[Bony orbital decompression in thyroid eye disease]

This article summarizes the results of research on the morphological and functional features of different types of orbital bone decompression in thyroid eye disease (TED) and presents an analysis of surgical anatomy of the lateral orbital wall in the context of performing deep lateral bone decompression of the orbit was carried out. The study includes an analysis of the results of orbital bone decompression with resection of the greater wing of the sphenoid bone using ultrasound osteodestructor in comparison with osteodestruction using a high-speed drill, description of transethmoidal orbital decompression with endonasal access both as a single method of surgical treatment of TED and in combination with lateral bone decompression of the orbit, including the advantages and disadvantages of the method, and presents a morphological description of the pathological changes in the medial orbital wall bone fragments obtained during endonasal transethmoidal orbital decompression in patients with TED.

[Alemtuzumab-induced Graves' disease]

Multiple sclerosis (MS) is a severe chronic autoimmune demyelinating disease of the central nervous system, mediated by Th1/Th17 lymphocytes as well as B lymphocytes, macrophages and other immune cells. Some patients with MS are treated with alemtuzumab, a monoclonal antibody against CD52+ cells, which belongs to the disease-modifying therapies (DMTs). The main effect of alemtuzumab is related to changes in immune recruitment. Alemtuzumab therapy can induce secondary autoimmunity against the background of immune rebalancing. The thyroid gland is generally involved in the autoimmune process. Graves' disease (GD) develops most often, followed by autoimmune thyroiditis.We present a clinical case of a patient with GD developed after alemtuzumab therapy for MS. The patient was referred to a radiologist at the Department of Radionuclide Therapy of Endocrinology Research Centre for radioiodine therapy (RAIT) due to relapse of thyrotoxicosis after anti-thyroid drug therapy for GD. The goal of treatment was achieved in 2 months, thyroid hormone therapy was initiated, against the background of this, there was compensation of thyroid function.

[Complications of transnasal endoscopic orbital decompression in thyroid eye disease]

PURPOSE

The study evaluates the frequency of complications after transnasal endoscopic orbital decompression (TEOD).

MATERIAL AND METHODS

The study included 40 patients (75 orbits) with thyroid eye disease (TED; also termed Graves' ophthalmopathy, GO; thyroid-associated orbitopathy, TAO), who were divided into three groups depending on the method of surgical treatment. The first group consisted of 12 patients (21 orbits) who were treated with TEOD as the only method of surgical treatment. In the second group, there were 9 patients (18 orbits) who underwent TEOD and lateral orbital decompression (LOD) simultaneously. The third group consisted of 19 patients (36 orbits) who underwent TEOD as the second stage after LOD. Pre- and postoperative observation included assessment of visual acuity, visual field, exophthalmos, heterotropia/heterophoria angle.

RESULTS

In group I the new-onset strabismus with binocular double vision was detected in 1 patient (8.3%). In 5 patients (41.7%), there was an increase in the angle of deviation and an increase in diplopia. In group II the new-onset strabismus with diplopia occurred in 2 patients (22.2%). In 8 patients (88.9%), an increase in the angle of deviation and an increase in diplopia were revealed. In group III the new-onset strabismus and diplopia occurred in 4 patients (21.0%). An increase in the deviation angle and an increase in diplopia were noted in 8 patients (42.1%). The number of postoperative otorhinolaryngologic complications in group I was 4 (19.0% of the number of orbits). Two intraoperative complications were recorded in group II - 1 case of cerebrospinal rhinorrhea (5.5% of the number of orbits) and 1 case of retrobulbar hematoma without permanent vision loss (5.5% of the number of orbits). The number of postoperative complications was 3 (16.7% of the number of orbits). In group III the number of postoperative complications was 3 (8.3% of the number of orbits).

CONCLUSION

The study showed that the most common ophthalmological complication after TEOD is strabismus with binocular double vision. Otorhinolaryngologic complications included synechiae of the nasal cavity, sinusitis and mucocele of the paranasal sinuses.

[Transnasal endoscopic orbital decompression in the algorithm of surgical treatment of endocrine ophthalmopathy]

OBJECTIVE

To develop an algorithm for the use of transnasal endoscopic orbital decompression (TEOD) in endocrine ophthalmopathy (EOP).

MATERIAL AND METHODS

The results of 225 TEODs are analyzed. 139 patients with EOP were under observation, who were divided into two groups. Group 1 included 64 patients with an inactive form of EOP, group 2 included 75 patients with EOP complicated by optical neuropathy. Group 2 patients are divided into three subgroups. In the first subgroup there were 36 patients who underwent only TEDO, in the second subgroup there were 17 patients who underwent simultaneous TEOD and lateral bone orbital decompression (LBOD), in the third subgroup there were 22 patients who underwent TEOD and with an interval of 7-14 days - LBOD. After surgery, visual acuity, visual fields and color perception, regression of exophthalmos, as well as the presence of strabismus and diplopia were evaluated.

RESULTS

In patients of group 1 (64 patients, 104 TEODs), the average regression rate of exophthalmos was 5.49±1.22. Diplopia was observed in 23 (36%) patients, strabismus - in 18 (28%) patients. The transient nature of diplopia and strabismus was noted in 11% of cases. Patients of the first subgroup showed an increase in visual acuity from 0.4±0.28 to 0.7±0.2 (p<0.05). Strabismus and diplopia were observed in 54% of cases. In the subgroup with step-by-step performed TEOD and LBOD, the increase in visual acuity was more pronounced and amounted to 74% (from 0.78±0.71 to 0.2±0.3 according to LogMAR, p<0.05), postoperative strabismus and diplopia remained at a high level - 40% of the number of surgical operations performed. The best results of improving visual functions were obtained in patients of the second subgroup with simultaneous TEOD and LBOD (balanced orbital decompression): the increase in visual acuity was 79% (from 0.57±0.47 to 0.12±0.2 according to LogMAR, p<0.05). In patients of this subgroup, strabismus develops less frequently (22% of the number of operated orbits).

CONCLUSION

Transnasal endoscopic decompression of the orbit in the inactive form of the disease is indicated for exophthalmos of more than 4-8 mm. In optical neuropathy, transnasal endoscopic orbital decompression is indicated regardless of the initial visual acuity of the patient and should be supplemented with lateral bone orbital decompression with visual acuity below 0.1. The obtained results allowed us to form an algorithm for surgical treatment of patients with endocrine ophthalmopathy and optical neuropathy using transnasal endoscopic orbital decompression as a surgical intervention.

[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.

[Potential of bony regrowth after deep lateral orbital decompression]

The article describes a very rare case of bony regrowth after deep lateral orbital decompression for thyroid eye disease. Bony regrowth was observed in the area of the resected «trigone» of the greater wing of the sphenoid bone and in the area of the exposed dura mater. This case demonstrates that bony regrowth can be a possible cause of exophthalmos (proptosis) recurrence after orbital decompression in thyroid eye disease without clinical or laboratory evidence of reactivation of the disease.

[Autoantibodies, immunoglobulins and cytokine profile in patients with graves' disease and Graves' orbitopathy]

BACKGROUND

Graves' Orbitopathy (GO) - also known as Thyroid Eye Disease (TED) - is an autoimmune condition in the modern sense. It is closely associated with autoimmune thyroid diseases. Cytokine-mediated mechanisms play a critical part in immunopathogenesis of autoimmune thyroid diseases including GO. Investigating cytokine profiles as well as antibodies to tissue-specific antigens is essential for explaining GO pathogenesis and developing future therapeutic strategies.

AIMS

The study examines serum levels of cytokines, autoantibodies and immunoglobulins IgG and IgG4 as mediators of autoimmune inflammation in patients with GO and Graves' Disease (GD).

MATERIALS AND METHODS

The study included 52 patients (104 orbits) aged 25-70 years (mean age 48,8±12,3) in the active phase of GO and GD verified with the international diagnostic standards. These patients did not get any treatment for GO before. The control group consisted of 14 individuals (28 orbits) aged 30-68 years without known autoimmune disease.Serum levels of IgG, IgG4,TNFα, IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-17A, IL-13, sIL-6R, sTNFα- RI и TNFα- R2 IL-2R, TGFβ1, TGF β3, antibodies to TSH-receptor, free T4, free T3 and TSH were measured. A diagnostic ultrasound exam of thyroid gland, multislice computed tomography (MSCT) / magnetic resonance imaging (MRI) of orbits were performed.

RESULTS

Mean duration of GO prior to being admitted to the centre was 8,8±1,5 months (range: 1 - 48 months). According to the degree of thyrotoxicosis compensation: 24 patients were clinically euthyroid, TSH 3,3±0,7 mU/L, free T4 11,9±0,59 pmol/L, free T3 3,97±0,1 pmol/L; 28 patients were considered to have subclinical thyrotoxicosis: TSH 0,03±0,01 mU/L, free T4 14,2±1,0 pmol/L, free T3 5,77±0,49 pmol/L. Serum levels of sTNFα-R2 (p=0,041, p≤0,05), sIL-2R (p=0,020, p≤0,05), TGFβ1 (p=0,000, p≤0,001) were significantly higher in patients with GO compared to the control group. Serum levels of sTNFRα2 (p=0,038, p&lt;0,05) and TGFβ1 (P=0,011, p≤0,05) were positively correlated with the duration of GO. The positive correlations between the serum level of sIL-6R (p=0,034, p≤0,05) and the severity of GO as well as between the serum level of sTNFα- R 1 (P=0,012, p≤0,05) and activity of GO were observed. 54% of patients had elevated concentration level of IgG4 in IgG ( &gt;5%).

CONCLUSION

High levels of soluble cytokine receptors sTNFα-R2 and sIL-2R and cytokine TGFβ1 in patients with long-standing untreated GO and GD being euthyroid or having subclinical thyrotoxicosis indicate activation of regulatory T cells aimed at suppressing autoimmune processes. High concentration level of IgG4 in IgG and cytokine TGFβ1 can determine the development of fibrotic changes in the orbital tissues. A decrease in the concentration of cytokine TGFβ1 can indicate an unfavorable course of the disease GO.

[IgG4-associated disease in differential diagnosis of inflammatory orbitopathy]

IgG4-associated disease (IgG4-RD) is a systemic inflammatory disease characterized by tumorlike sclerosing masses in different organs. Differential diagnosis in orbital IgG4-RD includes majority of conditions, such as thyroid eye disease (TED), sarcoidosis, granulomatosis with polyangiitis, idiopatic orbital inflammation, limphoproliferative diseases and others. A case of IgG4-RD with different organs involvement and complicated differential diagnosis is presented. This case demonstrates very uncommon manifestation of IgG4-RD, when orbital involvement was very similar with TED. Systemic process was not recognized during a long period of time and diagnosis of IgG4-RD was established only after biopsy of abnormally increased lacrimal gland. Differential diagnosis included other systemic diseases, first of all sarcoidosis, GPA, and lymphoma. Biopsy results were consistent with the gold standard of diagnosis, e. g. more than 40% of plasma cells were IgG4 positive. This case demonstrates the necessity of orbital biopsy before starting immunosuppression to avoid inappropriate treatment strategy.

[Comparative electron microscopy study of the bone surfaces relief after ultrasonic and mechanical high-speed bone removal in orbital decompression]

PURPOSE

To compare the results of scanning electron microscopy studies of the surface of bone fragments of orbital lateral wall formed by mechanical and ultrasonic bone removal devices.

MATERIAL AND METHODS

The surfaces of 7 bone fragments have been investigated after bony orbital decompression in patients with thyroid eye disease (TED). Electron microscopy of the bone relief was performed after exposure to an ultrasonic surgical system or a high-speed drill.

RESULTS

Electron microscopy revealed that relief of the bony surface within a compact substance after application of an ultrasonic aspirator had parallel grooves of the same type up to 100 μm in depth and 80-100 μm wide, with relatively smooth edges. In the area of impact on spongy substance the bone surface became more amorphous, rougher due to the exposure of cellular structures at different depths. High-speed drill used in the area of compact substance left monotonous, almost flat relief with individual compact conglomerates of bone 'dust'. Removal of thinned fragments of the compact substance of the specimen led to appearance of the cellular structure typical for a spongy substance.

CONCLUSION

Data on features of the relief of the edges of bone 'window' obtained for the first time, as well as specifics of working in conditions of limited surgical access allowed the conclusion that modern ultrasonic bone aspiration is promising for deep lateral wall decompression and some other orbital interventions.

[Surgical rehabilitation of patients with thyroid eye disease: systematic approach]

AIM

to analyze the results of surgical treatment of patients with thyroid eye disease (TED), including the type of surgery, indications, and outcomes.

MATERIAL AND METHODS

Hundred thirty-nine patients with TED (112 females, 27 males) aged 45.8±13.6 years.

RESULTS

Bony orbital decompression was performed in 91 patients (128 orbits). After the surgery, visual acuity increased from 0.84±0.47 up to 0.94±0.32 (р<0.05), exophthalmos got reduced by the average of 3.4 mm. Strabismus surgery was performed in 15 patients. The absence of diplopia in the primary position of gaze was achieved in 12 cases and the degree of residual heterophoria averaged 3.33 PD (2-6 PD). Ocular motility improved from 10.7° up to 34.58°. Eyelid surgery was performed in 81 patients.

CONCLUSIONS

1. Surgical treatment for thyroid eye disease is indicated in patients with visual impairment and/or significant decrease in the quality of life, if pathogenetic treatment fails. 2. The choice of surgical strategy depends on several factors, such as TED activity and severity, thyroid function, pathologic changes in the orbital tissues, and surgeon's experience and preference. 3. Current surgical techniques for thyroid eye disease enable correction of disease consequences, such as exophthalmos, optic neuropathy, impairment of ocular movement, and exposure keratopathy. 4. Adherence to the systematic approach that includes bony orbital decompression, strabismus surgery, and correction of lagophthalmos and eyelid retraction, ensures high-level functional and cosmetic rehabilitation in patients with TED.

Federal clinical recommendations on diagnostics and treatment of endocrine ophthalmopathy associated with autoimmune thyroid pathology

Endocrine ophthalmopathy (EOP) is a multidisciplinary problem at the intersection of endocrinology and ophthalmology. The patients presenting with this condition experience deficit of adequate medical aid due to the poor cooperation between ophthalmologists and endocrinologists. There are practically no specialized centres in this country where the patients with EOP could receive the combined treatment of this pathology including the surgical intervention. Taken together, late diagnostics and delayed seeking the efficacious medical assistance, the absence of stable compensation of the functional disorders of the thyroid gland, erroneous identification of the phase of the disease, and incorrect choice of the methods for its treatment, the lack of coordination and consistency in the actions of ophthalmologists and endocrinologists are responsible for the low effectiveness of EOP treatment. On the other hand, the absence of the unified approach to diagnostics and treatment of endocrine ophthalmopathy, the necessity of introducing the international experience gained in this field into the routine clinical practice and pooling efforts of representatives of different medical disciplines (endocrinologists, ophthalmologists, radiologists, endocrine surgeons, and neurosurgeons) created the prerequisites for the solution of the EOP problems and gave impetus to the development of the recommendations being proposed.

[Graves' disease and pregnancy]

Thyvrotoxicosis is a clinical syndrome related to the negative influence of excess thyroid hormones. Its main cause in young and mid-aged patients is Graves' disease. Therapy with thyrostatic medications are most frequently used in this country as the primary method for the treatment of this disease. The experience of both Russian and foreign authors indicate that 70% of Graves' disease cases require radical treatment. Special caution is needed in the choice of therapies for young women planning pregnancy. Graves'disease developing prior to pregnancy is a contraindication for it because of high risk of its interruption and complications. Such women should be recommended careful contraception. A 27-year-old patient with Graves' disease is described who planned pregnancy and received conservative therapy for an unnecessary, long time. Therapy of thyrotoxicosis during pregnancy and after it is described.

[Left ventricular remodeling in patients in patients with thyrotoxicosis]

The aim of this paper was to investigate cardiac remodelling in thyrotoxicosis. The geometric parameters of the left ventricle (LV) and the readings of tissue Doppler echocardiography were compared in 27 patients (mean age 53.3±9.2 years) who had first-diagnosed moderate thyrotoxicosis without concomitant cardiac pathology and in 16 healthy individuals (mean age 45.1±4.7 years). The baseline data and the results of incremental treadmill exercise tests were analyzed. It was shown that in the relatively early periods of thyrotoxicosis development, there were decreases in the left ventricle (LV) longitudinally and transversely and in the thickness of LV, without altering its sphericity and conicity. Along with weight loss, there were reductions in cardiac sizes with decreases in the local rates of cardiac wall movement, peak systolic and early diastolic rates of mitral movement velocities. During a treadmill test, there was a drastic reduction in the exercise tolerance threshold as compared to healthy individuals: 57.81±14.7 and 148.3±11.7 W, respectively.

[Cardiac functional reserve and left ventricular parameters in patients with diffuse toxic goiter after drug correction of euthyroidism with thiamazol]

The aim of the investigation was to assess the time course of structural-and-functional and spatiogeometric changes following drug correction of euthyroidism in patients with diffuse toxic goiter and to determine prospects for restoring the cardiac functional reserve after elimination of thyrotoxicosis. The geometric parameters of the left ventricle (LV) and the readings of tissue Doppler echocardiography and exercise tests were compared in 27 female patients (mean age 53.3±9.2 years) who had thyrotoxicosis and 6 months after thyrosole-induced normalization of thyroid-stimulating and thyroid hormone. There were significant increases in myocardial mass and peak systolic and diastolic mitral ring motion rates and an increasing trend for LV linear sizes after correction of euthyroidism. Despite the fact that there were no significant differences in the majority of LV geometric parameters, with euthyroidism achievement, the cardiac functional reserve doubled as compared with the baseline values (105.7±11.4 and 57.8±14.7 W, respectively; p < 0.001), but remained below the control level (148.7±11.7 W; p < 0.05), which may contribute to the development of heart failure in future under certain conditions.

[Radioiodine therapy for Graves disease as a risk factor of endocrine ophthalmopathy]

In 1973 and 1976 2 cases of endocrine ophthalmopathy (EO) after external irradiation of the anterior surface of the neck due to a tumor (Hodgkin's lymphoma) was described. Further observations showed that treatment of Graves' disease (BG) with radioactive iodine (131I) can worsen the course of EO. So, L. De Groot et al., Observing 264 patients after exposure to 131I for BG, found progression of EO in 4% of patients after the 1st course of therapy and in 12% after subsequent sessions. Later the appearance or significant progression of EO in  patients treated with 131I has been observed. Some studies have shown that the progression of EO after treatment with 131I without glucocorticoids administration can be observed in 18-30% of cases. Along with this, there is an opinion that 131I does not affect the incidence of clinical symptoms in the orbit and that hypothyroidism that occurs after it does not lead to the progression of eye symptoms. The relationship between treatment and the onset or progression of EO is not clear. Nevertheless, there is evidence of an adverse effect of an elevated level of antibodies to the thyroid stimulating hormone receptor in the blood serum after 131I training for EO.

[Radioiodine therapy for Graves' disease as a risk factor of endocrine ophthalmopathy]

In 1973 and 1976 R. Wasnich and R. Jackson described 2 cases of endocrine ophthalmopathy (EO) that occurred after external irradiation of the anterior surface of the neck due to a tumor (Hodgkin's lymphoma). Further observations showed that treatment of Graves' disease with radioactive iodine (131I) can worsen the course of EO. So, L. De Groot et al., Observing 264 patients after exposure to 131I for Graves' disease, found progression of EO in 4% of patients after the 1st course of therapy and in 12% after subsequent sessions. L. Bartalena et al. observed the appearance or significant progression of EO in 15% of 150 patients treated with 131I. At the same time, against the background of glucocorticoid therapy, only 10% of patients worsened the course of EO. Other studies have shown that the progression of EO after treatment with 131I without glucocorticoid administration was observed in 18-30% of cases. Along with this, it is believed that 131I does not affect the incidence of clinical symptoms in the orbit, and hypothyroidism that occurs after it does not lead to the progression of eye symptoms. The relationship between treatment and the onset or progression of EO is not clear. Nevertheless, there is evidence of an adverse effect of an elevated level of antibodies to the thyroid stimulating hormone receptor (TSH) in the blood serum after 1131I training for EO. This review is devoted to a review of the problem presented.

[Clinical guidelines developed by the Russian Association of Endocrinologists for the diagnosis and treatment of nodular goiter]

The guidelines presented do not pretend to be a systematic presentation of all aspects of the diagnosis and treatment of nodular goiter and are not intended to replace guidelines for various medical disciplines. In real clinical practice, situations may arise that are beyond the scope of the recommendations presented, in connection with which the final decision regarding a specific patient and responsibility for him lies with the attending physician.The recommendations presented are mainly devoted to the diagnosis and treatment of nodular (multinodular) euthyroid colloid, differently proliferating goiter in adults (over 18 years of age) and are the agreed opinion of the RAE experts who developed them. Nodular (multinodular) toxic goiter, tumors (malignant and benign), as well as other diseases that can manifest themselves by nodular formations of the thyroid gland (thyroid gland), are discussed mainly in the context of differential diagnosis. The recommendations also do not affect the features of diagnosis and treatment of nodular goiter in children and adolescents.

[The specific features of hypothyroidism developing with the use of cordorone]

Hypothyroidism (HT) is one of the thyroid dysfunctions occurring with the use ofcordorone. The authors examined the clinical features of this condition in 26 patients living in Moscow and its region (mild and moderate iodine deficiency areas). The blood levels of thyrotropic hormone (TTH), free thyroxine (Т4) free triiodothyronine (T3), thyroid peroxidase antibodies, and lipid spectrum were estimated. Thyroid ultrasound study and Holler ECG monitoring were performed. HT was found to develop in the presence of the abnormally changed (66%) and intact (34%) thyroid. Examining the course of cardiac arrhythmias (CA) as HT progresses has ascertained that this condition does not lead to their recurrences. As compared with the controls, the patients were found to have higher frequencies of dyslipidemias (p < 0.05). Blood lipid changes appeared as the higher levels of total and LDL cholesterol (p < 0.05); a positive correlation was also established between these parameters and the levels of TTH. The use of L-thyroxine replacement therapy, as indicated on an individual basis, during ongoing cordorone intake did not result in relapses of prior CA and it contributed to blood lipid spectrum parameters. Thus, HT is a condition that does not cause a loss of the antiarrhythmic effects ofcordarone manifests itself as the impaired blood lipid spectrum. L-thyroxine replacement therapy may be, if required, performed during the ongoing use of an antiarrhythmic agent.

[Thyroid functional features after diagnostic studies with iodine-containing X-ray contrast substances]

Iodine-containing radiopaque preparations have been widely used for diagnostic purposes. The absolute amount of iodine introduced in this case is 200,000 to 350,000 times the daily requirement for the element. Throughout life, a person consumes only about 3-5 g of iodine, while during coronary angiography the dose of parenterally administered iodine is about 25-52 g. In this regard, the possibility of development should be taken into account when conducting diagnostic studies using radiopaque drugs iodine-induced conditions, especially in people of an older age group, among which the prevalence of thyroid pathology is especially high. The presence of autonomous formations in the thyroid gland (thyroid gland), often unrecognized, can lead to the development of iodine-induced thyrotoxicosis (IIT) after the introduction of pharmacological doses of iodine, which in turn can lead to deterioration in the course of IHD and the development of arrhythmic complications. We continue discussion the need for screening for the detection of functional thyroid dysfunctions and an ultrasound of the thyroid gland before the introduction of iodine-containing radiopaque drugs. The controversial issue remains the need for preventive treatment with thyreostatic drugs of people at risk of developing IIT.

[Functional autonomy in endemic goiter]

Diagnostics and treatment of functional thyroid autonomy is more concerned with endocrinologists, however, the consequences of functional thyroid dysfunctions have to be faced by other medical specialists, primarily general pgactitioners and cardiologists, and often not months but years pass before the patient goes to the endocrinologist. We present 2 fairly typical cases of untimely diagnosis of functional autonomy from our clinical practice.