This review is a basic overview of the field, with up-to-date knowledge of the surgical techniques for GO. We review and summarize recent literature on the advances in surgery for GO to provide up-to-date insights on the optimal surgical treatment for GO.

Automatic measurement of exophthalmos based orbital CT images using deep learning

Introduction: Objective, accurate, and efficient measurement of exophthalmos is imperative for diagnosing orbital diseases that cause abnormal degrees of exophthalmos (such as thyroid-related eye diseases) and for quantifying treatment effects. Methods: To address the limitations of existing clinical methods for measuring exophthalmos, such as poor reproducibility, low reliability, and subjectivity, we propose a method that uses deep learning and image processing techniques to measure the exophthalmos. The proposed method calculates two vertical distances; the distance from the apex of the anterior surface of the cornea to the highest protrusion point of the outer edge of the orbit in axial CT images and the distance from the apex of the anterior surface of the cornea to the highest protrusion point of the upper and lower outer edges of the orbit in sagittal CT images. Results: Based on the dataset used, the results of the present method are in good agreement with those measured manually by clinicians, achieving a concordance correlation coefficient (CCC) of 0.9895 and an intraclass correlation coefficient (ICC) of 0.9698 on axial CT images while achieving a CCC of 0.9902 and an ICC of 0.9773 on sagittal CT images. Discussion: In summary, our method can provide a fully automated measurement of the exophthalmos based on orbital CT images. The proposed method is reproducible, shows high accuracy and objectivity, aids in the diagnosis of relevant orbital diseases, and can quantify treatment effects.

Characterization of human tear proteome reveals differentially abundance proteins in thyroid-associated ophthalmopathy

Background

Thyroid-associated ophthalmopathy (TAO) is a common orbital inflammatory disease, but the abnormal expression of proteins in tears of TAO patients has not been systematically studied. The purpose of this study is to compare and analyze the total tear protein profile of TAO patients and to provide protein cues for TAO pathogenesis.

Methods

Tear samples were isolated from 30 TAO patients with obvious ocular surface damage and 30 healthy control subjects. Tear samples from 30 individuals were mixed and divided into three sample pools. Easy nano-scale LC-MS/MS based on labeling-free quantitative technology was utilized to profile tear proteome.

Results

Here, electrospray ionization mass spectra and SDS-PAGE results confirmed the good parallelisms among samples. A total of 313 proteins were obtained from six tear pools, among them, 103 differential abundance proteins (DAPs) were identified, including 99 up-regulated DAPs (including APOA1, HV103, IGH, and Transferrin variant) and four down-regulated DAPs (including FABA, VCC1, NUCB2, and E-cadherin) in the TAO group compared with the control group. GO analysis showed that up-regulated DAPs were mainly enriched in lipid metabolism and platelet molecular function, and down-regulated DAPs were involved in binding, cell junction, and cellular process. KEGG results indicated that DAPs were involved in 117 kinds of signal transduction pathways, among which the immune-related pathway of complement and coagulation cascades had the greatest relevance.

Conclusion

In conclusion, label-free LC-MS/MS is an effective strategy for profiling tear proteins component. Our study provides proteins and pathways altered in TAO and provides protein cues for further study on the precise mechanism of TAO pathogenesis.

Is Estrogen a Missing Culprit in Thyroid Eye Disease? Sex Steroid Hormone Homeostasis Is Key to Other Fibrogenic Autoimmune Diseases - Why Not This One?

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.

Graves’ Ophthalmopathy in the Setting of Primary Hypothyroidism

Graves’ ophthalmopathy (GO) is commonly associated with hyperthyroidism secondary to Graves’ disease (GD). Although rare, there have been case reports of it occurring in patients who are hypothyroid with underlying Hashimoto’s thyroiditis (HT), as well as in euthyroid patients. Below, we describe a case of GO developing in a patient who has hypothyroidism secondary to HT successfully treated with high-dose steroids.

We present a case of a 53-year-old female known to have primary hypothyroidism (Hashimoto’s thyroiditis) diagnosed at the age of 39 years and has been on levothyroxine since diagnosis. She presented to our endocrine clinic complaining of new-onset diplopia and periorbital swelling for five months. There is no previous hyperthyroid state or radioactive iodine therapy. Examination showed left-sided upper and lower eyelid swelling, limited abduction with diplopia, and mild punctate keratopathy. Laboratory investigation revealed positive thyroid-stimulating immunoglobulin of 500 IU/mL (normal value: <140 IU/mL) with thyroid-stimulating hormone (TSH) and free thyroxine (FT4) in the euthyroid range. She was found to have a small heterogeneous thyroid gland on ultrasound suggestive of atrophic thyroiditis, and magnetic resonance imaging (MRI) of the orbits demonstrated bilateral ocular proptosis with extraocular muscle enlargement.

The patient was diagnosed with active moderate-severe isolated GO with a background of HT, clinically and biochemically euthyroid on levothyroxine. She was referred to an ophthalmologist and was started on a course of high-dose oral prednisone tapered over three months, which was followed by oral selenium and botox injections to both medial recti muscles.

Graves’ ophthalmopathy is an uncommon presentation in hypothyroid and euthyroid patients but should be considered in the differential diagnosis. The incidence varies between studies from 2% to 7.5%. Awareness of this clinical presentation is important, as early detection and treatment can prevent visual complications. To date, there are no clear guidelines on how to treat GO with underlying HT. Treating our patient with high-dose steroids extrapolated from treating GO secondary to GD showed significant improvement in her symptoms.

Clinical and diagnostic evaluation of the effectiveness of treatment of optic neuropathy in patients with edematous endocrine ophthalmopathy

The aim: to conduct a clinical and diagnostic evaluation of the effectiveness of the administration of a complex of drugs in the region of hemolymphocirculation in optical neuropathy in patients with edematous form of endocrine ophthalmopathy.

Materials and methods. The results of diagnosis and treatment of 31 patients (61 eyes) with optical neuropathy on the background of edematous exophthalmos in endocrine ophthalmopathy were analyzed. To identify hidden forms of optical neuropathy, such studies were prescribed as computer microperimetry on a confocal infrared ophthalmoscope, a complex of electroretinographic studies: registration of maximum ERG, oscillatory potentials. Latent forms of optical neuropathy were detected in 22 cases. In 9 cases, there were obvious forms of optical neuropathy. All patients underwent a 10-day course of intensive complex treatment, consisting of injections into the region of hemolymphocirculation (projection of the pterygoid fossa) No. 6–8 (No. 3–4 on each side) with an interval of 24 hours of a drug mixture, the formulation of which included Lidocaine 20 mg, Dexazone 4 mg, Hemase 3000 UNITS, Dalargin 1 mg.

Results. In all patients, there was a pronounced positive dynamics in the form of a significant (from 0.6 to 1.0) increase in visual acuity, a decrease in exophthalmos from (2.0 to 3.0 mm), an increase in color and contrast sensitivity.

Conclusions. Due to the violation of venous and lymphatic outflow due to thickening of extraocular muscles and retrobulbar fiber, injections into the hemolymphocirculation region (projection of the pterygoid fossa) of drugs with a wide range of decongestant and metabolic effects are justified, effective and safe. 

Epidemiological Status of Thyroid Eye Disease in Central Iran

Purpose

To focus on clinical manifestations and epidemiology of thyroid eye disease (TED) in Central Iran's population.

Methods

In this retrospective case study, we analyzed all patients with TED who were referred to our oculoplastic clinic from 2015 to 2019. The patients' epidemiological characteristics and clinical presentation were compared between different thyroid disease groups and genders.

Results

Overall, 383 patients (155 male; 40.5% and 228 female; 59.5%) were included. The mean age was 39.55 years (standard deviation ± 13.45, range 10-72). Most patients (89%) were hyperthyroid with the highest duration of ocular involvement among all categories (25.6 months). The most common signs on ophthalmic examinations were proptosis (80.4%), followed by eyelid retraction (72.3.0%). TED was classified as mild in 24.5%, moderate to severe in 67.6%, and sight-threatening in 7.9%. Thirty patients (7.8%) had active TED.

Conclusions

This series with a relatively more significant number of TED cases in Central Iran found similar epidemiological and clinical characteristics of TED compared to other studies from Iran. Most of our patients were hyperthyroid, with more females compared to males. Proptosis and eyelid retraction were the most common manifestations. Most TED patients were classified as moderate to severe.

[Treatment of Graves' disease in patients with thyroid eye disease]

Graves' disease (GD) is an autoimmune disease that is often complicated by thyroid eye disease (TED). Clinical presentations of TED can develop simultaneously with the manifestation of GD, after the manifestation of GD amid treatment, and before the development of thyrotoxicosis. Treatment of such patients is a difficult task, because on the one hand, it is necessary to take into account the clinical picture of thyrotoxicosis, and on the other - the symptoms of eye damage. The combination of the two pathologies determines the need for simultaneous treatment of GD and TED, and the choice of a treatment method for GD will depend on the manifestations of TED. This article presents current views on the treatment of GD with concomitant TED. The choice of GD treatment method will be largely determined by the clinical manifestations of TED and will be conducted jointly by endocrinologists and ophthalmologists.

Monitoring and Predicting Treatment Response of Extraocular Muscles in Grave's Orbitopathy by 99mTc-DTPA SPECT/CT

Objective: To investigate single-photon emission computed tomography/computed tomography (SPECT/CT) for assessing inflammation in the extraocular muscles (EOMs) and predicting the therapeutic efficacy of periocular glucocorticoid therapy (PGT) for Grave's ophthalmopathy (GO). Materials and Methods: A total of 412 eyes from 206 patients with GO referred for 99mTc-DTPA orbital SPECT/CT were enrolled. Fourteen age- and gender-matched healthy controls (28 eyes) were included. The thickness and uptake ratio (UR) of four EOMs were derived from SPECT/CT. Eighty-six eyes from patients with GO patients received PGT. Changes in SPECT/CT parameters were evaluated between the pre- and post-treatment. Results: 195 eyes and 217 eyes were classified as active and inactive stages by clinical activity score (CAS). Values of the thickness and UR of each EOM, Tmax, and Umax were all significantly higher in the active GO than in the inactive GO and controls (p < 0.01). Among the 86 eyes (48 GO patients) included in the efficacy analysis, 56 eyes and 30 eyes were classified as responders and non-responders. Values of thicknesses and UR of each EOM, the maximum thickness (Tmax), and the maximum UR (Umax) all dropped following PGT in the responders (p < 0.01). Logistic regression analysis identified the Umax as an independent predictor for the responders (p < 0.01). Moreover, the Umax demonstrated incremental predictive value over clinical characters and CAS, as evidenced by the improved area under the curve (0.85 vs. 0.78) and global chi-square (34.12 vs. 18.1). Conclusion: 99mTc-DTPA SPECT/CT has the potential to assess inflammatory activity by detecting the involvement of EOMs in GO. Pre-treatment UR provides independent and incremental values for the prediction of PGT treatment response.

Antiphospholipid antibodies in patients with Graves' orbitopathy: preliminary data

PURPOSE

Graves' orbitopathy (GO) is an inflammatory autoimmune disorder of the orbit and while the antiphospholipid antibodies (aPL) Abs were associated with the markers of inflammation in the antiphospholipid syndrome (APS), there is no literature that investigate the presence of aPL Abs in GO. We analyzed the prevalence of aPL Abs and the differences between aPL (+) and aPL (-) subgroups of GO patients.

METHODS

Study included consecutive patients with GO (66 with Graves' (GD), 10 with Hashimoto (HD), and 8 were euthyroid). Anticardiolipin (aCL) and anti-beta 2glycoprotein I (aβ2gpI) Abs were measured by ELISA.

RESULTS

aPL Abs were present in 9/84 (10.71%) patients. The IgM aβ2gpI Abs were present in 8/66 and in 1/10 patients with GD and HD. The IgG aCL Abs were present in one GD patient, and IgM aCL were present in 3/66 GD and in 1/10 patients with HD. In GD group, anti-Tg Abs were in positive correlation with aβ2gpI IgG (p = 0.000) and with anti-TPO Abs (p = 0.016). In HD group, anti-Tg Abs were in positive correlation with IgM aCL (p = 0.042), while anti-TPO Abs were in positive correlation with aβ2gpI IgM (p = 0.014).

CONCLUSION

This study is the first report of the aPL Abs presence in GO patients. The anti-thyroid Abs were linked to aPL suggesting that their presence is not the sole consequence of hyperstimulation of autoreactive B-lymphocytes. Larger studies are necessary to confirm potential cause-effect relations.

An Interesting Case of Euthyroid Graves' Ophthalmopathy, With Negative Thyroid-Stimulating Hormone Receptor Antibodies

Thyroid eye disease (TED), also known as Graves' orbitopathy or ophthalmopathy (GO) or Graves' eye disease, is an autoimmune condition of the retroocular tissues associated with Graves' disease. In isolated GO, the patient can present without thyroid hormone dysfunction or systemic symptoms of Graves' disease, in which case it is called euthyroid Graves' ophthalmopathy (EGO). It is very rare for this condition to have negative thyroid-stimulating hormone receptor (TSHR) autoantibodies, and we present such a rare case of a young female, who had progressive bilateral vision loss, intermittent left-sided retroocular headache, and severe bilateral proptosis. The patient was diagnosed with EGO based on multidisciplinary consults, diagnostic orbital magnetic resonance imaging (MRI) results, and a good response to treatment with intravenous steroids. Later, the patient was followed as an outpatient and treated with thyroid orbitopathy-specific immunotherapy with teprotumumab. The patient's response to teprotumumab was excellent and caused significant improvement in visual acuity, proptosis, and chemosis. This adds valuable literature to the medical field and gives insight to clinicians to consider the diagnosis of GO even with seronegative TSHR autoantibodies and euthyroid hormone status. It also adds to the understanding of the complex pathophysiology of this rare condition.

Evaluation of the Effect of Proptosis on Choroidal Thickness in Graves' Ophthalmopathy

Objectives:

To evaluate the effect of proptosis on choroidal thickness in patients with Graves’ ophthalmopathy.

Materials and Methods:

Twenty-five eyes of 25 Graves’ patients with proptosis, 25 eyes of 25 Graves’ patients without proptosis, and 25 eyes of 25 healthy individuals were included in this prospective study. The subfoveal choroidal thickness and choroidal thicknesses at 6 points from the fovea at 500 μm intervals were measured by Cirrus HD-OCT. All measurements were compared among the proptosis, non-proptosis, and control groups and the active, inactive, and control groups.

Results:

The mean subfoveal choroidal thickness in the proptosis group was 289.7±68.5 μm, 322.5±55.8 μm in the non-proptosis group, and 316.1±63.0 μm in the control group. The mean nasal choroidal thickness was 260.5±63.5 μm in the proptosis group, 293.9±57.9 μm in the non-proptosis group, and 279.5±63.1 μm in the control group. The mean temporal choroidal thickness was 261.8±60.9 μm in the proptosis group, 289.0±51.8 μm in the non-proptosis group, and 287.8±56.2 μm in the control group. Mean choroidal thickness was 264.7±58.5 μm in the proptosis group, 296.2±47.5 μm in the non-proptosis group, and 288.3±55.1 μm in the control group. There were no statistically significant differences among the groups with respect to choroidal thickness measurements (p>0.05).

Conclusion:

No significant difference in choroidal thickness was detected between Graves’ patients with and without proptosis and the controls. There was no effect of clinical activation on choroidal thickness.

Efficacy and Safety of Different Intravenous Glucocorticoid Regimens in the Treatment of Graves' Ophthalmopathy: A Meta-Analysis

Purpose

The intravenous glucocorticoid (iv GC) represents the mainstay of therapy for Graves' ophthalmopathy (GO), but uncertainty remains concerning the optimal regimen. Although the European Group on Graves' Orbitopathy (EUGOGO) regimen has been commonly employed, evidence for its superiority to other regimens is still lacking. The aim of this meta-analysis was to compare the efficacy and safety of the EUGOGO regimen with higher-dose regimens in the management of GO.

Methods

A systematic review and meta-analysis of randomized controlled trials (RCTs) and cohort studies comparing the EUGOGO regimen with higher-dose regimens was conducted. PubMed, Embase, and Web of Science databases were searched for relevant studies. The efficacy outcomes were response rate, change in clinical activity score (CAS), rate of proptosis improvement, and retreatment rate. The safety outcome was the incidence of adverse events.

Results

In the five included eligible trials, 136 participants in the EUGOGO regimen and 177 participants in higher-dose regimens were evaluated. Compared with the EUGOGO regimen, higher-dose regimens had no beneficial effect on the response rate, change of CAS, rate of proptosis improvement, and retreatment rate (OR: 1.3; 95% CI: 0.36–4.65; SMD: –0.04; 95% CI: –0.54, 0.45; OR: 0.79; 95% CI: 0.44–1.44; OR: 0.87; 95% CI: 0.27–2.77). For the incidence of adverse events, the results also showed no significant difference between the 2 groups (OR: 1.14; 95% CI: 0.62–2.09).

Conclusion

The current evidence showed that the efficacy of the EUGOGO regimen was comparable with higher-dose regimens. Since there was no significant difference in the incidence of adverse events between the two regimens, appropriate selection of patients and careful monitoring were required in both regimens. More well-designed, large-scale, and longer follow-up period studies were needed to further verify the finding of this analysis.

Thyroid Eye Disease: Navigating the New Treatment Landscape

Thyroid eye disease (TED) is a complex inflammatory disease that can have a long clinical course with sight-threatening and debilitating ocular sequelae. Until recently, there were limited therapeutic options available. In the last decade we have gained a deeper understanding of the underlying pathophysiology, which has led to the development of novel effective targeted therapies. This article discusses the challenges encountered in the clinical evaluation and treatment of TED patients, with the goal to empower endocrinologists and ophthalmologists to work together to provide effective multidisciplinary care. We will review recommendations of past clinical guidelines around evaluation and management of TED patients, discuss the randomized controlled trials of new biologic therapies, and explore how to navigate the emerging therapeutic landscape.

Predictive Factors for Changes in Quality of Life after Steroid Treatment for Active Moderate-to-Severe Graves' Orbitopathy: A Prospective Trial

OBJECTIVES

To investigate the predictive factors for changes in the quality of life (GO-QoL) of patients with Graves' orbitopathy (GO) prior to and after specific treatment.

METHODS

A prospective follow-up study was conducted at an academic tertiary referral orbital center with a joint thyroid-eye clinic on 100 consecutive patients with GO. Before and after the standard 12-week course of weekly intravenous methylprednisolone (cumulative dose 4.5 g), the GO-QoL questionnaire provided by the European Group on Graves' Orbitopathy (EUGOGO) was completed. Endocrine and ophthalmic assessments were performed at each visit.

RESULTS

All patients were biochemically euthyroid and untreated for GO at baseline and presented with active and moderate-to-severe disease. Both GO-QoL subscales (visual functioning [VF] and appearance [AP]) significantly increased after immunosuppressive therapy and showed a sustained improvement for 6 months. At baseline, demographic variables (sex, age, and smoking) influenced QoL in the stepwise linear regression (p < 0.01, adjusted R ² = 0.24 for VF and p < 0.01, adjusted R ² = 0.21 for AP). In contrast, 6 months after treatment, the improved QoL was now exclusively associated with ophthalmic parameters (p < 0.01, adjusted R ² = 0.47 for VF; p < 0.01, adjusted R ² = 0.23 for AP).

CONCLUSIONS

Predictive factors for GO-QoL differed not only between the 2 subscales but also before and after the first treatment of GO.

Graves' Orbitopathy: Report of 82 cases

INTRODUCTION

Graves' disease (GD) is a common autoimmune disorder. Graves'orbitopathy (GO) is its most common extrathyroidal manifestation. It is rare but may reveal the disease.

AIM

To describe the demographic, clinical and therapeutic features of GO.

METHODS

We carried out a retrospective and descriptive analysis of 82 patients with GO. This study was conducted in Ophthalmology and Endocrinology departments of Taher Sfar University Hospital in Mahdia, between January 2010 and December 2017. GD patients diagnosed with GO were included.

RESULTS

The mean age was 36.17 years ± 12.81. Patients aged 19-40 years had the highest rate of GO. The male-to-female ratio was 0.49. Family history of autoimmune thyroid disease was present in 15% and associated autoimmune disease in 4% of cases. Smoking was seen in 71% of patients. The onset of GO was simultaneous with onset of GD in 45%, before in 21% and after the onset of GD in 34% of cases. GO was bilateral in 76% of patients. The most common ocular symptoms were prominent eyes (55% of patients), ocular pain (11%) and diplopia (41%). Proptosis and upper eyelid retraction were the most common clinical signs (93% and 90% respectively). Dysthyroid optic neuropathy was present in one eye, keratitis in one eye and glaucoma in five eyes. Severe disease was noted in 11% and active disease was present in 7% of patients. CT-scan and magnetic resonance imaging scan (MRI) were performed in 48% and 42% of cases respectively. Proptosis was the most common radiological sign. Thyroid dysfunction was managed with anti-thyroid medication only (59%), thyroxine replacement (37%), radioactive iodine (35%) and thyroidectomy (6%). 20% of patients received corticosteroids. One patient required immunosuppressive therapy.

CONCLUSION

GO is a complex disease, which is associated with impaired quality of life and can potentially result in sight-threatening complications. Appropriate diagnosis, convenient therapy and a regular follow-up are necessary to improve results and avoid the aesthetic and functional sequelae.

Application of electrophysiological tests in the evaluation of early thyroid-associated ophthalmopathy

PURPOSE

To compare the electrophysiology between mild thyroid-associated ophthalmopathy (TAO) patients and normal population.

METHODS

The present research was a retrospective observational study and enrolled consecutive patients diagnosed with mild TAO according to European Group on Graves's Orbitopathy with corrected to normal vision. Full-field electroretinography, pattern visual evoked potential (PVEP) and isolated-check visual evoked potential (icVEP) were performed for TAO patients and age-matched normal subjects.

RESULTS

Thirty-two eyes with mild TAO and forty-six eyes from normal subjects were included. Statistically significant increase in the amplitude of dark-adapted 0.01, 3 and 10 ERG and total oscillatory potentials and light-adapted 3 and 30 Hz flicker ERG were observed in TAO patients compared with the normal subjects, but not the latency. No significant difference was observed in the P100 amplitude or latency in 1° and 15' PVEP between TAO patients and normal subjects. The signal-to-noise ratio (SNR) was not significantly different in TAO patients at the contrast of 1%, 2%, 8%, 16% or 32% icVEP, and the SNR in contrast 4% icVEP was significantly smaller in TAO patients compared to normal subjects.

CONCLUSION

Mild TAO patients can have electrophysiological changes that might indicate neural changes in the early disease phase.

Neferine suppresses autophagy-induced inflammation, oxidative stress and adipocyte differentiation in Graves' orbitopathy

Previous studies in Graves’ orbitopathy (GO) patient‐derived fibroblasts showed that inhibition of autophagy suppresses adipogenic differentiation. Autophagy activation is associated with inflammation, production of reactive oxygen species and fibrosis. Neferine is an alkaloid extracted from Nelumbo nucifera, which induces Nrf2 expression and inhibits autophagy. Here, we have elucidated the role of neferine on interleukin (IL)‐13‐induced autophagy using patient‐derived orbital fibroblasts as an in vitro model of GO. GO patient‐derived orbital fibroblasts were isolated and cultured to generate an in vitro model of GO. Autophagy was determined by Western blot detection of the markers such as Beclin‐1, Atg‐5 and LC3 and by immunofluorescence detection of autophagosome formation. Analysis of differentiation towards an adipogenic lineage was performed by Oil red O staining. The expression of inflammatory factors was detected by ELISA and semiquantitative RT‐PCR. Neferine inhibited autophagy in GO orbital fibroblasts, as indicated by the suppression of IL‐13‐induced autophagosome formation, overexpression of autophagy markers, increased LC3‐II/LC3‐I levels and finally down‐regulation of p62. Neferine suppressed IL‐13‐induced inflammation, ROS generation, fibrosis and adipogenic differentiation in GO patient‐derived orbital fibroblasts. The anti‐inflammatory, antioxidant and antiadipogenic effects of neferine were accompanied by the up‐regulation of Nrf2. These results indicated that orbital tissue remodelling and inflammation in GO may be mediated by autophagy, and neferine suppressed autophagy‐related inflammation and adipogenesis through a mechanism involving Nrf2.

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.

Usefulness of two-point Dixon T2-weighted imaging in thyroid-associated ophthalmopathy: comparison with conventional fat saturation imaging in fat suppression quality and staging performance

OBJECTIVE

To compare the two-point Dixon T₂ weighted imaging (T₂WI) with conventional fat-sat T₂WI in fat suppression (FS) quality and staging performance for patients with TAO.

METHODS

We enrolled 37 thyroid-associated ophthalmopathy (TAO) patients and 15 healthy controls who underwent both coronal two-point Dixon and fat-sat T₂WI. Qualitative (overall imaging quality, FS uniformity) and quantitative [signal intensity ratio of extraocular muscle (EOM-SIR)] parameters were assessed between the two-point Dixon T₂WI and fat-sat T₂WI. Additionally, water fraction of intraorbital fat (IF-WF) was measured on Dixon image. Dixon-EOM-SIR, Fat-sat-EOM-SIR and Dixon-IF-WF values were compared between active and inactive TAO groups, and the diagnostic efficiency for the active phase were evaluated.

RESULTS

Two-point Dixon T₂WI showed significantly higher overall image quality score, FS uniformity score as well as EOM-SIR value than fat-sat T₂WI in both TAO and control groups (all p < 0.05). Active TAOs had significantly higher Dixon-EOM-SIR (p < 0.001), Fat-sat-EOM-SIR (p < 0.001) and Dixon-IF-WF (p = 0.001) than inactive TAOs. ROC curves analyses indicated that Dixon-EOM-SIR ≥3.32 alone demonstrated the highest staging sensitivity (75.0%). When integrating Dixon-EOM-SIR ≥3.32 and Dixon-IF-WF ≥0.09, improved staging efficiency and specificity could be achieved (area under the curve, 0.872; specificity, 97.1%).

CONCLUSION

Compared with conventional fat-sat technique, two-point Dixon T₂WI offers better image quality, as well as improved staging sensitivity and specificity for TAO. Dixon T₂WI is suggested to be used to evaluate the patients with TAO in clinical practice.

ADVANCES IN KNOWLEDGE

Two-point Dixon T₂WI offers better image quality than fat-sat T₂WI. Dixon-EOM-SIR alone demonstrated the highest staging sensitivity. Combining with Dixon-IF-WF showed improved staging efficiency and specificity. Dixon T₂WI is suggested to be used to evaluate TAO patients in clinical practice.

Comparison of two regimens for patients with thyroid-associated ophthalmopathy receiving intravenous methyl prednisolone: A single center prospective randomized trial

Intravenous (i.v.) glucocorticoid is recommended for active moderate-to-severe thyroid-associated ophthalmopathy (TAO). However, the details of the treatment schedule are still debatable. The present prospective randomized trial was performed to compare clinical outcomes and serum cytokines between the two regimens. A cohort of 90 patients with active moderate-to-severe TAO was randomized to receive i.v. methyl prednisolone on a weekly protocol or daily scheme. The response rate was evaluated at the 12-week follow-up visit. Serum interleukin (IL)-2, IL-6 and IL-17 levels were measured in 160 patients with TAO, 60 patients with isolated Graves' disease (GD) and 60 normal control (NC) at baseline, as well as patients with active moderate-to-severe TAO at the 12^th week after treatment. The daily scheme had a higher response rate than the weekly protocol without a significant difference (77.8 vs. 63.6%, P>0.05). No major adverse events were recorded under either regimen. Overall, minor events were more common on the daily scheme (11.36 vs. 4.35%, P<0.05)than on the weekly protocol, whereas the deterioration of eye symptoms (two patients) was only reported on the weekly protocol. At baseline, the IL-17 level in the TAO group was higher than that in the isolated GD and NC groups (P<0.05). In addition, the IL-17 level in the active TAO group was higher than that in the inactive TAO group (P<0.05). Furthermore, the IL-17 level had significantly decreased under the two regimens at the 12-week visit (P<0.05). In conclusion, for patients with active moderate-to-severe TAO, daily i.v. glucocorticoid therapy has a relative higher response rate than the weekly protocol with a few more minor adverse events. These two regimens have their own merits with regard to adverse effects. IL-17 has the potential to be a biomarker for evaluating TAO activity and treatment effects.

Trends in Treatment of Active, Moderate-to-Severe Thyroid Eye Disease in the United States

Introduction

Limited data exist on US referral/management patterns for moderate-to-severe thyroid eye disease (TED), a disabling condition.

Methods

US ophthalmologists and endocrinologists experienced in treating TED provided medical record data of moderate-to-severe TED patients and information on referral/treatment practices. Data on signs/symptoms, medical/surgical treatments, treatment response, and referral history were collected. Moderate and severe cases were stratified to interrogate treatment/practice differences.

Results

A total of 181 physicians provided data on 714 patients (49.4 ± 13.6 years old, 65% women, 14% severe disease). Reporting physicians diagnosed 55% of patients themselves and solely managed 37% of cases, with similar referral/comanagement patterns between moderate and severe cases. Topical therapies included lubricating (79%) and glucocorticoid (39%) eye drops. Systemic therapies included oral glucocorticoids (36%), IV glucocorticoids (15%), and rituximab and/or tocilizumab (12%). Few patients underwent orbital radiation (4%) or surgical intervention (4%). IV glucocorticoids (33% vs. 12%), biologics (26% vs. 10%), orbital radiation (11% vs. 3%), and ocular surgery (12% vs. 3%) were used more often in severe versus moderate cases (all P < 0.001). However, severe disease was less responsive to therapy (very responsive to therapy: 28% vs. 49%, P < 0.001).

Conclusions

Participating physicians were primarily responsible for just over one-half of TED diagnoses, but solely treated <40% of patients. Severe TED was treated more often with surgery and systemic immunologic therapies than moderate disease, but was less likely to respond to treatment. These results reinforce that moderate-to-severe TED is difficult to treat with an unmet medical need in the United States.

Thyroid-Associated Orbitopathy: Evaluating Microstructural Changes of Extraocular Muscles and Optic Nerves Using Readout-Segmented Echo-Planar Imaging-Based Diffusion Tensor Imaging

Objective

We aimed to investigate the ability of readout-segmented echo-planar imaging (rs-EPI)-based diffusion tensor imaging (DTI) in assessing the microstructural change of extraocular muscles (EOMs) and optic nerves in patients with thyroid-associated orbitopathy (TAO) as well as in evaluating disease activity.

Materials and Methods

We enrolled 35 TAO patients and 22 healthy controls (HCs) who underwent pre-treatment rs-EPI-based DTI. Mean, axial, and radial diffusivity (MD, AD, and RD) and fractional anisotropy (FA) of the medial and lateral EOMs and optic nerve for each orbit were calculated and compared between TAO and HC groups and between active and inactive TAO groups. Factors such as age, sex, disease duration, mediation, and smoking history between groups were also compared. Logistic regression analysis was used to evaluate the predictive value of significant variables for disease activity.

Results

Disease duration was significantly shorter in active TAOs than in inactive ones (p < 0.001). TAO patients showed significantly lower FA and higher MD, AD, and RD than HCs for both medial and lateral EOMs (p < 0.001), but not the AD value of lateral EOMs (p = 0.619). Active patients had significantly higher FA, MD, and AD than inactive patients for medial EOMs (p < 0.005), whereas only FA differed significantly in the lateral EOMs (p = 0.018). The MD, AD, and RD of optic nerves were significantly lower in TAO patients than HCs (p < 0.05), except for FA (p = 0.129). Multivariate analysis showed that the MD of medial EOMs and disease duration were significant predictors for disease activity. The combination of these two parameters showed optimal diagnostic efficiency for disease activity (area under the curve, 0.855; sensitivity, 68.4%; specificity, 96.9%).

Conclusion

rs-EPI-based DTI is promising in assessing microstructural changes of EOMs and optic nerves and can help to indicate the disease activity of TAO, especially through the MD of medial EOMs.

Evaluation of changes in choroidal thickness after implantable collamer lens surgery in high myopia patients with graves' Ophthalmopathy (inactive phase)

BACKGROUND

To evaluate the safety and effectiveness of the Visian Implantable Collamer Lens (ICL) implantation in high myopic patients with inactive Graves' ophthalmopathy (GO) by observing the changes of choroidal thickness (CT).

METHODS

Eight patients (16 eyes) with high myopia accompanied with inactive GO were selected as the experimental group (group A) and 18 high myopic patients (36 eyes) without GO were selected as a control group (group B). The outcomes of uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BCVA), safety index, efficacy index, intraocular pressure (IOP), vault, corneal endothelial count, and choroidal thickness (CT) were observed. The values of CT were measured using swept-source optical coherence tomography (SS-OCT) scans.

RESULTS

The UCVA and BCVA in all operated eyes were better than that before surgery. The postoperative safety index and efficacy index were 1.23 and 1.19 in the group A, respectively, and 1.26 and 1.21 in the group B, respectively. In both groups, foveal CT increased significantly in high myopic patients at 2 h and at 3 months after surgery, compared to preoperative values. The same tendencies were observed in the inner nasal and outer nasal regions. Compared with patients without GO, the increase of CT was more obvious in GO patients, 2 h postoperatively (P = 0.006) and 3 months postoperatively (P = 0.011).

CONCLUSIONS

The ICL implantation is safe and effective in high myopic patients with inactive GO. Subfoveal and nasal CT may be useful parameters for monitoring the activity of GO patients.

Is concomitant treatment with steroids and radiotherapy more favorable than sequential treatment in moderate-to-severe graves orbitopathy?

PURPOSE

Glucocorticoids (GCs) and external radiotherapy (RT) are used for treating moderate-to-severe Graves' orbitopathy (GO). We aimed to assess whether GCs and RT were more effective when administered concomitantly or sequentially.

METHODS

We retrospectively analyzed clinical outcomes [assessed by Clinical Activity Score (CAS) and NOSPECS classification] in 73 patients treated with both i.v. GCs and RT. The patients were divided in two groups: In group A (53 patients), RT was delivered concomitantly with GCs, and in group B (20 patients) RT was administered subsequently to the end of methylprednisolone.

RESULTS

At baseline, CAS (median 4.0) and the percentage of patients encompassing the various grades of the classes 2, 3 and 4 of the NOSPECS score were similar in both groups. Six months after RT, CAS decreased to 2 in both groups (p = 0.0003 vs baseline) as well as NOSPECS class 4 (p < 0.0001 vs baseline). NOSPECS class 2 improved more in group A than in group B (p = 0.016). The median cumulative dose of GCs was lower in group A than in group B (median 4.500 vs 6000 mg, p < 0.007); the overall length of therapy was shorter in group A than in group B (68 vs 106 days, p < 0,02). The most common acute adverse effect was transient conjunctivitis (five in group A and three in group B); seven patients (five in group A and two in group B, age between 60 and 66 years) developed cataract, requiring surgery in five cases.

CONCLUSIONS

Concomitant administration of GC and RT showed a favorable effect in moderate-to-severe GO, thus suggesting that RT should be carried out early during steroid therapy, when clinical symptoms do not improve or deteriorate after the first i.v. administrations of GCs.

Therapeutic Effect of Guggulsterone in Primary Cultured Orbital Fibroblasts Obtained From Patients with Graves' Orbitopathy

Purpose

Inflammation, hyaluronan production, and adipogenesis are the main pathological events leading to Graves' orbitopathy (GO). Guggulsterone (GS), a phytosterol found in the resin of the guggul plant, is a well-known treatment for several inflammatory disorders, such as arthritis, obesity, and hyperlipidemia. Here we investigated the effects of GS treatment on GO pathology.

Methods

Using primary cultures of orbital fibroblasts from GO patients and non-GO controls, we examined the effects of GS on hyaluronan production and the production of proinflammatory cytokines induced by interleukin (IL)-1β, using real-time reverse transcription-polymerase chain reaction analysis, western blots, and enzyme-linked immunosorbent assays. Further, adipogenic differentiation was evaluated by quantification of Oil Red O staining and assessment of protein levels of peroxisome proliferator activator gamma (PPARγ), CCAAT-enhancer-binding proteins (C/EBP) α and β, and sterol regulatory element-binding protein-1 (SREBP-1).

Results

Treatment with noncytotoxic concentrations of GS resulted in the dose-dependent inhibition of IL-1β-induced inflammatory cytokines, including IL-6, IL-8, MCP-1, and COX-2, at both mRNA and protein levels. The hyaluronan level was also significantly suppressed by GS. Moreover, GS significantly decreased the formation of lipid droplets and expression of PPARγ, C/EBP α/β, and SREBP-1 in a dose-dependent manner. GS pretreatment attenuated the phosphorylation of nuclear factor-kappa B induced by IL-1β.

Conclusions

Our data show significant inhibitory effects of GS on inflammation, production of hyaluronan, and adipogenesis in orbital fibroblasts. To our knowledge, this is the first in vitro preclinical evidence of the therapeutic effect of GS in GO.

Preliminary evidence of the association between DNAm and orbital volumetry in GO

Background

The pathogenesis underlying the alterations of orbital architecture in Graves' orbitopathy (GO) is not yet fully understood. The present study aimed to investigate the association of DNA methylation in peripheral blood and orbital volumetry in Chinese patients with GO.

Methods

A total of 35 GO subjects (70 orbits) were subjected to CT scan. The total cross-sectional area of the extraocular muscles (orbital muscles, OM), total orbit area (TOA), and the exophthalmometry were measured and OM/TOA ratio was calculated. Targeted bisulfite sequencing was performed on seven candidate genes.

Results

No significant correlation was established between the DNA methylation levels of these genes and exophthalmometry. The MBP methylation level was found to be correlated with OM/TOA ratio (P < 0.05). Multiple linear regression analysis on parameters including age, sex, TRAb, duration of GO, and DNA methylation levels of seven genes with OM/TOA ratio confirmed that MBP and OM/TOA ratio had a significant correlation (P < 0.05). The partial least squares analysis showed that the top three genes with the highest loadings were MBP, BOLL, and BECN1 and that OM/TOA ratio affected the DNA methylation block than exophthalmometry.

Conclusions

This study provided preliminary evidence that MBP is a potential gene associated with OM enlargement in GO patients according to the combination of DNA methylation sequencing and orbital CT measurement.

Peribulbar injection of glucocorticoids for thyroid-associated ophthalmopathy and factors affecting therapeutic effectiveness: A retrospective cohort study of 386 cases

Thyroid-associated ophthalmopathy (TAO) is common in Graves' disease. However, to date, no standard treatment has been established for TAO. The present study aimed to assess peribulbar injection of corticosteroids for TAO treatment as well as factors affecting therapeutic effectiveness. A retrospective cohort study was performed at West China Hospital, Sichuan University (Chengdu, China). Patients with TAO were administered peribulbar injection of triamcinolone acetonide and dexamethasone monthly. Ocular signs after each injection were assessed until the end of treatment. All patients were followed up for at least six months. Best corrected visual acuity, proptosis values, eye motility assessed by the Hess chart, as well as eyelid width and downward movement were determined. In addition, clinical data were retrospectively reviewed to explore factors affecting therapeutic effectiveness by logistic regression analysis. In the present study, 386 patients with TAO (515 eyes) were evaluated; 71.37% of cases of eyelid swelling were relieved and upper eyelid retraction was improved in 47.58% of affected patients. Eye movement disorders, diplopia and strabismus were all alleviated to varying degrees, with few adverse reactions. Logistic regression analysis demonstrated that therapeutic effectiveness was relatively lower in males [odds ratio (OR)=0.32, P=0.001] and patients with thyroid dysfunction (OR=0.41, P=0.002), and that non-smokers had a higher odds of substantial improvement (OR=4.62, P=0.008). The duration of TAO was not significantly associated with the clinical outcome. Patients with reduced disease severity and elevated clinical activity score exhibited higher effectiveness (all P<0.05). In conclusion, peribulbar injection of corticosteroids is effective in treating mild to moderate TAO, with the therapeutic response affected by gender, smoking and disease severity.

Novel Roles of Chloroquine and Hydroxychloroquine in Graves' Orbitopathy Therapy by Targeting Orbital Fibroblasts

CONTEXT

Graves' orbitopathy (GO) causes infiltrative exophthalmos by inducing excessive proliferation, adipogenesis, and glycosaminoglycan production in orbital fibroblasts (OFs). Interference with OF autophagy is a potential therapy for proptosis.

OBJECTIVES

Here, we aimed to evaluate the effects of chloroquine (CQ) and hydroxychloroquine (HCQ), the autophagy inhibitors commonly used in clinical practice, on OFs.

DESIGN/SETTING/PARTICIPANTS

OFs isolated from patients with GO (GO-OFs) or control individuals (non-GO-OFs) were cultured in proliferation medium (PM) or subjected to differentiation medium. OFs were treated with CQ or HCQ (0, 0.5, 2, and 10 μM), and subsequently examined in vitro.

MAIN OUTCOME MEASURES

CCK-8, EdU incorporation, and flow cytometry assays were used to assess cellular viability. Adipogenesis was assessed with Western blot analysis, real-time polymerase chain reaction (PCR) , and Oil Red O staining. Hyaluronan production was determined by real-time PCR and enzyme-linked immunosorbent assay. Autophagy flux was detected through red fluorescent protein (RFP)-green fluorescent protein (GFP)-LC3 fluorescence staining and Western blot analyses.

RESULTS

CQ/HCQ halted proliferation and adipogenesis in GO-OFs in a concentration-dependent manner through blockage of autophagy, phenotypes that were not detected in non-GO-OFs. The inhibitory effect of CQ/HCQ on hyaluronan secretion of GO-OFs was also concentration dependent, mediated by downregulation of hyaluronan synthase 2 rather than hyaluronidases. Moreover, CQ (10 μM) induced GO-OF apoptosis without aggravating oxidative stress.

CONCLUSIONS

The antimalarials CQ/HCQ affect proliferation, adipogenesis, and hyaluronan generation in GO-OFs by inhibiting autophagy, providing evidence that they can be used to treat GO as autophagy inhibitors.

Evaluation of medical and surgical decompression in patients with dysthyroid optic neuropathy

PURPOSE

To evaluate the effectiveness of steroid-pulse therapy and three-wall orbital decompression in patients with dysthyroid optic neuropathy (DON).

METHODS

Twenty-five patients (46 eyes) with a diagnosis of DON between 2008 and 2015 were included in the study. The first group (7 patients, 16 eyes) consisted of patients with a steroid-pulse treatment only and the second group (18 patients, 30 eyes) included patients with medical and surgical decompression.

RESULTS

Twenty patients were female; five patients were male. After the diagnosis of DON, all patients were treated with steroid-pulse treatment (intravenous 500 mg prednisolon twice/week for 4 weeks, 250 mg twice/week for 2 weeks) as a first-line treatment (medical decompression). In 30 eyes (18 patients) out of 46 eyes, (25 patients) an orbital decompression was needed to preserve the optic nerve function. In those therapy-resistant cases (surgical decompression group), the orbital decompression led to statistically significant improvements in best-corrected visual acuity (BCVA), protan and tritan value of the color vision (p = 0.007, p < 0.0001, p = 0.019, respectively, comparison of first visit to last visit).

CONCLUSION

According to our data, the mild cases of DON with better initial visual acuity (in our case series mean: 0.3 logMAR) seem to respond well to steroid treatment. However, therapy-resistant cases with an impaired initial BCVA (in our case series, mean: 0.6 logMAR) seem to need the surgery to preserve the optic nerve function. In conclusion, this retrospective study confirms the effectiveness of surgical decompression in therapy-resistant cases of DON.

Analysis of Foveal and Parafoveal Microvascular Density and Retinal Vessel Caliber Alteration in Inactive Graves' Ophthalmopathy

Purpose

We aimed to evaluate foveal and parafoveal density using optical coherence tomography angiography and the alteration on the retinal vessel diameter in patients with inactive Graves' ophthalmopathy compared to age-matched normal population. Materials and Methods. Patients with inactive Graves' ophthalmopathy (study group) and healthy individuals (control group) were enrolled in the cross sectionally designed study. The optical coherence tomography angiography parameters and retinal vessel diameter measurements were assessed between the study and control groups. Foveal and parafoveal microvascular density in the retina was measured using optical coherence tomography angiography. Retinal artery and vein diameter and artery/vein ratio were assessed for retinal vessel caliber changes.

Results

Patients with inactive Graves' ophthalmopathy had higher values of intraocular pressure, proptosis, and axial length (P=0.001, P=0.001, P=0.001, P=0.001, P=0.001, P=0.001, P=0.001, P=0.001, P=0.001, P=0.001, P=0.001,

Conclusion

Optical coherence tomography angiography could be a novel and promising noninvasive diagnostic technique in patients with inactive Graves' ophthalmopathy to detect foveal and parafoveal vessel density changes compared to healthy subjects. The decrease of retinal vessel diameter might be observed in patients with inactive graves ophthalmopathy.

Orbital diseases mimicking graves' orbitopathy: a long-standing challenge in differential diagnosis

Graves' orbitopathy (GO) is the most common cause of orbital tissue inflammation, accounting for ~ 60% of all orbital inflammatory conditions in the population aged 21-60 years, and for ~ 40% in the population aged > 60 year. GO is observed in 25-30% of patients with Graves' hyperthyroidism and more rarely in association with hypothyroid autoimmune thyroiditis. In addition, a small proportion of GO patients (1-2%) do not have a clinically overt thyroid dysfunction. Clinically, GO is characterized by proptosis, inflammation involving the eyelids and the conjunctiva, extraocular muscle hypertrophy, with consequent reduction of ocular motility and diplopia, and in the most severe cases, compression of the optic nerves at the orbital apex, with reduction of visual acuity. At CT scan or MRI, a muscle increase involving the superior, medial and inferior rectus is quite typical. In the most severe forms, compression of the optic nerves at the orbital apex can be observed. Euthyroid GO is usually an early sign of a full-blown Graves' disease; however, in some cases, the orbital disease can remain isolated. Moreover, euthyroid GO can rarely be unilateral, which makes the picture even more confusing. Under those circumstances, the diagnostic process becomes obviously quite difficult, having other conditions mimicking GO been excluded. A number of inflammatory conditions affecting orbital tissue can mimic GO, thereby requiring an accurate evaluation for a proper differential diagnosis. The majority of these conditions are immune mediated. Most of them are benign, but they can be rather aggressive and some can cause visual loss. The most common inflammatory condition affecting orbital tissues and mimicking GO is idiopathic orbital inflammation. Other, more rare, orbital diseases that should be considered in the differential diagnosis are infections, orbital manifestations of systemic diseases, primitive and secondary orbital neoplasms, and orbital vascular alterations. In most instances, when an orbitopathy occurs in the absence of hyperthyroidism, the diagnosis of the disease underlying the ocular symptoms and signs is based on exclusion of the other conditions. Here we review the conditions that can mimic GO and how to distinguish them from this obnoxious eye disease.

Immunohistochemical analysis of human orbital tissue in Graves' orbitopathy

PURPOSE

Immunohistochemistry of orbital tissues offers a correlation between the microscopic changes and macroscopic clinical manifestation of Graves' orbitopathy (GO). Summarizing the participation of different molecules will help us to understand the pathogenesis of GO.

METHODS

The pertinent and current literature on immunohistochemistry of human orbital tissue in GO was reviewed using the NCBI PubMed database.

RESULTS

33 articles comprising over 700 orbital tissue samples were included in this review. The earliest findings included the demonstration of HLA-DR and T cell (to a lesser extent B cell) markers in GO orbital tissues. Subsequent investigators further contributed by characterizing cellular infiltration, confirming the presence of HLA-DR and TSHR, as well as revealing the participation of cytokines, growth factors, adhesion molecules and miscellaneous substances. HLA-DR and TSHR are over-expressed in orbital tissues of GO patients. The inflammatory infiltration mainly comprises CD4 + T cells and macrophages. Cytokine profile suggests the importance of Th1 (especially in early active phase) and Th17 immunity in the pathogenesis of GO. Upregulation of proinflammatory/profibrotic cytokines, adhesion molecules and growth factors finally culminate in activation of orbital fibroblasts and perpetuation of orbital inflammation. The molecular status of selected parameters correlates with the clinical presentation of GO.

CONCLUSION

Further investigation is warranted to define precisely the role of different molecules and ongoing search for new players yet to be discovered is also important. Unfolding the molecular mechanisms behind GO will hopefully provide insights into the development of novel therapeutic strategies and optimize our clinical management of the disease.

New insights into the pathogenesis and nonsurgical management of Graves orbitopathy

Graves orbitopathy, also known as thyroid eye disease or thyroid-associated orbitopathy, is visually disabling, cosmetically disfiguring and has a substantial negative impact on a patient's quality of life. There is increasing awareness of the need for early diagnosis and rapid specialist input from endocrinologists and ophthalmologists. Glucocorticoids are the mainstay of treatment; however, recurrence occurs frequently once these are withdrawn. Furthermore, in >60% of cases, normal orbital anatomy is not restored, and skilled rehabilitative surgery is required. Clinical trials have shown that considerable benefit can be derived from the addition of antiproliferative agents (such as mycophenolate or azathioprine) in preventing deterioration after steroid cessation. In addition, targeted biologic therapies have shown promise, including teprotumumab, which reduces proptosis, rituximab (anti-CD20), which reduces inflammation, and tocilizumab, which potentially benefits both of these parameters. Other strategies such as orbital radiotherapy have had their widespread role in combination therapy called into question. The pathophysiology of Graves orbitopathy has also been revised with identification of new potential therapeutic targets. In this Review we provide an up-to-date overview of the field, outline the optimal management of Graves orbitopathy and summarize the research developments in this area to highlight future research questions and direct future clinical trials.

Radioiodine therapy and Graves' disease - Myths and reality

Introduction

Autoimmune reactions in Graves’ disease (GD) occur not only in the thyroid gland, but also in the orbital connective tissue, eyelids, extraocular muscles. The occurrence of orbitopathy in the course of GD is influenced by environmental factors, e.g. cigarette smoking.

Objectives

The aim of the study was to analyze the effect of cigarette smoking on the efficacy of activity of radioiodine(131I) therapy in patients with GD. We also studied the influence of cigarette smoking and the efficacy of prednisone prophylaxis on the risk of thyroid-associated ophthalmopathy (TAO) development after radioiodine therapy (RIT) during two years of follow-up.

Patients and methods

Medical records of hyperthyroid patients treated with radioiodine had been included. Patients were scheduled to visit outpatient clinics at baseline and 1, 3, 6, 9, 12, 18, and 24 months after RIT.

Results

The studied group consisted of 336 patients (274 women, 62 men) diagnosed with GD and treated with RIT; 130 patients received second therapeutic dose of ¹³¹I due to recurrent hyperthyroidism. Among all studied patients, 220 (65.5%) were smokers and 116 (34.5%) non-smokers. In the group of smokers 115 (52.2%) of patients received single RIT, 105 (47.8%) received second dose of RAI due to recurrent hyperthyroidism. In non-smokers 91 (78.6%) received single activity of RAI, while 25 (21.4%) patients required second RIT due to recurrent hyperthyroidism. The ophthalmic symptoms in the group of smokers after RIT were less frequent, if the patient received preventative treatment in the form of oral prednisone (P = 0.0088).

Conclusions

The results of our study suggest that cigarette smoking reduces the efficacy of treatment with ¹³¹I in patients with GD. The study also confirmed the effectiveness of steroid prophylaxis against TAO development or exacerbation after RIT.