Muscle Enlargement Research Articles

Diplopia and Extraocular Muscle Enlargement as an Initial Presentation of Breast Cancer

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Risk Factors for New Onset Diplopia After Graduated Orbital Decompression.

The aim of the study was to identify possible risk factors for new onset diplopia in 20° of primary position (NOD PP) after orbital decompression. A predisposition for NOD has been established for patients with pre-existing diplopia in secondary gaze; therefore, the authors focused on patients without preoperative diplopia. Retrospective chart review of patients who underwent balanced orbital decompression between 2012 and 2019 due to Graves orbitopathy at the authors' institution. Exclusion criteria were incomplete clinical data set, revision surgery, and medial or lateral decompression only. The following clinical parameters were evaluated preoperatively and postoperatively: Hertel exophthalmometry, objective measurement of misalignment using the prism-cover-test, assessment of the field of binocular single vision, and measurement of monocular excursions. In addition, the diameter of the extraocular eye muscles was measured in all preoperative CT scans. We included 327 patients (612 orbits), 126 patients (242 orbits) had no preoperative diplopia. In patients with NOD PP (34%, n = 43/126), enlargement of the medial rectus muscle and restriction of abduction and elevation were significantly more frequent than in patients with no NOD PP. The degree of exophthalmos decrease positively correlated with postoperative squint angle. We were able to identify the diameter of the medial rectus muscle, restriction of abduction, and elevation as well as an extensive reduction of exophthalmos as risk factors for NOD PP in patients with no preoperative diplopia.

Extraocular Muscle Enlargement in Bilateral Diffuse Uveal Melanocytic Proliferation Associated with Hepatocellular Carcinoma

A 64-year-old man with bilateral diffuse uveal melanocytic proliferation (BDUMP) (Figs A and B) associated with hepatocellular carcinoma presented with painless ocular movement limitations. Visual acuity was count fingers and 20/100, respectively. The eyelids and orbital changes were not observed. Extraocular muscle restriction was not presented on the forced duction test in both eyes. Orbit magnetic resonance imaging demonstrated tendon sparing extraocular muscle enlargement on the rectus and oblique muscles (Fig C), and the test for thyroid function and antibodies were within normal ranges.

Ontogenetic and in silico models of spatial-packing in the hypermuscular mouse skull.

Networks linking single genes to multiple phenotypic outcomes can be founded on local anatomical interactions as well as on systemic factors like biochemical products. Here we explore the effects of such interactions by investigating the competing spatial demands of brain and masticatory muscle growth within the hypermuscular myostatin-deficient mouse model and in computational simulations. Mice that lacked both copies of the myostatin gene (-/-) and display gross hypermuscularity, and control mice that had both copies of the myostatin gene (+/+) were sampled at 1, 7, 14 and 28 postnatal days. A total of 48 mice were imaged with standard as well as contrast-enhanced microCT. Size metrics and landmark configurations were collected from the image data and were analysed alongside in silico models of tissue expansion. Findings revealed that: masseter muscle volume was smaller in -/- mice at day 1 but became, and remained thereafter, larger by 7days; -/- endocranial volumes begin and remained smaller; -/- enlargement of the masticatory muscles was associated with caudolateral displacement of the calvarium, lateral displacement of the zygomatic arches, and slight dorsal deflection of the face and basicranium. Simulations revealed basicranial retroflexion (flattening) and dorsal deflection of the face associated with muscle expansion and abrogative covariations of basicranial flexion and ventral facial deflection associated with endocranial expansion. Our findings support the spatial-packing theory and highlight the importance of understanding the harmony of competing spatial demands that can shape and maintain mammalian skull architecture during ontogeny.

Dixon-T2WI magnetic resonance imaging at 3tesla outperforms conventional imaging for thyroid eye disease.

To determine the diagnostic performances of a single Dixon-T2-weighted imaging (WI) sequence compared to a conventional protocol including T1-, T2-, and fat-suppressed T2-weighted MRI at 3T when assessing thyroid eye disease (TED). This IRB-approved prospective single-center study enrolled participants presenting with confirmed TED from April 2015 to October 2019. They underwent an MRI, including a conventional protocol and a Dixon-T2WI sequence. Two neuroradiologists, blinded to all data, read both datasets independently and randomly. They assessed the presence of extraocular muscle (EOM) inflammation, enlargement, fatty degeneration, or fibrosis as well as the presence of artifacts. The Wilcoxon signed-rank test was used. Two hundred six participants were enrolled (135/206 [66%] women, 71/206 [34%] men, age 52.3±13.2 years). Dixon-T2WI was significantly more likely to detect at least one inflamed EOM as compared to the conventional set (248/412 [60%] versus 228/412 [55%] eyes; (p= 0.02). Dixon-T2WI was more sensitive and specific than the conventional set for assessing muscular inflammation (100% versus 94.7% and 71.2% versus 68.5%, respectively). Dixon-T2WI was significantly less likely to show major or minor artifacts as compared to fat-suppressed T2WI (20/412 [5%] versus 109/412 [27%] eyes, p< 0.001, and 175/412 [42%] versus 257/412 [62%] eyes, p< 0.001). Confidence was significantly higher with Dixon-T2WI than with the conventional set (2.35 versus 2.24, p= 0.003). Dixon-T2WI showed higher sensitivity and specificity and showed fewer artifacts than a conventional protocol when assessing thyroid eye disease, in addition to higher self-reported confidence. • Dixon-T2WI has better sensitivity and specificity than a conventional protocol for assessing inflamed extraocular muscles in patients with thyroid eye disease. • Dixon-T2WI shows significantly fewer artifacts than fat-suppressed T2WI. • Dixon-T2WI is faster and is associated with significantly higher self-reported reader confidence as compared to a conventional protocol when assessing inflammatory extraocular muscles.

Acute Septic Arthritis of the Temporomandibular Joint with Suspected Bacteremia: A Case Report

Septic arthritis of the temporomandibular joint （SATMJ） is a rare disease, with the main symptoms of pain, swelling, redness, and TMJ malocclusion. In most cases the causative factor is unknown. The present report describes a case caused by bacterial infection revealed by blood culture test results in which the originally infected organ could be identified. The patient was a female in her 60s with the chief complaint of trismus.At the first visit, tenderness of the right temporomandibular joint and diffuse swelling, as well as trismus were noted. Anterior deviation of the right mandibular condyle was seen in X-ray images and enlargement of the right masticatory muscle was indicated by CT imaging. Streptococcus constellatus was detected in a blood culture test. Following administration of meropenem （MEPM）, the symptoms were improved. This result suggests that bacterial infection associated with chronic periodontitis of the maxillary right second molar may have led to hematogenous infection of the temporomandibular joint in this case.

Ocular motility changes after inferomedial wall and balanced medial plus lateral wall orbital decompression in Graves' orbitopathy: a randomized prospective comparative study

OBJECTIVES:To compare the surgical outcomes of inferomedial wall orbital decompression (IM-OD) and balanced medial plus lateral wall orbital decompression (ML-OD) in patients with inactive Graves’ orbitopathy (GO) with regard to exophthalmos reduction and ocular motility abnormalities.METHODS:Forty-two patients with inactive GO eligible for OD were randomly assigned to either the IM-OD or ML-OD groups. Pre and postoperative evaluations included Hertel exophthalmometry, sensory, and motor extraocular motility assessment, standardized photographs in the nine gaze positions, and computed tomography (CT) of the orbits. ClinicalTrials.gov: NCT03278964.RESULTS:Exophthalmometry reduction was statistically significant in both groups (p<0.001), but was greater in the ML-OD group (p=0.010). New-onset esotropia occurred in 11.1% and 23.5% of patients who underwent IM-OD and ML-OD, respectively, with no statistically significant difference in the frequency of pre and postoperative strabismus in either group. The mean increase in preoperative esotropia was 24±6.9 and 12±8.8 prism diopters in patients who underwent IM-OD and ML-OD, respectively. In the IM-OD group, abduction and elevation worsened at the first (p<0.05) and third (p<0.05) postoperative visits but were restored at 6 months. The versions did not change postoperatively with ML-OD. The preoperative CT-measured medial rectus muscle area predicted new-onset strabismus (p=0.023). Significant postoperative medial rectus muscle enlargement occurred in both groups (p<0.001). Restriction in elevation and abduction was significantly associated with enlarged inferior (p=0.007) and medial rectus muscle areas (p=0.002).CONCLUSIONS:IM-OD is as safe as ML-OD with regard to new-onset strabismus, and represents a good alternative for patients who do not require significant exophthalmos reduction. ML-OD offers greater exophthalmos reduction and smoother postoperative recovery. Patients with preoperative enlarged medial rectus muscle on CT are at risk for new-onset esotropia, and preoperative esotropia is likely to increase after OD.

Identification of Markers Predicting Clinical Course in Patients with IgG4-Related Ophthalmic Disease by Unbiased Clustering Analysis.

Purpose: To describe the clinical features of patients with immunoglobulin G4 (IgG4)-related ophthalmic disease (IgG4-ROD) grouped by unbiased cluster analysis using peripheral blood test data and to find novel biomarkers for predicting clinical features. Methods: One hundred and seven patients diagnosed with IgG4-ROD were divided into four groups by unsupervised hierarchical cluster analysis using peripheral blood test data. The clinical features of the four groups were compared and novel markers for prediction of clinical course were explored. Results: Unbiased cluster analysis divided patients into four groups. Group B had a significantly higher frequency of extraocular muscle enlargement (p < 0.001). The frequency of patients with decreased best corrected visual acuity (BCVA) was significantly higher in group D (p = 0.002). Receiver operating characteristic (ROC) curves for the prediction of extraocular muscle enlargement and worsened BCVA using a panel consisting of important blood test data identified by machine learning yielded areas under the curve of 0.78 and 0.86, respectively. Clinical features were compared between patients divided into two groups by the cutoff serum IgE or IgG4 level obtained from ROC curves. Patients with serum IgE above 425 IU/mL had a higher frequency of extraocular muscle enlargement (25% versus 6%, p = 0.004). Patients with serum IgG4 above 712 mg/dL had a higher frequency of decreased BCVA (37% versus 5%, p ≤ 0.001). Conclusion: Unsupervised hierarchical clustering analysis using routine blood test data differentiates four distinct clinical phenotypes of IgG4-ROD, which suggest differences in pathophysiologic mechanisms. High serum IgG4 is a potential predictor of worsened BCVA, and high serum IgE is a potential predictor of extraocular muscle enlargement in IgG4-ROD patients.

The imaging signs and significances of the enlargement of the infraorbital nerve and the frontal nerve in orbital lymphoproliferative diseases

Objective: To describe imaging signs of infraorbital nerve enlargement (IONE) and frontal nerve enlargement (FNE) in orbital lymphoproliferative diseases (LPDs), and to explore the diagnostic value and differential diagnostic role of the signs. Methods: A retrospective case series study. The data of 222 cases (262 eyes) of LPDs and 95 cases (134 eyes) of inflammatory pseudotumors (IPs) pathologically confirmed by the Peking University People's Hospital and the Third Medical Center of the Chinese PLA General Hospital from January 2013 to December 2018 were analyzed. The LPDs were lymphoma (including atypical lymphoid hyperplasia) in 91 cases (110 eyes) and reactive lymphoid hyperplasia (RLH) in 131 cases (152 eyes). The patients with LPD included 101 males and 121 females, aged (58±17) years, and the patients with IP included 44 males and 51 females, aged (49±21) years. All patients underwent orbital CT or MRI with T1 weighted imaging, T2 weighted imaging and enhanced T1 weighted imaging scanning. Slice thickness was 3 mm. In the coronal CT or MRI, the criterion for determining IONE was the inferior orbital nerve diameter greater than the optic nerve, and the criterion for determining FNE was the forehead nerve diameter equal to or greater than the optic nerve. The pathological types and imaging features of nerve enlargement were recorded. The incidence rates of different pathological types were compared using chi-square test. Results: The enlarged nerves showed homogeneous soft tissue density on CT images, accompanied with enlarged bony infraorbital nerve grooves (foramina). MRI showed moderate signals of T1 and T2 weighted imaging, with clear boundaries and obvious enhancement, which could spread to the pterygopalatine fossa and the cranial cavity. The accompanying images included the enlargement of lacrimal glands or extraocular muscles, intraorbital mass or sinuses opacity. The IONE and/or FNE were found in 12 patients with LPD, but were not found in any patients with IP. The difference was statistically significant (12/222 vs. 0/95, χ²=5.337, P=0.021). Among the cases with nerve enlargement, there were 2 cases of diffuse large B cell lymphoma and 10 cases of RLH (2/91 vs. 10/131, χ²=3.103, P=0.078), as well as 7 cases of IgG4-related ophthalmic disease (IgG4-ROD) and 3 cases of non-IgG4-ROD (7/28 vs. 3/103, χ2=15.232, P=0.000). Conclusions: Lymphoma and RLH can express IONE and/or FNE, in which the IgG4-ROD is the most common and specific type. CT and MRI scans can show enlarged nerves and accompanying signs. Neural thickening can also be applied as a discrimination marker of LPDs and IPs. (Chin J Ophthalmol, 2020, 56: 832-838).

The loss of flight in ant workers enabled an evolutionary redesign of the thorax for ground labour

BackgroundExplanations for the ecological dominance of ants generally focus on the benefits of division of labour and cooperation during foraging. However, the principal innovation of ants relative to their wasp ancestors was the evolution of a new phenotype: a wingless worker caste optimized for ground labour. Ant workers are famous for their ability to lift and carry heavy loads, but we know surprisingly little about the morphological basis of their strength. Here we examine the consequences of the universal loss of flight in ant workers on skeletomuscular adaptations in the thorax for enhanced foraging on six legs.ResultsUsing X-ray microcomputed tomography and 3D segmentation, we compared winged queens and wingless workers in Euponera sikorae (subfamily Ponerinae) and Cataglyphis savignyi (subfamily Formicinae). Workers are characterized by five major changes to their thorax: i) fusion of the articulated flight thorax (queens) into a rigid box optimized to support the muscles that operate the head, legs and abdomen, ii) redesign of internal cuticular structures for better bracing and muscle attachment, iii) substantial enlargement of the neck muscles for suspending and moving the head, iv) lengthening of the external trochanter muscles, predominant for the leg actions that lift the body off the ground, v) modified angle of the petiole muscles that are key for flexion of the abdomen. We measured volumes and pennation angles for a few key muscles to assess their increased efficacy. Our comparisons of additional workers across five genera in subfamilies Dorylinae and Myrmicinae show these modifications in the wingless thorax to be consistent. In contrast, a mutillid wasp showed a different pattern of muscle adaptations resulting from the lack of wing muscles.ConclusionsRather than simply a subtraction of costly flight muscles, we propose the ant worker thorax evolved into a power core underlying stronger mandibles, legs, and sting. This contrasts with solitary flightless insects where the lack of central place foraging generated distinct selective pressures for rearranging the thorax. Stronger emphasis is needed on morphological innovations of social insects to further our understanding of the evolution of social behaviours.

Histopathologic Findings in Idiopathic Orbital Myositis

To report the histologic and clinical features of idiopathic orbital myositis (IOM) patients who underwent extraocular muscle (EOM) biopsy over 20 years, to provide the first methodical reference to the expected histopathologic findings, and to discuss the histopathologic differences from common differential diagnoses. Cohort study. All patients with a diagnosis of IOM who underwent EOM biopsy from 2000 through 2019 were included. Patients who had a different final diagnosis were excluded. Tissue samples of EOM and medical records of all participants were reviewed. Histopathologic features of muscle biopsy, including tissue morphologic features and cellular composition. Thirteen patients met both inclusion and exclusion criteria, and their tissue samples were revisited. Nine patients showed histopathologic findings that suggested a conclusive diagnosis of IOM, and the study focused on them. The average age at presentation was 49 years, and 66.7% of patients were women. The most commonly biopsied EOM was the medial rectus (44.4%). The most common indications for biopsy were nonresolving orbital disease with inadequate response to corticosteroids (44.4%) or a high suspicion of malignancy because of known pre-existing systemic malignancy or the presence of an atypical orbital mass in addition to enlarged muscles (44.4%). The histopathologic findings that suggested a diagnosis of IOM were splaying of muscle fibers by inflammatory infiltrates (n= 9) and mild fibrosis (n= 8) in the endomysium or replacing muscle fibers, with no granulomas or vasculitis. The inflammatory infiltrates identified were of chronic inflammatory cells, consisting of lymphocytes (n= 9), plasma cells (n= 6), and histiocytes (n= 6). Other less commonly identified cells were eosinophils (n= 4), polymorphonuclears (n= 1), and giant cells (n= 1). Muscle fiber degeneration or regeneration was evident in 5 patients. Four patients from the initial cohort showed inconclusive histologic findings on revision and were reassigned as suspected IOM. The histopathologic features of involved muscles in IOM resemble those seen in idiopathic orbital inflammation and differ from those seen in common differential diagnoses. Extraocular muscle biopsy should be strongly considered whenever the presentation of orbital myositis is not typical or when significant underlying conditions are a possibility.

Investigation of Meibomian Gland Function and Dry Eye Disease in Patients with Graves' Ophthalmopathy.

We prospectively evaluated the relationship between meibomian gland dysfunction (MGD) and Graves’ ophthalmopathy (GO) in 19 patients (38 eyes) with subjective dry eye symptoms, compared to 14 age-matched normal participants (14 eyes). Extraocular muscle and lacrimal gland enlargement were evaluated by magnetic resonance imaging (MRI). Ocular surface examinations included fluorescein staining for keratoconjunctival epithelial damage, tear breakup time (TBUT) evaluation, and Schirmer’s test. Dry eye symptoms were evaluated with the Dry Eye-related Quality-of-Life Score (DEQS) questionnaire. Lid-margin abnormalities, meibum grade, and meiboscores were assessed using meibography. Clinical activity scores and T2 signal intensity ratios were used to define GO activity. All GO patients had obstructive MGD and 79% exhibited levator muscle enlargement. Ocular surface parameters of TBUT (p = 0.000), meibum score (p = 0.000), eyelid vasculitis (p = 0.000), meiboscore of the upper lid (p = 0.002), total meiboscores (p = 0.001), and DEQS (p = 0.000) significantly differed between GO patients and normal subjects. In addition, GO patients had significantly more abnormalities of the central region of the upper eyelid than normal subjects (p = 0.000). Thus, MGD might be related to eye discomfort and deterioration of the ocular surface in GO patients. Inflammation and morphological meibomian gland changes might be characteristic of GO.

Treatment of idiopathic orbital myositis with frequent relapses: First case with tacrolimus and review of literature

A 41-year-old man presented with a 2-year history of recurrent painful ophthalmoplegia. Previous brain magnetic resonance imaging showed isolated enlargement of extraocular muscles with enhancement. A diagnosis of idiopathic orbital myositis (IOM) was given. Though the patient initially responded dramatically to corticosteroid, he began developing steroid resistance from his third attack and experienced frequent relapses. Therefore, tacrolimus was added to his regimen. The patient had full symptom recovery after tacrolimus and reported no relapses in the 1-year follow-up. This is the first case showing the efficacy of tacrolimus in treatment of IOM. Our case illustrates the importance of immunosuppressive agents in IOM patient refractory to steroid for both symptom control and relapse prevention.

Clinical-Radiological Patterns and Histopathological Outcomes in Non-Thyroid Extraocular Muscle Enlargement: Retrospective Case Series and Current Concepts.

To report a single-center experience with non-thyroid causes of extraocular muscle enlargement (EME), describing the association between clinical-radiological findings at presentation and the final histopathological diagnosis. Retrospective consecutive case series of 59 patients with single or multiple EME on orbital imaging, in the absence of an etiological diagnosis at the time of presentation. All patients were submitted to orbital muscle biopsy in order to achieve a final etiological diagnosis. Patients with a confirmed diagnosis of thyroid-associated orbitopathy and vascular causes of EME which were angiographically and clinically diagnosed were excluded. Orbital ultrasound and radiologic evaluation (CT and/or MRI) were performed before surgery in all cases. Main outcomes measured included initial clinical-radiological findings and final histopathological features of EME. A diagnosis of lymphoma was confirmed in 13 cases (22%). Sixteen cases (27%) were diagnosed as orbital inflammatory disease including nonspecific idiopathic orbital inflammatory disease in 9 cases, IgG4-related disease in 4 cases, and sclerosing idiopathic orbital inflammatory disease in 3 cases. In 11 patients (18%), a diagnosis of metastatic tumor was made, whereas sarcoidosis, vascular malformations, Erdheim-Chester, and necrobiotic xanthogranuloma were diagnosed in 8 eyes (13.5%). Three patients (5%) with single muscle enlargement developed Graves disease 10 months later. Four patients (6.7%) were diagnosed with granulomatosis with polyangiitis. In 2 cases (3.3%), the diagnosis was unknown, with inconclusive biopsy results. Differential patterns for inflammatory/vascular, lymphomatous and metastatic EME were identified based on age and gender distribution and clinical-radiological characteristics at presentation. Initial clinical and radiological features may orientate the differential diagnosis of non-thyroid EME.

Re: "Clinical-radiological Patterns and Histopathological Outcomes in Non-thyroid Extraocular Muscle Enlargement: .

Ophthalmic Plastic and Reconstructive Surgery 36(3):p 315, May/June 2020. | DOI: 10.1097/IOP.0000000000001639

Reply re: "Clinical-radiological Patterns and Histopathological Outcomes in Non-thyroid Extraocular Muscle Enlargement: Retrospective Case Series and Current Concepts".

Savino, Gustavo M.D.; Midena, Giulia M.D.; Tartaglione, Tommaso M.D.; Milonia, Luca M.D.; Caputo, Carmela Grazia M.D.; Grimaldi, Gabriela M.D. Author Information

Histopathologic study of extraocular muscles in thyroid-associated ophthalmopathy coexisting with ocular myasthenia gravis: a case report

BackgroundCoexistence of thyroid-associated ophthalmopathy (TAO) and ocular myasthenia gravis (OMG) is very rare. Little is known about the orbital histopathology associated with this condition. The authors reported a case of TAO coexisting with OMG and explored the histopathologic changes in extraocular muscles.Case presentationA 32-year-old man complaint of bilateral proptosis for 2 years. The patient was documented with a history of OMG and was treated with blepharoplasty to correct ptosis 3 years prior to presentation. Physical examination revealed right upper eyelid retraction resulting from the eyelid surgery. Computed tomographic scan demonstrated bilateral enlargement of the extraocular muscles. Thyroid function test confirmed hyperthyroid status. The patient was diagnosed with TAO (clinical activity score = 2/7) coexisting with OMG. Orbital decompression surgery reduced proptosis but resulted in new onset of left upper eyelid retraction because of the increased motor impulses to sustain eyelid elevation. Extraocular muscles were sampled during surgery and subjected to histopathologic stain. The stain results were analyzed against samples from age-, gender- matched TAO and control (non-TAO non-OMG) subjects. The measurement of myofiber size and glycosaminoglycan/collagen-occupied area was repeated in 3 randomly chosen fields of each slide. The variation of myofiber size was larger in the TAO + OMG (289.9 ± 142.5 μm2) samples than the TAO (544.1 ± 160.6 μm2) and control (157.0 ± 47.7 μm2) samples. Glycosaminoglycan was more abundant in the TAO + OMG (48.8 ± 12.2%) samples than the TAO (28.4 ± 3.6%) and control (3.3 ± 0.8%) samples. Collagen fibers accumulated in the TAO (60.5 ± 6.4%) samples but not in the TAO + OMG (36.1 ± 4.3%) and control (33.9 ± 2.7%) samples. Typical OMG changes were observed in the TAO + OMG samples but not in the TAO and control samples. These changes included central nuclei, aggregation of mitochondria and fiber type grouping. The histopathologic findings of TAO + OMG were summarized as inhomogeneously enlarged muscle fibers and predominantly endomysial accumulation of glycosaminoglycan.ConclusionThis study highlights the possibility of TAO coexisting with OMG and demonstrates the histopathologic features in this rare condition.

Optical Coherence TomographyStudy of peripapillary Nerve Fiber layer ThicknessinThyroid Associated Ophthalmopathy

Abstract Background Thyroid Associated Ophthalmopathy (TAO) or Graves Opthalmopathy (GO) is a very common autoimmune disorder of the thyroid gland which activates the gland function and result in hyperthyroidism. Some patients with graves disease(GD) develop localized manifestations including GO and dermopathy. Dysthyroid optic neuropathy (DON) is impairment of optic nerve function due to GO, the most serious complication of GO which occurs in about 4–8% of patients, it occurs due to ischemia and inflammation of the optic nerve, also compression of the optic nerve due to enlargement of extraocular muscles at the apex of orbit. Objective To assess peripapillary retinal nerve fiber layer (pRNFL) thickness in GD and to correlate it with the severity of the disease. Patients and Methods This study was conducted on 40 eyes of 21 recently diagnosed GO patients (two patients were single eyed) recruited from Endocrinology clinic and examined at Ophthalmology clinic, Ain Shams University Hospital in the period from March 2018 to September 2018. Complete ophthalmologic examination, proptosis assessment of direction and degree, Visual Field (VF) examination, clinical activity score (CAS), severity score assessment and Optical Coherence Tomography (OCT) were performed to all patients . Results In the whole group of patients; the mean average pRNFL was 109.53 um ± 12.33 SD (range: 86 – 140), median MD was -4.53 (range:-0.66 to-18.95) and -8.04 ± -2.15 SD, mean PSD was 5.55 ± 3.8 SD (range: 1.11 to 12.73). Normal average pRNFL thickness (according to normative data base included in the OCT program) was found in 15 eyes (37.5%) and those had abnormal increase in thickness was 12 eyes (30%). Abnormal decrease in thickness was detected in 13 eyes (32.5%). Conclusion PRNFL thickness abnormalities were detected in 25 eyes (62%) of recently diagnosed GO patients. This might be associated with localized visual field defects. Regular follow up of intra ocular pressure (IOP), serial VF examinations, are required to decide further management of those patients, as OCT results were correlated with degree of eye protrusion and the severity of the disease (CAS and severity score).

Intravenous Glucocorticoid Treatment for Korean Graves' Ophthalmopathy Patients.

BackgroundHigh-dose intravenous steroids are the first-line treatment for patients with moderate-to-severe and active Graves' ophthalmopathy (GO). We aimed to investigate the response rate of methylprednisolone (MPD) treatment among Korean patients with active moderate-to-severe GO and to identify predictive factors of treatment response.MethodsThis is a retrospective observational study. We included 54 active moderate-to-severe GO patients treated with 4.5 g intravenous MPD over 12 weeks between November 2011 and November 2018. Response was defined as an improvement in at least two of five indicators (clinical activity score [CAS], soft-tissue involvement, exophthalmos, diplopia, and visual acuity) at immediate and 3 months after treatment completion. We examined predictive factors for response using logistic regression analysis.ResultsTwenty-four (44.4%) and 22 (40.7%) patients showed response at immediate and 3 months after intravenous (IV) steroid treatment. Of the five ophthalmic parameters, all patients in the responsive group (100.0%) showed a decrease in CAS and 90.9% showed less soft tissue involvement after IV steroid treatment. Among variables, the sum of extraocular muscle width was positively (odds ratio [OR], 1.163; 95% confidence interval [CI], 0.973–1.389; P = 0.096) associated with treatment response. While, the OR of age was 0.918 (95% CI, 0.856–0.985; P = 0.017) and thyrotropin binding inhibitory immunoglobulin (TBII) was 0.921 (95% CI, 0.864–0.982; P = 0.012).ConclusionIn Korean active moderate-to-severe GO patients, intravenous steroid treatment is not as effective as previously reported. Parameters associated with CAS and soft-tissue involvement were found to be influenced by IV MPD treatment. Extraocular muscle enlargement, younger age and lower TBII are predictive factors for a good steroid treatment response.

Role of a new bioassay for thyroid-stimulating antibodies (aequorin TSAb) in Graves' ophthalmopathy.

Graves' ophthalmopathy (GO) is characterized by an autoimmune reaction against thyrotropin (TSH) receptors and is diagnosed by TSH receptor antibody (TRAb). A novel assay for thyroid-stimulating antibody (TSAb) was recently introduced using a frozen Chinese hamster ovary cell line expressing TSH receptors, cyclic adenosine monophosphate (cAMP)-gated calcium channel, and aequorin (aequorin TSAb). The aim of this study was to evaluate the role of aequorin TSAb in GO. We studied 136 Japanese patients with GO (22 euthyroid and 8 hypothyroid GO patients) at our hospital. TRAbs were estimated by first generation TRAb (TRAb 1st), second generation TRAb (hTRAb 2nd), conventional porcine TSAb, and the new aequorin TSAb assays. Aequorin TSAb, porcine TSAb, TRAb 1st, and hTRAb 2nd were positive in 125/136 (92%), 110/136 (81%), 81/130 (62%), and 93/114 (82%) patients, respectively. In patients with hyperthyroid GO, they were positive in 98/106 (98%), 96/106 (91%), 78/101 (77%), and 84/93 (90%) patients, respectively. In patients with euthyroid GO, they were positive in 19/22 (86%), 9/22 (41%), 1/21 (5%), and 6/17 (35%) patients, respectively. Aequorin TSAb levels were significantly related to TRAb 1st (r = 0.4172, p < 0.0001), hTRAb 2nd (r = 0.2592, p < 0.0001), and porcine TSAb (r = 0.4665, p < 0.0001). Clinical activity score (CAS) was significantly greater in patients with high titers of aequorin TSAb than in those with low titers. Aequorin TSAb levels were significantly related to the signal intensity ratio of the enlarged eye muscle and proptosis evaluated by MRI before steroid pulse therapy. Aequorin TSAb assay was more sensitive than the conventional assays, especially in euthyroid GO.