Abstract
BackgroundThe optimal initial local treatment for patients with Graves’ ophthalmopathy (GO) is not fully characterized. The purpose of this retrospective study is to describe the clinical outcomes of RT as initial local therapy for GO and define predictors of the need for post-RT salvage bony decompressive surgery.Methods91 patients with active GO and without prior surgery were treated with RT as initial local therapy between 01/1999 and 12/2010, with a median follow-up period of 18.3 months (range 3.7 - 142 months). RT dose was 24 Gy in 12 fractions. 44 patients (48.4%) had prior use of steroids, with 31 (34.1%) being on steroids at the initiation of RT. The most common presenting symptoms were diplopia (79%), proptosis (71%) and soft tissue signs (62%).Results84 patients (92.3%) experienced stabilization or improvement of GO symptoms. 58 patients (64%) experienced improvement in their symptoms. 19 patients (20.9%) underwent salvage post-RT bony decompressive surgery. Smoking status and total symptom score at 4 months were independent predictors of post-RT bony decompression with odds ratios of 3.23 (95% CI 1.03 – 10.2) and 1.59 (95% CI 1.06 – 2.4), respectively. Persistent objective vision loss at 4 months post-RT was the most important symptom type in predicting salvage decompression. Chronic dry eye occurred in 9 patients (9.9%) and cataracts developed in 4 patients (4.4%).ConclusionsRT is effective and well tolerated as initial local therapy for active GO, with only 21% of patients requiring decompressive surgery post RT. Most patients experience stabilization or improvement of GO symptoms, but moderate to significant response occurs in the minority of patients. Smoking status and total symptom severity at 4 months, primarily persistent objective vision loss, are the primary determinants of the need for post-RT salvage bony decompression. Patients who smoke or present with predominantly vision loss symptoms should be advised as to their lower likelihood of symptomatic response to RT and their increased likelihood of requiring post-RT decompressive surgery.
Highlights
The optimal initial local treatment for patients with Graves’ ophthalmopathy (GO) is not fully characterized
The combination of both processes produces the typical spectra of GO symptoms, including proptosis, EOM dysfunction leading to diplopia, periorbital edema, and compressive optic neuropathy in more severe instances
Patients We reviewed the medical records of 102 consecutive patients treated in our department for GO between 01/1999 and 12/2010. 3 patients were lost to follow-up prior to 4 months post-Radiation therapy (RT) and were excluded. 8 additional patients had undergone orbital/lid surgery prior to RT and were excluded
Summary
The optimal initial local treatment for patients with Graves’ ophthalmopathy (GO) is not fully characterized. Graves’ disease is an autoimmune disease characterized by the production of autoantibodies that activate the thyroid stimulating hormone (TSH) receptor This receptor is primarily located in thyroid tissue, and has been found to be expressed in the connective and adipose tissue of retrobulbar contents [1]. Some patients with GO produce autoantibodies that interact with orbital fibroblasts, leading to the secretion and deposition of collagen and mucopolysaccharides behind the globe that result in increased intraorbital pressure. The combination of both processes produces the typical spectra of GO symptoms, including proptosis, EOM dysfunction leading to diplopia, periorbital edema, and compressive optic neuropathy in more severe instances. 20 – 25% of patients with Graves’ disease will present with clinically significant GO, only about 3 – 5% will develop severe disease [3]
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