Anti-nuclear autoantibodies in Graves' disease and Graves' orbitopathy

OBJECTIVE

A relationship between thyroid and non-organ-specific autoimmunity could be relevant for Graves' orbitopathy (GO), which affects connective tissue. We investigated the association between GO and anti-nuclear antibodies (ANAs).

METHODS

Retrospective investigation was conducted in 265 patients with Graves' disease (GD), 158 with and 107 without GO. Primary outcome was: prevalence of ANAs in GO vs no-GO. Secondary outcomes were: (1) relationship between ANAs and GO features; (2) prevalence of ANAs in GD compared with non-autoimmune hyperthyroidism [(78 patients with toxic nodular goiter (TNG)]; (3) distribution of ANA patterns.

RESULTS

ANAs were detected in 212 (80%) GD patients, but prevalence did not differ between GO (79.7%) and no-GO (80.3%). Higher ANA titers (1:160) were more common in GO (51.5 vs 38.3%), but only nearly significantly (OR 0.5; 95% CI: 0.3-1; P = 0.059). Proptosis was lower in ANA-positive patients (mean difference: - 1.4 mm; 95% CI from - 2.5 to - 0.3; P = 0.011), in whom nearly significantly lower CAS (Mann-Whitney U: 1.5; P = 0.077) and eyelid aperture (mean difference: - 0.9 mm; 95% CI from - 2 to 0; P = 0.062) were observed. Prevalence of ANAs in GD was lower than in TNG (80 vs 91%; OR 0.3; 95% CI: 0.1-0.9; P = 0.028), but nuclear speckled pattern was more frequent (OR 22.9; 95% CI 1.3-381.3; P = 0.028).

CONCLUSIONS

Although ANAs are not more frequent in GO, they seem to exert a protective role on its severity and on development of GD. A switch of T cell population in ANA-positive patients, resulting in a different phenotype, may be responsible. Further studies are needed to investigate the mechanisms.

Sirolimus as a second-line treatment for Graves' orbitopathy

OBJECTIVES

A beneficial effect of sirolimus in Graves' orbitopathy (GO) was reported, suggesting a possible use in clinical practice. We conducted an observational, single-centre, no-profit, clinical study to investigate the efficacy of sirolimus as a second-line treatment for moderate-to-severe, active GO compared with methylprednisolone.

METHODS

Data from consecutive patients given sirolimus (2 mg orally on first day, followed by 0.5 mg/day for 12 weeks) or methylprednisolone [500 mg iv/weekly (6 weeks), 250 mg/weekly (6 weeks)] as a second-line treatment were collected and compared.

PRIMARY OBJECTIVE

overall GO outcome at 24 weeks, based on a composite evaluation. Secondary objectives at 24 weeks: (1) improvement in quality of life, evaluated using a specific uestionnaire (GO-QoL); (2) reduction in proptosis; (3) reduction in the clinical activity score (CAS); (4) improvement of eye ductions; and (5) reduction in eyelid aperture.

RESULTS

Data from 30 patients (15 per group) treated between January 15, 2020, and June 15, 2021, were analysed. Proportion of GO responders (primary outcome) at 24 weeks was significantly greater in sirolimus group compared with methylprednisolone group (86.6% vs 26.6%; OR: 17.8; 95% CI from 2.7 to 116.8; P = 0.0026). GO-quality of life (GO-QoL) score was greater in sirolimus group. Proportion of proptosis responders was greater in sirolimus group, as well as proportion of clinical activity score (CAS) responders. No serious adverse events were observed, with no differences between groups.

CONCLUSIONS

Sirolimus seems to be an effective second-line treatment for GO. Further randomized clinical trials are needed to confirm our observations.

Effects of circadian rhythm disruption on retinal physiopathology: Considerations from a consensus of experts

The circadian rhythms originate within the organism and synchronize with cyclic fluctuations in the external environment. It has been demonstrated that part of the human genome is under control of the circadian clock and that a synchronizer that helps to maintain daily rhythms is Melatonin, a neuro-hormone primarily synthesized by the pineal gland during the night. The chronic disruption of circadian rhythm has been linked to many conditions such as obesity, metabolic syndrome, type 2 diabetes, cancer, and neurodegenerative diseases. Studies in the mice showed that the disruption of the retinal circadian rhythm increases the decline during the aging of photoreceptors, accelerating age-related disruption of cone cell structure, function, and viability and that the melatonin receptor deletion seems to influence the health of retinal cells, speeding up their aging. In conclusion, preserving the circadian rhythms could be to add to the prevention and treatment of age-related degenerative retinal diseases, and although additional studies are needed, melatonin could be a valid support to favor this “chronoprotection action”.

Role of the mononuclear cell infiltrate in Graves' orbitopathy (GO): results of a large cohort study

OBJECTIVE

The extent to which mononuclear cells and TSH-receptor autoantibodies (TRAb) contribute to Graves' orbitopathy (GO) is not completely defined. Here we investigated the relationship between the immunohistochemical phenotype of orbital infiltrating cells and GO features in a large number of patients.

METHODS

We conducted an observational cohort study in 76 consecutive patients with GO (16 men and 60 women) who underwent orbital decompression over a period of 18 consecutive months. An ophthalmological evaluation was performed in all patients, as well as immunohistochemistry for CD3, CD4, CD8, CD56 (T-cell markers), CD25 (T and B-cell marker), CD20, CD19 (B-cell markers), and CD138 (plasmacell marker) in specimens collected at decompressive surgery.

RESULTS

Having established cutoff values for each marker, cell infiltrates were found in 60 patients (78.9%; CD3: 39.4%, CD4 55.2%, CD8 50%, CD56: 0%, CD25: 28.9%, CD20: 51.3%, CD19: 25%, CD138: 26.3%). Eleven (14.4%) stained exclusively for CD138 (plasmacells). Patients with CD4-positive mononuclear cells had a significantly greater GO clinical activity score (CAS) (mean difference 1.07, 95% CI - 0.33 to - 1.82, P = 0.004 by univariate, P = 0.05 by multivariate analysis). CAS as well as the remaining GO features were not affected significantly by the mononuclear cell subpopulations in multivariate analyses.

CONCLUSIONS

Mononuclear cell infiltrates are present in the majority of GO patients, with a small percentage represented exclusively by plasmacells. CD4 cells exert a major role on GO activity. These findings may represent a further advancement in the comprehension of GO pathogenesis.

Correlation between serum anti-TSH receptor autoantibodies (TRAbs) and the clinical feature of Graves' orbitopathy

BACKGROUND

Graves' orbitopathy (GO) is the most common extrathyroidal manifestation of Graves' disease (GD). Several studies support the involvement of TSH receptor autoantibodies (TRAbs) in the pathogenesis of GO, and a correlation between GO features and TRAbs has been reported, but not confirmed by all studies. Thus, we conducted a cross-sectional investigation to determine whether there is a correlation between TRAbs and the clinical features of GO in an initial phase of the eye disease.

METHODS

Ninety consecutive patients with untreated GO (67 women and 23 men, age 48.9 ± 12.6 years) were included. Patients who had received treatments other than anti-thyroid drugs for hyperthyroidism or lubricants for GO were excluded. All patients underwent an endocrinological and ophthalmological evaluation, the latter including exophthalmometry, measurement of eyelid width, clinical activity score (CAS), visual acuity, assessment of diplopia, and NOSPECS score. TRAb levels were measured by a third-generation competitive immunoassay.

RESULTS

There was a statistically significant, direct correlation between serum TRAb levels and CAS by linear regression analysis (R = 0.278, P = 0.007). The correlation was confirmed by a multiple regression analysis (R = 0.285; P = 0.006) including age and FT3 levels, which also correlated with CAS. There were no relationships between TRAbs and exophthalmometry, eyelid aperture, degree of diplopia, visual acuity, and NOSPECS score.

CONCLUSIONS

The levels of TRAb in subjects with a recent-onset, untreated GO are directly correlated with the clinical activity of the disease, confirming a possible role of these antibodies in the pathogenesis of GO.

Putative protective role of autoantibodies against the insulin-like growth factor-1 receptor in Graves' Disease: results of a pilot study

BACKGROUND

The insulin-like growth factor-1 receptor (IGF-1R) is a key element in the pathogenesis of Graves' Orbitopathy (GO), but the role of IGF-1R autoantibodies (IGF-1RAbs) has not been established.

METHODS

We designed a cross-sectional investigation to measure IGF-1RAbs in patients with Graves' disease (GD), with or without GO, who underwent radioiodine therapy followed by glucocorticoids (GC). Twenty-nine patients were included, 15 of which with GO. Patients were evaluated at baseline and three and 6 months after radioiodine. The primary objective was the prevalence of positive tests for IGF-1RAbs. The secondary objectives were: (1) IGF-1RAbs concentrations and their variations; (2) relationship between IGF-1RAbs and the features of GO; (3) relationship between IGF-1RAbs and anti-thyroid autoantibodies.

RESULTS

IGF-1RAbs above the cut-off value were found only in one patient with GD without GO. IGF-1RAb levels were greater in patients with GD without GO, at baseline (P < 0.0001), and after three (P < 0.0001) and six (P = 0.0001) months. No correlations were observed between IGF-1RAbs and the features of GO, nor between IGF-1RAbs and anti-thyroglobulin or anti-thyroperoxidase autoantibodies. There was an inverse correlation between anti-TSH receptor autoantibodies (TRAbs) and IGF-1RAb levels in GD patients with GO at 6 months (P = 0.03).

CONCLUSIONS

IGF-1RAbs appear to be greater in patients with GD without GO compared with those with GO, suggesting a putative protective role of IGF-1RAbs on the development of GO, in line with the beneficial effects of Teprotumumab on GO. The inverse correlation between IGF-1RAbs and TRAbs 6 months after radioiodine may reflect antigen spreading and/or GC treatment.

Optical Coherence Tomography Findings of Incomplete Posterior Vitreoschisis with Vitreomacular Traction Syndrome and Impending Macular Hole: A Case Report

Purpose

Vitreomacular traction syndrome is a clinical entity characterized by partial posterior vitreous detachment in combination with persistent macular adherence. Recently, optical coherence tomography (OCT) allowed visualization of incomplete posterior vitreoschisis leading to vitreomacular traction.

Methods

The authors report on a 57-year-old woman with blurred vision in her left eye.

Results

OCT scan showed incomplete posterior vitreoschisis with vitreomacular traction syndrome and impending macular hole in her left eye.

Conclusions

The intraoperative findings together with the evidence that the internal limiting membrane (ILM) thickness is thinner than the axial resolution of the Stratus OCT (8 μm) and a spontaneous ILM detachment has never been demonstrated are likely to support the hypothesis that posterior vitreoschisis exists and can be associated with vitreomacular traction syndrome.

Diagnostic ability of Humphrey perimetry, Octopus perimetry, and optical coherence tomography for glaucomatous optic neuropathy

PurposeTo evaluate and compare the diagnostic accuracy of the Humphrey Field Analyzer (HFA), Octopus perimetry, and Cirrus OCT for glaucomatous optic neuropathy.MethodsEighty-eight healthy individuals and 150 open-angle glaucoma patients were consecutive and prospectively selected. Eligibility criteria for the glaucoma group were intraocular pressure ≥21 mm Hg and glaucomatous optic nerve head morphology. All subjects underwent a reliable standard automated perimetry with the HFA and Octopus perimeter, and were imaged with the Cirrus OCT. Receiver-operating characteristic (ROC) curves were plotted for the threshold values and main indices of the HFA and Octopus, the peripapillary retinal nerve fiber layer thicknesses, and the optic nerve head parameters. Sensitivities at 85 and 95% fixed-specificities were also calculated. The best areas under the ROC curves (AUCs) were compared using the DeLong method.ResultsIn the glaucoma group, mean deviation (MD) was -5.42±4.6 dB for HFA and 3.90±3.6 dB for Octopus. The MD of the HFA (0.966; P<0.001), mean sensitivity of the Octopus (0.941; P<0.001), and average cup-to-disc (C/D) ratio measured by the Cirrus OCT (0.958; P<0.001) had the largest AUCs for each test studied. There were no significant differences among them. Sensitivities at 95% fixed-specificity were 82% for pattern standard deviation of the HFA, 81.3% for average C/D ratio of OCT, and 80% for the MD of the Octopus.ConclusionsHFA, Octopus, and Cirrus OCT demonstrated similar diagnostic accuracies for glaucomatous optic neuropathy. Visual field and OCT provide supplementary information and thus these tests are not interchangeable.

Placental mitochondrial content and function in intrauterine growth restriction and preeclampsia

Intrauterine growth restriction (IUGR) and pregnancy hypertensive disorders such as preeclampsia (PE) associated with IUGR share a common placental phenotype called "placental insufficiency", originating in early gestation when high availability of energy is required. Here, we assess mitochondrial content and the expression and activity of respiratory chain complexes (RCC) in placental cells of these pathologies. We measured mitochondrial (mt)DNA and nuclear respiratory factor 1 (NRF1) expression in placental tissue and cytotrophoblast cells, gene and protein expressions of RCC (real-time PCR and Western blotting) and their oxygen consumption, using the innovative technique of high-resolution respirometry. We analyzed eight IUGR, six PE, and eight uncomplicated human pregnancies delivered by elective cesarean section. We found lower mRNA levels of complex II, III, and IV in IUGR cytotrophoblast cells but no differences at the protein level, suggesting a posttranscriptional compensatory regulation. mtDNA was increased in IUGR placentas. Both mtDNA and NRF1 expression were instead significantly lower in their isolated cytotrophoblast cells. Finally, cytotrophoblast RCC activity was significantly increased in placentas of IUGR fetuses. No significant differences were found in PE placentas. This study provides genuine new data into the complex physiology of placental oxygenation in IUGR fetuses. The higher mitochondrial content in IUGR placental tissue is reversed in cytotrophoblast cells, which instead present higher mitochondrial functionality. This suggests different mitochondrial content and activity depending on the placental cell lineage. Increased placental oxygen consumption might represent a limiting step in fetal growth restriction, preventing adequate oxygen delivery to the fetus.

Bimatoprost 0.01% vs bimatoprost 0.03%: a 12-month prospective trial of clinical and in vivo confocal microscopy in glaucoma patients

PURPOSE

To evaluate the safety of two commercially available formulations of bimatoprost eye drops: 0.03 and 0.01% ophthalmic solutions.

METHODS

This was a randomized, prospective, parallel-group, open-label, cohort study. A total of 60 glaucoma patients (60 eyes) under bimatoprost 0.03% monotherapy since at least 1 year were enrolled. Selected patients were randomized to receive a single drop of bimatoprost 0.01% (n=30) or bimatoprost 0.03% (n=30) ophthalmic solutions for 12 months. Statistical analysis was performed using paired t-test and repeated measures ANOVA test.

RESULTS

Global clinical score (the sum of pruritus, stinging/burning, blurred vision, sticky eye sensation, eye dryness sensation, and foreign body sensation) significantly decreased in the bimatoprost 0.01% group from baseline 4.7 ± 3.8 to 2.9 ± 2.3 (P < 0.001) and 2.5 ± 2.0 (P < 0.001) at 6-month and 12-month follow-ups, respectively. Comparison between groups showed differences at both follow-up visits (P = 0.003 and P < 0.001, respectively). In vivo confocal microscopy revealed a significant increase in goblet cell density in the bimatoprost 0.01% group compared with the bimatoprost 0.03% group (P<0.001 at both follow-up visits). All functional parameters and conjunctival hyperemia improved in the bimatoprost 0.01% group at each follow-up visit (P < 0.05) and in comparison with bimatoprost 0.03% (P < 0.05).

CONCLUSION

The results of this trial suggest that bimatoprost 0.01% eye drops seem to decrease the ocular discomfort with respect to bimatoprost 0.03% eye drops.

Behçet's disease: features of neurological involvement in a dedicated centre in Italy

OBJECTIVES

The aim of the present study was to retrospectively assess the prevalence of neurological involvement and the clinical patterns of presentation in a monocentric cohort of patients with BD, who have been followed in the last twenty years at our centre.

METHODS

One hundred and seventeen patients were retrospectively studied. The male/female ratio was 1.6:1, with a mean disease duration of 11±5 years. Their mean age was 42±9 years (min:18, max:77), while the mean age at disease onset was 25±4 years (min:10, max:58). The mean ± SD duration of follow-up at our centre was 7±2 (min:1, max:11) years.

RESULTS

Neurological involvement was observed in 38% (44 patients, 36 males and 8 females; mean age at onset 25±4 years). Organic brain involvement, demonstrated by MRI was due to ischaemic pons-mesencephalon lesions in 19 patients and to meningoencephalitis with brainstem involvement in 16. Peripheral nervous system involvement was confirmed by electroneuromyographic study in 4 patients, and consisted of peripheral neuropathy prominent in the lower extremities in all cases; we have also observed only 2 cases of endocranial hypertension and 3 BD patients suffering from pulsatile, severe headache, without abnormal neurological examination, responding only to medium-high doses of steroids. Excluding peripheral neuropathy and isolated headache, the onset of CNS involvement (total prevalence: 32% of the cohort) was observed in 2 patients within the first year from the onset of BD, in 4 cases between the first and the third year, in 24 between the third and the fifth year, 7 between the fifth and the tenth year; none presented a CNS involvement after the first 10 years of disease.

CONCLUSIONS

Neuro-BD is more frequent in young males and it never represents a presenting feature of the disease. The most frequent time of onset of neurological involvement seems to be within the first 10 years of disease. Since neurological involvement may result in severe functional disability or be a life-threatening disease, a careful follow-up during the first years after onset is recommended.

Short-term changes in the optic nerve head and visual field after trabeculectomy

AIMS OR PURPOSE: To evaluate short-term changes in optic nerve head topography and visual field induced by surgical reduction of intraocular pressure.

METHODS

A prospective study was performed on 56 eyes of 56 patients with uncontrolled primary open-angle glaucoma despite maximum medical therapy, which underwent trabeculectomy. Optic nerve head evaluations by means of Heidelberg Retina Tomograph, and visual field tests were performed pre-operatively, and at 3 and 6 months after surgery. Differences in intraocular pressure, visual field indices, and Heidelberg Retina Tomograph parameters were evaluated with the t-test for paired data. A linear regression model was calculated to analyze the relationship between intraocular pressure reduction and visual field changes, and optic nerve head changes.

RESULTS

Mean intraocular pressure decreased from 24.4 ± 5.0 mm Hg to 12.1 ± 3.1 mm Hg (month 3, P<0.001), and 10.6 ± 2.8 mm Hg (month 6, P<0.001) after trabeculectomy. Mean retinal nerve fiber layer thickness (baseline, 0.19 ± 0.034; month 3, 0.24 ± 0.039, P=0.05; month 6, 0.21 ± 0.037, P=0.05) showed a statistical significant change compared with baseline values.

CONCLUSIONS

In this 6-months study, a significant increase in retinal nerve fiber layer thickness was detected after glaucoma filtration surgery.

Optic nerve head changes in early glaucoma: a comparison between stereophotography and Heidelberg retina tomography

OBJECTIVE

To evaluate and compare the diagnostic accuracy of the Heidelberg retina tomograph (HRT) version 3 with that of glaucoma specialists using stereophotography in discriminating between normal eyes and patients with early glaucomatous visual field loss.

METHODS

A total of 105 eyes of 105 individuals were prospectively and consecutively recruited. The sample comprised 51 normal and 54 early glaucomatous eyes, as defined by intraocular pressure and standard automated perimetry results, regardless of optic disc appearance. Receiver operating characteristic (ROC) curves were plotted for the HRT3 parameters and a linear discriminant function (LDF) developed in our hospital. Best sensitivity-specificity pairs were compared between the HRT3 parameters, with the highest areas under the ROC curve (AUCs) and evaluation of optic disc stereophotographs. Agreement between methods for measuring vertical cup-to-disc ratio was evaluated with the Bland-Altman plot.

RESULTS

The average visual field mean deviation was -2.90 dB. The HRT3 parameters with the largest AUCs were our LDF (0.900), rim volume (0.883), and vertical cup/disk ratio (0.880), with no significant differences between these parameters. Sensitivity-specificity pairs were 79.6-100% (clinical evaluation), 83.3-86.3% (our LDF), 64.8-96.1% (final glaucoma probability score), and 68.5-90.2% (global Moorfields regression analysis).

CONCLUSIONS

The diagnostic accuracy for differentiating normal eyes from those with early visual field defects was similar between clinical evaluation of the optic disc and evaluation with the HRT3. The use of our LDF increased the sensitivity-specificity balance with respect to the HRT-provided parameters. The diagnostic accuracy of the HRT classifications was comparable to that of an experienced glaucoma specialist.

Open-sky capsulorrhexis in triple procedure: with or without trypan blue?

not available.

Free-floating cyst in the anterior chamber: ultrasound biomicroscopic reports

PURPOSE

To report a free-floating dislodged pigmented cyst in the anterior chamber and to describe the ultrasound biomicroscopic (UBM) features of the lesion.

METHODS

Case report.

RESULTS

A 26-year-old man presented with noise in his left eye in the prone position. Slit-lamp examination revealed a small pigmented mass lesion at the 6 o'clock position in the anterior chamber, slowly moving with changing head postures. UBM revealed an unfixed dislodged pigmented cyst with a thin wall and no internal reflectivity, changing its shape from ovoid to circular. Five years later, the anterior segment does not show any modification and the cyst has not changed in size or appearance.

CONCLUSIONS

Cysts of the iris pigment epithelium arise in the posterior iris layer. They may be central, midzonal, peripheral, or dislodged. Dislodged cysts may be repositioned and fixed or free-floating in the vitreous or in the anterior chamber. Surgical removal must be considered only for a rapid enlargement or significant reduction in endothelial cell count. UBM can distinguish solid from cystic lesions, giving detailed information on internal structure, reflectivity, shape, and thickness.

[Diagnosis of traumatic hernia of the right hemidiaphragm. Considerations on a case]

Rupture of the right hemidiaphragm is an unusual event and often misunderstood. Failure to diagnose this lesion in the acute stage, in addition to contributing to its high mortality, means that it frequently becomes apparent only months or even years after the event. Even at this late stage, diagnosis is not always easy, especially when the history is not correctly weighed and proper investigation is thus lacking. Pneumoperitoneum and liver scintiscanning are recommended in this respect. A recently observed case is presented as a more or less typical example of this rare disease.