Related quality of life questionnaire specific to dysthyroid ophthalmopathy evaluated in a population of patients with Graves' disease

Risk Factors for Ocular Surface Irritation Symptoms in Inactive Mild and Moderate-to-Severe Graves' Orbitopathy

INTRODUCTION

This study aims to analyze risk factors for ocular surface irritation symptoms in patients with non-corneal-damage inactive mild and moderate-to-severe Graves' orbitopathy (GO).

METHODS

This retrospective study enrolled 307 patients with non-corneal-damage inactive GO admitted to Sun Yat-sen Memorial Hospital from April 2017 to September 2023. The activity and severity of GO were evaluated using the Clinical Activity Score (CAS) and the European Group on Graves' Orbitopathy (EUGOGO) classification, respectively. Multivariate logistic regression analysis was performed to analyze risk factors for ocular surface irritation symptoms.

RESULTS

Among patients with inactive GO, for mild cases, CAS (P < 0.001), upper eyelid lag (P = 0.049), and extraocular muscle involvement (P = 0.019) in the symptomatic group were greater than those in the asymptomatic group, and multivariate logistic regression analysis demonstrated that upper eyelid lag (P = 0.048), CAS 1 (P < 0.001), CAS 2 (P = 0.005), and extraocular muscle involvement (P = 0.029) were risk factors for ocular surface irritation symptoms; for moderate-to-severe cases, CAS (P = 0.004), extraocular muscle involvement (P < 0.001), marginal reflex distance 1 (MRD1) (P = 0.030), and thyroid-stimulating hormone (TSH) (P = 0.034) in the symptomatic group were greater than those in the asymptomatic group, while multivariate logistic regression analysis indicated that extraocular muscle involvement (P = 0.018) and MRD1 (P = 0.012) were risk factors for ocular surface irritation symptoms.

CONCLUSION

In non-corneal-damage inactive mild and moderate-to-severe GO, eyelid malposition and periocular muscle inflammation are risk factors for ocular surface irritation symptoms.

Selenium in the treatment of mild-to-moderate Graves' orbitopathy: a 5-year prospective controlled cohort study

PURPOSE

Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease. However, limited studies have investigated the actual efficacy of selenium in GO therapy. This longitudinal study explored the effect of selenium on QOL and prognosis of patients with mild-to-moderate GO.

METHODS

We conducted a 5-year prospective controlled cohort clinical trial to determine the effect of selenium on 74 patients with mild-to-moderate GO. Patients received selenium yeast or placebo orally for 6 months and were followed up at 6 months and at 5 years by biochemical examination, ophthalmologist evaluation and QOL questionnaire to assess oculopathy and QOL.

RESULTS

(1) During a follow-up period of 3-6 months, in the selenium group, the symptoms of tearing, grittiness and conjunctival congestion improved (P < 0.01); clinical activity scores and total GO-QOL scores increased relative to baseline (P < 0.01); TRAb was decreased at the 6-month evaluation (P = 0.003); and patients treated with selenium had a higher rate of improvement and a lower rate of worsening than patients treated with placebo (P < 0.05). (2) Exploratory evaluations at 6 months after drug withdrawal confirmed the earlier results; further changes included alleviation of blurred vision and double vision symptoms in the selenium group (P < 0.01). (3) At the 5-year follow-up, compared with baseline, proptosis, clinical activity scores, TRAb level and total GO-QOL scores in both the selenium and placebo groups were significantly improved (P < 0.01).

CONCLUSION

Six months of selenium supplementation may effectively change the early course of mild-to-moderate GO, but this regimen makes no difference in long-term outcomes.

Quality of Life in Patients with Chronic Thyroid Eye Disease in the United States

INTRODUCTION

Thyroid eye disease (TED) is an autoimmune condition producing ocular pain, dysmotility, and ocular structure and function changes. As disease activity changes, redness, swelling, and pain can improve, but eye comfort, appearance, and motility alterations often persist. There are limited data on chronic TED patient-reported outcomes. This study examined chronic US TED patient-reported symptoms and quality of life (QOL).

METHODS

Existing data from an online survey regarding chronic TED signs/symptoms and patient QOL were retrospectively examined. The Graves' Ophthalmopathy QOL instrument (GO-QOL; 0-100, 100 = highest QOL) evaluated overall, appearance, and vision-related QOL. Influencing factors were examined by stratifying patients into low (overall QOL ≤ 50), moderate (> 50 and < 75), and high (≥ 75) QOL categories.

RESULTS

One hundred patients (47 women, 81 Caucasian, 45.2 ± 7.6 years) were included. The duration of inactive TED was 3.0 ± 4.6 years and total duration of TED was 5.8 ± 5.9 years. Patients reported an average of 20 doctor visits/year and high prevalence of anxiety (34%) and depression (28%). Prior TED treatments for the polled population included systemic corticosteroids during active TED (25%), orbital radiation (5%), and surgery (25%). The overall GO-QOL score was 60.5 ± 21.8 (vision-related: 58.6 ± 24.0, appearance-related: 62.3 ± 25.1). Patients with low QOL more frequently reported hypothyroidism, anxiety, and a larger number of chronic TED signs/symptoms (average: 4.2). Compared to high QOL patients, low QOL patients had more pain (39% vs. 13%), blurry vision (30% vs. 17%), and diplopia (27% vs. 3%, all p ≤ 0.025). Additionally, the low QOL group more often had TED-specific surgical history (45% vs. 10%, p = 0.002), more often reported disability/unemployment (21% vs. 3%, p = 0.055), and had a higher number of doctor visits (40 vs. 5 visits/person/year, p < 0.001).

CONCLUSION

TED severely impacts patient QOL, despite becoming stable and chronic. Patients reported vision and appearance impairment and psychosocial impact long after acute TED had subsided.

Effectiveness of orbital decompression for endocrine orbitopathy and impact on quality of life: A retrospective study

To evaluate the effectiveness of orbital decompression intervention in terms of variation of the exophthalmos and to highlight its association with changes in quality of life before and after surgery. Medical records of patients with moderate-severe GO who underwent orbital decompression surgery were retrospectively reviewed. Clinical parameters, including demographic characteristics, surgical technique, exophthalmos values, and QoL using the GO-QoL questionnaire were studied before and after orbital decompression and analyzed. Thirty patients were included in the study. Surgery was bilateral 26 patients and unilateral in 4 patients (56 operated orbits). Before surgery the average value of exophthalmometry was 24.96 (±2.68) mm. The questionnaires submitted for assessment of the quality of life (GO-QoL) yielded average values of 43.3 for the visual function (VF) and 44.03 for the appearance (AP). 20 patients (64.3%) underwent combined bone and fat decompression surgery, 9 underwent fat decompression, and 1 underwent bone decompression. After surgery, the average values of exophthalmometry were 21.8 (±2.34) mm, with an average reduction of 3.20 (±2.35) mm. (p < 0.0001) GO-QoL questionnaires administered after surgery showed a mean VF score of 76.73 (±26.75), and AP score of 73.71 (±21.89). (p < 0.001, paired t-test) Orbital decompressive surgery is not only effective on GO, but also on a long-term improvement in overall well-being, self-confidence and QoL.

Quality of Life in Thyroid Eye Disease: A Systematic Review

PURPOSE

The aim of this systematic review is to provide 1) an understanding of the components of quality of life (QOL) questionnaires and 2) an up-to-date insight of the types of QOL questionnaires available, strengths and limitations based on current literature.

METHODS

A literature search was conducted from 18 to 21 of February 2019 using 6 major databases: Cochrane Library, Ovid Medline, PubMed, Scopus, Taylor and Francis, and Web of Science. All papers were skimmed by title and abstract to determine whether the paper fulfilled the screening criteria. In cases of uncertainty, the paper was read in totality to justify its inclusion. After that, duplicates were eliminated and the remainder was subjected to a second set of inclusion and exclusion criteria before finalizing the list of included studies.

RESULTS

An initial search returned with 402 studies, which were subsequently filtered using prespecified criteria to 27 studies to collate information regarding questionnaires assessing QOL of thyroid eye disease patients.

CONCLUSIONS

The QOL of thyroid eye disease patients is best assessed using disease-specific questionnaires. Among the different types of questionnaires, the Graves Ophthalmopathy Quality of Life (GO-QOL) questionnaire is preferred due to its' ability to explore QOL in-depth and proven efficacy in many countries after cultural adaptation at the expense of time. Single-item questionnaires like the Thyroid Eye Disease Quality of Life (TED-QOL) are more suitable as screening tools in busy metropolitan settings while semi-structured interviews are important in developing new ways of assessing the QOL of thyroid eye disease patients.

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.

Proposal for Standardization of Primary and Secondary Outcomes in Patients with Active, Moderate-to-Severe Graves' Orbitopathy

Standardization of treatment outcomes in randomized clinical trials (RCTs) for active, moderate-to-severe Graves' orbitopathy (GO) is needed to make results of different RCTs comparable and to draw sound conclusions on the efficacy of a given treatment. Both subjective patient-reported outcome (PRO) and objective clinician-reported outcome (CRO) are important in this regard. In this paper, it is proposed that primary PRO should be the evaluation of treatment-related changes in the quality of life by the use of a validated and disease-specific questionnaire (GO-QoL). The proposed primary CRO is a revised composite index, which includes only objective items and provides an overall assessment of the effects of treatment. Secondary outcomes should also be provided in RCTs to show the effects of treatment on individual features of GO, as well on persistence of activity (by the 7-item Clinical Activity Score), safety, relapses of GO, need for subsequent medical and/or surgical treatments, and other indicators (orbital volume, cytokines, TSH receptor antibody levels). Assessment of the overall response to treatment by primary and secondary outcomes should be made 3 months after treatment completion.

Physician-Perceived Impact of Thyroid Eye Disease on Patient Quality of Life in the United States

Introduction

Thyroid eye disease (TED) is an autoimmune disease that causes retro-orbital inflammation and subsequent proptosis, corneal exposure, strabismus, and variable vision changes. European studies have shown that TED can severely impact quality of life (QOL), but little is known about the QOL of patients with TED in the USA. Given that patient QOL influences TED severity classifications and subsequent treatment, understanding physician-perceived patient QOL is extremely important.

Methods

This retrospective chart review (conducted in 2018) examined QOL in US patients with moderate-to-severe TED, as reported by treating physicians who regularly manage patients with TED (≥ 5 patients in prior 12 months). The physicians graded patients’ overall QOL (7-point Likert scale; 1 = “not at all impaired”, 7 = “extremely impaired”), assessing mental health, vision changes, and ocular structural signs/symptoms. Patient demographics and clinical findings were examined to understand the impact of disease presentation on physician-perceived QOL.

Results

Medical record data of 714 US patients with moderate-to-severe TED were provided by 181 physicians (73 endocrinologists, 108 ophthalmologists). Patients had a mean age of 49.4 (standard deviation [SD] 13.6) years, and 102 cases (14%) were severe. Anxiety and/or depression was reported in 36% of patients (an increase from the 18.9% prevalence reported for the USA in 2017 by the US National Institute of Mental Health; P < 0.001). The mean physician-reported QOL impact score was 4.1 (SD 1.5). Furthermore, 62 and 89% of patients with moderate and severe TED, respectively, had a high physician-perceived QOL impact (≥ 4). The higher QOL impact group had significantly higher rates of pain symptoms, visual disturbances (including diplopia), and orbito-facial structural changes. Higher disease activity and severity were associated with lower physician-perceived QOL.

Conclusion

Patients’ QOL, as evaluated by US physicians, is highly impacted by the activity and severity of TED. Additionally, mental health issues were more frequently reported by patients with TED than in the general US population. Ocular pain, strabismus, and diplopia appear to be main drivers of physician-perceived QOL impairment in this sample of US patients with TED.

Little is known on how thyroid eye disease (TED) affects patient quality of life (QOL) in the USA. Patient QOL can affect how TED is treated; consequently, it is important to understand how physicians perceive QOL in patients with TED. We evaluated 714 patients, as reported by physicians, with this rare condition to better understand QOL in US patients with TED. The medical records of 612 patients with moderate TED and 102 patients with severe TED were examined. QOL impact was rated from 1 to 7, with 1 being “not at all impaired” and 7 being “extremely impaired.” Overall QOL, as assessed by treating physicians, is heavily impacted by both moderate and severe TED in US patients, with these patients also reported to have a higher frequency of mental health diagnoses than reported in the general US adult population. Higher levels of inflammation on and around the eye and more severe disease led to a higher QOL impairment. More specifically, pain, visual disturbances (including double vision), and changes to the face and tissues around the eye all negatively affected QOL.

Assessing the quality of life in Indian Graves' orbitopathy patients and validation of Hindi version of GO-QOL questionnaire

Purpose:

To validate the GO-specific quality of life (QOL) questionnaire in Hindi language and to determine the correlation of scores (visual functioning and appearance) with disease severity and activity.

Methods:

We recruited 114 consecutive patients with GO attending Endocrinology Clinic at tertiary care center. Eye examination was performed, and QOL was assessed by questionnaire.

Results:

The questionnaire was validated by 50 GO patients and test-retest reliability was performed in 15 patients. Hindi version GO-QOL was administered in 49 GO patients. GO was mild in 51.0% and sight-threatening in only 2.0% of cases. Orbitopathy was clinically active in only 10 (20.4%) cases. The GO-QOL scores (median) for visual function and appearance were 81.3 and 62.5, respectively. Patients with moderate-to-severe and sight-threatening GO had significantly lower median appearance scores (56.3 vs. 68.5, P = 0.01) compared to mild disease but no difference in visual scores. Patients with active disease had significant lower median visual function (53.1 vs. 85.7, P = 0.009) and psychosocial (appearance) scores (40.6 vs. 68.8, P = 0.03) compared to inactive disease. On multivariate regression analysis of GO-QOL scores, extraocular eye movement involvement (EOM), proptosis, and severity of eye disease were significantly associated with visual functioning while appearance was significantly associated only with the severity of eye disease.

Conclusion:

GO-QOL scores were significantly reduced in patients with GO.

Evaluation of Quality of Life in the Brazilian Graves' Disease Population: Focus on Mild and Moderate Graves' Orbitopathy Patients

Background: Quality of life (QoL) studies in patients with mild to moderate Graves' orbitopathy (GO) are scarce. Methods: The original GO-QoL questionnaire was translated to Portuguese and administered to 323 patients with Graves' disease. The clinically active score (CAS) was used to evaluate GO activity, and the NO SPECS and EUGOGO classifications were used to estimate GO severity. Results: The internal consistency of the GO-QoL, evaluated using Cronbach's alpha, was optimal. In people with Graves' disease and long-duration GO, both visual function and appearance scores were negatively associated with the CAS and NOSPECS and EUGOGO classifications (P < 0.001). Asymmetry and proptosis were significantly associated with the visual function and appearance domains, and diplopia was related to the visual function score. In addition, multivariate regression stepwise analysis revealed that disease severity, according to the EUGOGO classification, was associated with the visual function and appearance scores; asymmetry, presence of proptosis, and young age were associated with the appearance score (P < 0.001). The visual function and appearance scores were negatively correlated with the CAS and NOSPECS and EUGOGO classifications (P < 0.001). Conclusion: Graves' orbitopathy has a negative impact in QoL in patients with mild to moderate disease, even after an extended period, rendering GO a chronic disease. The GO-QoL questionnaire can be helpful in identifying patients in need of attention and support.

The relationship between quality of life, cognition, and thyroid status in Graves' disease

PURPOSE

To assess quality of life (QoL) and cognitive function among Graves' disease (GD) patients with different thyroid status, with and without ophthalmopathy.

METHODS

This is a cross-sectional clinic-based study involving 154 patients with GD (81.27% were female, mean age 45.6 ± SD 11.2 years) and 54 (35.06%) had ophthalmopathy. Data were collected after an informed consent from all patients was obtained. All patients completed the 36-Item Short Form Health Survey and Mini-Mental State Examination. Patients with ophthalmopathy also completed the Graves' Orbitopathy Quality of Life Questionnaire.

RESULTS

Patients with hyperthyroidism presented a greater impairment in QoL when compared to euthyroidism group. A lower score in physical role functioning was found in both subgroups with active disease (hyperthyroidism and euthyroidism using thionamides). A lower score was also seen in visual function, only in patients with hyperthyroidism, without difference in appearance. No difference was found in cognition between patients. Younger ages at diagnosis, male sex, euthyroidism and absence of ophthalmopathy were factors associated with better QoL, as well as a shorter disease duration was associated with better recall, attention and calculation.

CONCLUSIONS

An impairment in QoL among patients with active GD was evidenced, even in those receiving thionamides and in euthyroidism. Ophthalmopathy was a factor associated with a poor QoL and no clear evidence of cognitive impairment was demonstrated.

Validation of a novel patient-reported outcome measure for parathyroid and thyroid disease (PROMPT)

BACKGROUND

Patient-reported outcome measures are being used increasingly to assess disease severity and response to surgery. The purpose of this study was to create and validate a patient-reported outcome measure for symptoms of thyroid enlargement and hyperparathyroidism, 2 conditions where the presence of preoperative symptoms and response to surgery is often questioned.

METHODS

A questionnaire reviewing common symptoms was developed from a literature review and expert opinion. Internal validity, reliability, and initial responsiveness to surgery were evaluated.

RESULTS

Patient-Reported Outcome Measure for Parathyroid and Thyroid Disease (PROMPT) consists of 30 items: 10 compressive items and 20 hyperparathyroidism items; we evaluated 302 surveys collected over 10 months. PROMPT showed high internal consistency for compressive and hyperparathyroid constructs (Cronbach's α 0.84 and 0.95). Constructs were scored from 0-100, with greater scores corresponding to increased severity of symptoms. Preoperatively, patients with a goiter demonstrated greater compressive scores compared with other thyroid patients and hyperparathyroid patients (goiter, 47.5; nodule/other, 38.4; hyperparathyroid, 29.8; P < .0001). PROMPT demonstrated high test-retest reliability with acceptable intraclass correlation coefficients for both compressive score and hyperparathyroid score (0.840 and 0.646). Hyperparathyroid scores improved 2 weeks after (48.6 postop, 44.0 preop, P = .0470).

CONCLUSION

We validated a novel measure for symptoms of hyperparathyroidism and goiter. PROMPT demonstrates high internal consistency, test-retest reliability, and preliminary analysis, which suggests that it is sensitive to change after surgery.

Development and Validation of the Singapore Thyroid Eye Disease Quality of Life Questionnaire

Purpose

Current instruments to assess thyroid eye disease (TED) quality of life (QoL) were not developed using modern psychometric theory and may not be applicable to Asian populations. Therefore, we developed a psychometrically robust questionnaire, the Singapore Thyroid Eye Disease Quality of Life questionnaire (STED-QoL), for assessing QoL in Asian patients.

Methods

This cross-sectional study was conducted at the Singapore National Eye Centre between 2012 and 2015. In Phase 1, content for the questionnaire was developed using qualitative methods. A total of 20 patients participated in three different focus groups. Thematic analysis was conducted to identify relevant themes from which 12 items, rated on a 5-point Likert-type scale, were generated. In Phase 2, the pilot instrument was administered to 59 TED patients and psychometric assessment of the STED-QoL was conducted using Rasch analysis.

Results

After collapsing categories from five to four and deleting two misfitting items, we generated a 10-item STED-QoL befitting the Rasch model. The scale showed good criterion validity, with scores decreasing as severity of TED worsened: mild (1.78 logits), moderate (0.27 logits), and severe (0.92 logits). A ‘Psychosocial' subscale also had adequate psychometric properties and psychosocial scores were significantly worse in those who underwent surgery for TED compared to those who had not (0.41 vs. 1.82 logits, P = 0.021).

Conclusions

The STED-QoL is a robust 10-item questionnaire specifically developed to measure the impact of TED on QoL and psychosocial well-being in an Asian population.

Translational Relevance

QoL assessment is important for holistic management of TED patients.