Predictive factors of development of dysthyroid optic neuropathy among individuals with thyroid-eye disease

PURPOSE

Dysthyroid optic neuropathy (DON) is a severe visual loss condition in thyroid eye disease (TED). This study aimed to identify factors affecting moderate-to-severe TED or DON in Thai populations.

METHODS

We retrospectively reviewed the records of 230 TED patients at Rajavithi Hospital between January 1, 2017, and October 31, 2022.

RESULTS

Mild, moderate-to-severe TED, and DON were found in 60.43%, 22.61%, and 16.96% of participants, respectively. Female predominance was noted in all groups. The proportion of older age, hyperthyroidism, current smokers, and type 2 diabetes mellitus (T2DM) participants were significantly higher in the DON group. Multivariable logistic-regression analysis revealed that hyperthyroidism and current smoking significantly increased the risk of developing moderate-to-severe TED (OR = 3.001, p = 0.010, and OR = 4.153, p = 0.015, respectively). Exophthalmos was the strongest predictor (OR = 6.834, p < 0.001). Regarding DON risk factors, older age (≥55 years) had OR = 3.206 (p = 0.003), hyperthyroidism had OR = 3.228 (p = 0.005), and being a current smoker had OR = 3.781 (p = 0.011). T2DM posed the greatest risk of DON development (OR = 4.111, p = 0.004).

CONCLUSIONS

Hyperthyroidism and current smoking are significant risk factors for moderate-to-severe TED and DON. TED patients with diabetes mellitus or older age should be closely monitored and informed about their risk of developing DON.

Thyroid stimulating immunoglobulin concentration is associated with disease activity and predicts response to treatment with intravenous methylprednisolone in patients with Graves' orbitopathy

Background

Thyroid stimulating immunoglobulins (TSI) play a central role in the pathogenesis of Graves' orbitopathy (GO), while soluble interleukin-2 receptor (sIL-2R) is a marker for T-cell activity. We investigated TSI and sIL-2R levels in relation to thyroid function, disease activity and severity and response to treatment with intravenous methylprednisolone (IVMP) in patients with GO.

Methods

TSI (bridge-based TSI binding assay), sIL-2R, TSH and fT4 levels were measured in biobank serum samples from 111 GO patients (37 male, 74 female; mean age 49.2 years old) and 25 healthy controls (5 male, 20 female; mean age 39.8 years old). Clinical characteristics and response to treatment were retrospectively retrieved from patient files.

Results

Higher sIL-2R levels were observed in GO patients compared to controls (p < 0.001). sIL-2R correlated with fT4 (r = 0.26), TSH (r = -0.40) and TSI (r = 0.21). TSI and sIL-2R concentrations were higher in patients with active compared to inactive GO (p < 0.001 and p < 0.05, respectively). Both TSI and sIL-2R correlated with total clinical activity score (CAS; r = 0.33 and r = 0.28, respectively) and with several individual CAS items. Cut-off levels for predicting active GO were 2.62 IU/L for TSI (AUC = 0.71, sensitivity 69%, specificity 69%) and 428 IU/mL for sIL-2R (AUC = 0.64, sensitivity 62%, specificity 62%). In multivariate testing higher TSI (p < 0.01), higher age (p < 0.001) and longer disease duration (p < 0.01) were associated with disease activity. TSI levels were higher in patients with a poor IVMP response (p = 0.048), while sIL-2R levels did not differ between responders and non-responders. TSI cut-off for predicting IVMP response was 19.4 IU/L (AUC = 0.69, sensitivity 50%, specificity 91%). In multivariate analysis TSI was the only independent predictor of response to IVMP (p < 0.05).

Conclusions

High TSI levels are associated with active disease (cut-off 2.62 IU/L) and predict poor response to IVMP treatment (cut-off 19.4 IU/L) in GO. While sIL-2R correlates with disease activity, it is also related to thyroid function, making it less useful as an additional biomarker in GO.

Endoscope-navigation-assisted orbital decompression for graves' orbitopathy

PURPOSE

To compare the surgical outcomes of endoscope-navigation (EN)-assisted orbital decompression and non-EN-assisted orbital decompression for Graves' orbitopathy (GO) and to assess the potential clinical advantage of EN in orbital decompression surgery.

METHODS

This retrospective cohort study was performed on 227 orbits of 147 GO patients who underwent EN-assisted orbital decompression (185 orbits) or non-EN-assisted orbital decompression (42 orbits). Assessment included proptosis reduction, best-corrected visual acuity (BCVA), diplopia, ocular restriction and surgical complications.

RESULTS

The proptosis reduction in the EN group was 0.9 mm greater than that in the non-EN group in the entire cohort (p  =  0.004) and 1.0 mm greater than that in the non-EN group in the propensity score matching cohort (p  =  0.025) at 2 years postoperatively. In all, 78.2% of orbits with sight-threatening GO in the EN group and 52.6% of orbits in the non-EN group showed BCVA improvement (p  =  0.026). The proportion of patients with improvement in diplopia was significantly greater in the EN group than in the non-EN group (p  =  0.026).

CONCLUSIONS

EN offers anatomical localization and deep-seated tissue visualization in orbital decompression and significantly improves the surgical outcomes for GO.

Therapy With Intravenous Methylprednisolone Pulses Is Associated With Loss of Bone Microarchitecture in Trabecular Bone Score -Assessment Among Patients With Moderate-to-Severe Graves' Orbitopathy: A Pilot Study

BACKGROUND

Therapy with intravenous glucocorticoids (GCs) is associated with various side effects, however, the impact on bone remains elusive. Trabecular bone score (TBS) is a diagnostic tool providing information on bone microarchitecture based on images obtained from dual-energy X-ray absorptiometry. We investigated the influence of the intravenous methylprednisolone (IVMP) pulse administration on TBS in patients with moderate-to-severe Graves' orbitopathy (GO).

METHODS

Fifteen patients with GO were treated with 12 IVMP pulses (6x0.5g, 6x0.25 g on a weekly schedule). They received supplementation with 2000 IU of vitamin D and 1.0 g of calcium throughout the study period. TBS was assessed at baseline and after last IVMP pulse. To determine the difference between values at baseline and after treatment the least significant change (LSC) methodology was used. We compared pre- and posttreatment mean TBS values.

RESULTS

We found a significant decrease of TBS in 5 out of 15 (33%) patients. Mean TBS value decreased becoming 2.4% lower than at baseline (p<0.05).

CONCLUSIONS

IVMP pulse therapy exerts negative effect on bone microarchitecture in TBS assessment. The analysis of the clinical risk factors for osteoporosis and the evaluation of bone mineral density and TBS should be considered before initiating IVMP therapy.

Descemetocele and bilateral, severe Pseudomonas keratitis in an intensive care unit patient with Graves' orbitopathy: A case report

RATIONALE

Exposure keratopathy (EK) is common among intensive care unit (ICU) patients, especially those under sedation and with incomplete eyelid closure. EK can be mild punctate epithelial erosions exhibiting spontaneous recovery; rarely, severe complications including bacterial ulcers causing corneal perforation or opacity could occur. We describe a patient with pre-existing Graves' orbitopathy (GO) who developed bilateral, rapidly progressing bacterial keratitis due to EK with secondary aerosol inoculation from respiratory pathogens in ICU.

PATIENT CONCERNS

A 49-year-old intubated and sedated woman who underwent urgent craniotomy was admitted to ICU. The ophthalmology department was consulted for progressive chemosis. History of poorly controlled GO was revealed based on external ocular signs, including proptosis with lid retraction, and careful ophthalmological history taking. After 2 days of ICU admission, slit lamp examination revealed large inferior corneal epithelial defects and dellen (OU). Despite prescribing gentamicin ointment and lubricants, purulent discharge with corneal infiltration and thinning (OU) was observed 2 days later. Owing to a characteristic Pseudomonas odor from her endotracheal tube, corneal and endotracheal sputum cultures were obtained, which revealed Pseudomonas aeruginosa infection.

DIAGNOSIS

Pseudomonas keratitis secondary to EK INTERVENTIONS:: Topical fortified anti-Pseudomonas antibiotic eye drops with temporary tarsorrhaphy and lubricants OUTCOMES:: Despite multiple treatments, she developed enlarging descemetocele in the left eye with severe corneal stromal destruction and severe visual impairment due to central corneal scar formation in the right eye. After 2 months, the descemetocele ruptured owing to generalized tonic-clonic seizures after cranioplasty. Therefore, she underwent urgent penetrating keratoplasty in the left eye.

LESSONS

GO increases ocular surface inflammation and exposure, which may exacerbate EK and subsequent complication risks. Careful monitoring and aggressive treatment through appropriate eye care regimen are required in these patients.

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 computed tomography (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 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.

Effect of orbital decompression on dysthyroid optic neuropathy: A retrospective case series

In this study, we try to explore the effect of orbital decompression treatment on severe dysthyroid optic neuropathy.We retrospectively collected demographic and clinical characteristics of thyroid eye disease patients who performed orbital decompression. Then we analyzed the change of best-corrected visual acuity and exophthalmometry after surgery and the correlations among clinical parameters.A total of 22 cases (30 eyes) were included in the study. After orbital decompression, visual acuities improved in 16 eyes, declined in 8 eyes, and had no change in 5 eyes. Best-corrected visual acuity was significantly improved (0.1 vs 0.4, P = .039) and exophthalmometry was significantly declined (22.0 mm vs 16.5 mm, P = .001) after orbital decompression. Better postoperative best-corrected visual acuity was significantly correlated with better preoperative best-corrected visual acuity (r = 0.718, P < .05), and with normal optic disc (r = 0.568, P < .05), but not with age, exophthalmometry, keratopathy, and clinical activity score.These results showed that orbital decompression is a useful approach to manage dysthyroid optic neuropathy. The optimal time for surgery should be chosen based on clinical parameters, such as visual acuity and degree of crowding of orbital apex.

Blood Pressure Profile and N-Terminal-proBNP Dynamics in Response to Intravenous Methylprednisolone Pulse Therapy of Severe Graves' Orbitopathy

Hypercortisolemia is associated with increased risk of hypertension. Natural and synthetic glucocorticoids (GCs) have different effects on blood pressure (BP). The effect of synthetic GCs on BP depends on the dose, treatment duration, type of GCs, and route of administration. Intravenous methylprednisolone (IVMP) pulse therapy is the first line of treatment for severe Graves' orbitopathy (GO). The aim of this study was to evaluate influence of IVMP pulses on BP and N-terminal pro-brain natriuretic peptide (NT-proBNP) dynamics. A total of 32 patients with GO were treated with one IVMP pulse every week for 12 weeks. We performed 48-h BP monitoring (24-h before and 24-h after IVMP) and measured NT-proBNP before, 24 h, and 48 h after the 1st, 6th, and 12th IVMP pulse. Mean BP did not change after any of the pulses. We did not observe an increase in maximal systolic BP or mean nocturnal BP, except after the last pulse. Additionally, the dipping phenomenon was less frequent after the last pulse. We found a significant increase in median NT-proBNP levels after all analyzed pulses. Our study suggests that IVMP may have an unfavorable cumulative effect on BP. Variation in NT-proBNP concentration indicates a compensatory effect of brain natriuretic peptide secretion.

Time course of Graves' orbitopathy after total thyroidectomy and radioiodine therapy for thyroid cancer

The risk of cancer is relatively higher in Graves' patients presenting simultaneously with thyroid nodules. Radioiodine (RAI) therapy recommended in high-risk differentiated thyroid carcinoma may be associated with worsening of a pre-existing Graves' orbitopathy (GO) or developing a new onset. The impact of RAI therapy in patients with differentiated thyroid cancer on the course of a pre-exisiting GO has not been specifically investigated.The aim of this study is to assess the influence of RAI treatment administered for differentiated thyroid cancer on the course of a pre-existing GO.This is a retrospective multicenter study including 35 patients from the University Hospital of Clermont-Ferrand (7 patients) and Lyon-Est (6 patients) in France and from a literature review published as case reports or studies (22 patients).Seven patients exhibited a worsened pre-existing GO after total thyroidectomy followed by RAI treatment for thyroid cancer. Older men, those who initially presented with a lower clinical score of GO before RAI therapy, received higher doses of I especially when prepared with recombinant thyroid-stimulating hormone, and/or not prepared with glucocorticoids during RAI are at a higher risk to worsen their GO.This study is the first and complete study collection. We describe worsening of GO in 20% of patients after RAI treatment for thyroid cancer and determine a pool of predictive factors.

Thyroid eye disease: towards an evidence base for treatment in the 21st century

Thyroid eye disease (TED) is the most common extrathyroidal manifestation of Graves' disease. Incomplete understanding of its pathogenesis has hindered development of targeted therapies that might alter the natural course of disease. Smoking cessation and maintenance of euthyroidism appear to reduce the rate of onset and severity of TED. Recent evidence suggests that selenium may lessen the inflammatory symptoms in mild disease. Corticosteroids remain the primary treatment for patients with moderate to severe active TED. Surgical decompression is commonly undertaken in the chronic stable phase, and only rarely in the active phase when vision is threatened by compressive optic neuropathy. Orbital radiotherapy remains an adjunctive strategy during active disease. Targeted immunotherapies have the potential to alter disease progression, but further evidence is needed to establish safety and efficacy. In this article, we review evidence from prospective therapeutic trials of several treatment modalities. We focus on moderate to severe active TED.

Immunopathogenesis of Graves' ophthalmopathy: the role of the TSH receptor

Graves' ophthalmopathy is an inflammatory autoimmune disorder of the orbit. The close clinical and temporal relationships between Graves' hyperthyroidism and ophthalmopathy have long suggested that both conditions derive from a single systemic process and share the thyrotropin receptor as a common autoantigen. This receptor is expressed not only in thyroid follicular cells, but also in orbital fibroblasts with higher levels measured in orbital cells from ophthalmopathy patients than in cells from normal individuals. Recent studies from several laboratories have shown that thyrotropin receptor activation in orbital fibroblasts enhances hyaluronic acid synthesis and adipogenesis, both cellular functions that appear to be upregulated in the diseased orbit. The phosphoinositide 3-kinase/Akt signaling cascade, along with other effector pathways including adenylyl cyclase/cAMP, appears to mediate these processes. Future therapies for this condition may involve inhibition of thyrotropin receptor signaling in orbital fibroblasts.

Diagnostic ability of Barrett's index to detect dysthyroid optic neuropathy using multidetector computed tomography

OBJECTIVES

The objective of this study was to evaluate the ability of a muscular index (Barrett's Index), calculated with multidetector computed tomography, to detect dysthyroid optic neuropathy in patients with Graves' orbitopathy.

METHODS

Thirty-six patients with Graves' orbitopathy were prospectively studied and submitted to neuro-ophthalmic evaluation and multidetector computed tomography scans of the orbits. Orbits were divided into two groups: those with and without dysthyroid optic neuropathy. Barrett's index was calculated as the percentage of the orbit occupied by muscles. Sensitivity and specificity were determined for several index values.

RESULTS

Sixty-four orbits (19 with and 45 without dysthyroid optic neuropathy) met the inclusion criteria for the study. The mean Barrett's index values (+/- SD) were 64.47% +/- 6.06% and 49.44% +/- 10.94%in the groups with and without dysthyroid optic neuropathy, respectively (p<0.001). Barrett's index sensitivity ranged from 32% to 100%, and Barrett's index specificity ranged from 24% to 100%. The best combination of sensitivity and specificity was 79%/72% for BI=60% (odds ratio: 9.2).

CONCLUSIONS

Barrett's Index is a useful indicator of dysthyroid optic neuropathy and may contribute to early diagnosis and treatment. Patients with a Barrett's index >60% should be carefully examined and followed for the development of dysthyroid optic neuropathy.