Severity Of Thyroid Eye Disease Research Articles

Bridging and Validation of the Specific Graves Ophthalmopathy Quality of Life Questionnaire With Health State Utility Values

ObjectiveIn thyroid eye disease (TED), inflammation and expansion of orbital muscle and periorbital fat result in diplopia and proptosis, severely impacting patient quality of life (QOL). The reported health state utility (HSU) scores, which are QOL measures, allow quantification of TED impact and improvement with therapies; however, no current QOL instrument has been validated with HSU scores for TED. Here, we used the disease-specific Graves Ophthalmopathy Quality of Life (GO-QOL) questionnaire and HSU scores to validate QOL impact. MethodsThe GO-QOL scores from patients in 2 randomized, masked, placebo-controlled teprotumumab trials (N=171) were compared with 6 HSU values based on severity of proptosis/diplopia in those studies. Patient GO-QOL and HSU scores were compared at baseline and after 6-month treatment via regression analyses. GO-QOL and HSU scores were correlated for validation and quantification of QOL impact by severity state and to estimate quality-adjusted life year improvement. ResultsGO-QOL scores were correlated with TED severity, indicating that worse severity was associated with lower (worse) GO-QOL scores. Less severe health states were represented by higher (better) GO-QOL scores. Importantly, GO-QOL scores were positively correlated with utility scores of the 6 health states, allowing for conversion of the GO-QOL scores to utility scores. A positive (improved) 0.013 utility change was found for each 1-point (positive) improvement in GO-QOL score produced by teprotumumab versus placebo. ConclusionPatients with moderate-to-severe active TED health states demonstrate increasing TED severity associated with declining utility values and worsening GO-QOL scores. These results indicate that the GO-QOL scores can be used to bridge to the HSU scores for benefit quantification.

Artificial Intelligence as a Screening Tool to Detect Severity of Thyroid Eye Disease

Artificial Intelligence as a Screening Tool to Detect Severity of Thyroid Eye Disease

Evaluation of macular choroidal and microvascular network changes by activity scores and serum antibodies in thyroid eye patients and healthy subjects.

To investigate the choroidal thickness and the microvascular network changes around the macula in thyroid eye disease (TED) patients at different stages and the relationship of those changes with risk factors, serum antibodies and the severity of TED. A total of 85 participants were enrolled. All participants underwent ophthalmology and endocrinology examinations. Subfoveal choroidal thickness (SFCT), superficial (s) and deep (d) foveal avascular zone (FAZ) area, mean (m) and central (c) superficial vascular density (SVD), deep vascular density (DVD) measurements of the enrolled cases were performed with Topcon swept source optical coherence tomography (OCT)/OCT angiography (OCTA) DRI OCT Triton. Multiple linear regression analysis was used to explore the associations between SFCT, FAZ area, SVD, DVD and the relevant factors of TED. Those with active TED patients had higher c-DVD and m-DVD levels (P<0.05), however there is no statistically significant difference in SFCT between active and stable TED patients. Among the serum antibodies, it was observed that s-FAZ and d-FAZ increased, c-SVD and m-SVD decreased in patients with high thyroid stimulating hormone-receptor autoantibodies (TRAB) level, whereas SFCT thickened in patients with high levels of both TRAB and human thyroglobulin (hTG). There was no significant difference in SFCT, FAZ, SVD and DVD measurement at gender, between hyperthyroid and euthyroid patients and among those with or without thyroid papillary carcinoma. The results show that both disease activation and serum antibodies differentially affect both superficial and deep retinal vascular density. It has also been shown that high serum antibody levels affect choroidal thickness independent of clinical activity.

Thyroid Eye Disease and Its Association With Diabetes Mellitus: A Major Review.

Thyroid eye disease (TED) associated with diabetes mellitus (DM) presents unique challenges. DM is a risk factor for TED. Standard management of TED with glucocorticoids (GC), orbital radiation, or teprotumumab can cause adverse events in poor glycemic control. The authors reviewed the literature on the relationship between TED and DM and the management of co-existing diseases. The authors searched PubMed with keywords "thyroid eye disease," "diabetes mellitus," and similar terms from 2013 to 2022. The authors included relevant studies after screening the abstracts. Additional references to the selected studies were included where applicable. Data were extracted from the final articles according to the preplanned outline of the review. The initial search yielded 279 abstracts. The final review included 93 articles. TED and DM interact at multiple levels-genetic, immunologic, cellular, nutritional, and metabolic. Both DM and thyroid dysfunction exacerbate the morbidity caused by the other. Metabolic factors also affect the inflammatory pathway for TED. Patients with DM develop TED with greater frequency and severity, necessitating interventions for vision salvage. Agents (GC, teprotumumab, or radiation) used for TED are often unsuitable for treatment with DM, especially if there is poor glycemic control or diabetic retinopathy. There were no studies on using steroid-sparing agents in TED with DM. TED and DM co-exist because of multiple intersections in the pathophysiology. Challenges in the treatment include increased TED severity and risk of hyperglycemia and retinopathy. Multidisciplinary teams best undertake treatment of TED with DM.

Prevalence of Thyroid Eye Disease Among Thyroid Disorder Patients

Aim: To assess the prevalence of Thyroid Eye Disease among thyroid disorder patients. Introduction: Thyroid Eye Disease (TED) is a debilitating autoimmune disorder seen in hyperthyroid, hypothyroid and euthyroid patients. The global prevalence of TED is estimated to be 16 per 100,000 women and 2.9 per 100,000 men in the general population. Common symptoms include dry eyes, eyelid retraction, excessive watering, conjunctival redness and swelling, retro-orbital pain and blurred vision. This study aims to assess the prevalence of TED among dysthyroid patients attending Saveetha Medical College and Hospital, Chennai. Methodolody: The purpose of this study is to find the prevalence of TED among dysthyroid patients attending Saveetha Medical College and Hospital, Chennai during the months of July and August. A detailed history of each patient was taken after which a series of tests were conducted to identify and classify the severity of TED. This was done using NOSPECS (no signs, only signs, soft tissue involvement, proptosis, extraocular muscle involvement, corneal involvement, sight loss) classification. Schirmers test was performed to assess the prevalence of dry eyes among TED patients. Result: 122 patients consisting of 87 females and 35 males were included in this study. 43% (53 patients) were found to have Thyroid Eye Disease. There was no significant difference in prevalence between male and female subjects (43.6% and 42.8% respectively). The presence of TED was far greater in hyperthyroid than in hypothyroid patients. 44 out of 53 patients with TED were hyperthyroid (83%), 7 were hypothyroid (13.2%), and 2 patients were euthyroid (3.7%) . Schirmers test conducted on each patient revealed that 12% of the TED patients suffered from dry eyes. NCT test conducted to find the intraocular pressure in TED patients revealed no significant results. Conclusion: The high prevalence of TED seen in dysthyroid patients in this study calls for increased awareness regarding ocular manifestations in thyroid disorders. Patients should be encouraged to undergo regular checkups to ensure normal functioning of eyes and to prevent progression of the disease.

Automated evaluation of parapapillary choroidal microvasculature in thyroid eye disease.

The purpose of the study was to investigate the parapapillary choroidal microvasculature in thyroid eye disease (TED) using optical coherence tomography angiography (OCTA). Only one eye of each subject was included in the study. Patients with TED and controls were included in the study. Participants were divided into three groups: control, inactive TED (ITED) and active TED (ATED). OCTA scans of the optic discs were obtained in a 4.5 × 4.5-mm rectangular area. Radial peripapillary capillary (RPC) density and peripapillary retinal nerve fibre layer (pRNFL) thickness were automatically calculated by the device software. Parapapillary choroidal microvasculature (PPCMv) density was automatically calculated using MATLAB software. Forty-one patients with TED and 40 controls were included in the study. RPC density was significantly decreased in the ATED and dysthyroid optic neuropathy (DON) group compared to the controls and ITED group. There was significant increase in pRNFL in the ATED group. PPCMv density increased in the ATED group compared to the controls in whole ring area. The RPC density was significantly correlated with the TSHr Ab level (r < -0.396, p < 0.001). Clinical activity score correlated positively with PPCMv density (r = 0.349, p = 0.001) but negatively with RPC density (r = -0.321, p = 0.004). Changes in peripapillary microvascular perfusion may play a role in the development of DON. As the severity of TED increases with clinical activity, so do the changes observed in peripapillary parameters. The decrease in RPC density may be due to compression caused by optic disc oedema, which may result in reduced blood flow. The increase in PPCMv density may be related to factors such as orbital congestion.

Clinical Association of Thyroid Eye Disease with Disease Severity and Thyroid Functional Status-an Experience of a Tertiary Care Hospital, Karachi

Objectives: To determine the occurrence and severity of thyroid eye disease regarding thyroid function in patients with autoimmune thyroid disease (AITD).&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Endocrinology Clinics, Jinnah Postgraduate Medical Centre (JPMC) and Medicell Institute of Diabetes Endocrinology &amp; Metabolism (MIDEM) Karachi Pakistan, from Jan to Dec 2020.&#x0D; Methodology: Patients with AITD or the presence of eye disease were included in the study. Socio-demographic, clinical and laboratory parameters, including thyroid function tests (TFTs), thyroid autoantibodies (TRAb, Anti-TPO, Anti-Tg), presence or absence of eye disease and its severity according to NOSPECS, were documented on a predefined proforma.&#x0D; Results: A total of 220 patients with a mean age of 35.58±13.52 years and female predominance were included. Hyperthyroid, Hypothyroid and Euthyroid states were found in 125(56.82%), 43(19.5%) and 6(2.7%) of patients, respectively. Eye disease was found in 59(26.81%) patients. The mean NOSPECS score for patients with Grave’s Orbitopathy (GO) for males was 2.56±1.08, and for females, 2.59±1.01. Females had a greater number of TED-related signs and symptoms as compared to men (p=0.01). NOSPECS severity score of TED significantly correlated with fluctuating TFTs and overactive thyroid state (p&lt;0.0001).&#x0D; Conclusion: Patients with TED commonly presented with proptosis, lid retraction, and restricted movements. The severity of GO was significantly related to older age, female gender, smoking, fluctuating TFTs and hyperthyroidism. Endocrinologists and Ophthalmologists should both work in collaboration for appropriate management.

Thyroid eye disease in Eastern Province of Saudi Arabia: clinical profile and correlation with vitamin D deficiency

ABSTRACT Purpose To obtain clinical data about disease activity and severity of thyroid eye disease (TED) in a tertiary eye hospital in the Eastern Province of Saudi Arabia and to correlate this data with vitamin D levels. Methods A clinical observational study was conducted in a specialized eye hospital in Saudi Arabia. It included prospective enrollment of Saudi patients with confirmed TED to evaluate activity and severity according to Clinical Activity Score (CAS) and European Group on Graves’ Orbitopathy (EUGOGO), respectively, and also for blood investigation, including thyroid profile and vitamin D levels. In addition, some retrospective data collection included previous medical and surgical treatment and complications. Results A total of 74 TED patients were included, with a median age of 42 years and a female predominance of 64.9%. Smokers were 18.9%. A family history of thyroid disease was noted in 12.16% of patients. There were 10.8% of patients with active TED. A moderate to severe severity level was observed in 71% of the cases, mild in 15%, and sight-threatening in 6%. Smoking and older age were associated with the active form of TED. There was a 48.4% prevalence of vitamin D deficiency among TED patients and it was not associated with TED severity or activity. Conclusions This is the first study demonstrating the clinical profile of TED among Saudi patients. Smoking and older age were associated with TED. Vitamin D deficiency among TED patients was not worse than that of the general Saudi population.

The correlation of the neutrophil-lymphocyte ratio to clinical and imaging parameters in patients with thyroid eye disease.

Thyroid eye disease (TED) is the major extrathyroidal manifestation of Graves’ disease (GD). Treatment choice is based on clinical activity and severity of TED, as evaluated with clinical activity score (CAS) and magnetic resonance (MR) imaging. We aimed to determine the relationship between neutrophil-to-lymphocyte ratio (NLR), a readily available indicator of systemic inflammation, and clinical and MR imaging parameters in TED patients. Eighty-seven consecutive TED patients were included. The average signal intensity ratio (SIR), average extraocular muscle (EOM) diameter, and proptosis of the study eye were extracted from MR images. A baseline NLR ≥ 2.0 was recorded in 37 (42.5%) patients and NLR < 2.0 in 50 (57.5%) patients. TED patients with NLR ≥ 2.0 were older, had a higher CAS, average SIR, average EOM diameter and proptosis, and a lower serum thyrotrophin receptor antibody level than patients with NLR < 2.0 (all P < 0.05). All MR parameters showed significant correlation with CAS (P < 0.05). NLR correlated significantly with CAS (P = 0.001), average SIR (P = 0.004), average EOM diameter (P = 0.007), and proptosis (P = 0.007). Multiple regression revealed a significant correlation between NLR and CAS (P = 0.001), average SIR (P = 0.029), and proptosis (P = 0.037). Cox regression analysis showed that a high NLR at baseline was associated with a worse clinical outcome of TED (hazard ratio 3.7, 95% CI 1.22–11.2, P = 0.02), at a median follow-up of 25 months. In conclusion, NLR was correlated with CAS and MR imaging parameters and was associated with a worse clinical outcome of TED at follow-up in patients with TED. Additional prospective studies are needed to validate our findings.

Clinical profile of 80-year-old and older thyroid eye disease patients

Thyroid eye disease (TED), an autoimmune orbital disorder, follows a time-of-onset bimodal peak: 40-44 and 60-64years for women, 45-49 and 65-69years for men. TED, however, can also commence in old age. The study's purpose was to evaluate TED in octo- and nonagenarians. Medical records of 19 ≥ 80years geriatric patients at time of diagnosis were compared to 122 TED patients, aged 20-79. A second analysis was performed after subdividing the control group into two age groups, ≤ 40 ("young group," 16 patients) and 41-79years ("middle-aged group," 106 patients). The geriatric group's mean age was 84years (80-94), 11 males and 8 females. Mean follow-up time was 16months. Compared to the controls, the geriatric patients smoked less (p = 0.012), were more often hypothyroid (p = 0.019), and had concurrent myasthenia gravis (p = 0.02) at time of diagnosis. Diplopia was the most common presenting symptom among the elderly (p = 0.005) and proptosis among the controls, specifically the young group (p = 0.027). Bilateral signs were more common among seniors (p = 0.049). Optic neuropathy was diagnosed in 10% of the geriatric group (2/19) and 11% of middle-aged group (12/106), all being resolved after steroids or orbital decompression. Active disease (clinical activity score (CAS) score = > 3) was more common among the middle-aged group (p = 0.024) while the geriatric patients tended towards higher TED severity grades. Orbital decompression and eyelid repositioning surgeries were more common among the middle-aged group. Strabismus surgeries were more common among seniors. TED among octo- and nonagenarians has unique patterns, with different demographic features, more exposed to diplopia, hypothyroidism, association with myasthenia gravis, and bilateral involvement. Special attention should be given when medically managing this subgroup.

Evaluation of Microcirculation in Optic Nerve Head Using Laser Speckle Flowgraphy in Active Thyroid Eye Disease.

Background Laser speckle flowgraphy (LSFG) can be used to estimate optic nerve blood flow. This study used LSFG to evaluate optic nerve microcirculation in patients with thyroid eye disease (TED). Methods This was a retrospective review of patients with active TED who underwent LSFG between October 2020 and June 2021. The mean blur rate (MBR) for different severities of active TED was analyzed by one-way analysis of variance (ANOVA). Results A total of 30 patients (60 eyes) with a diagnosis of active TED who underwent LSFG were included. The mean age was 49 (range, 33–74) years. Mean best-corrected visual acuity was the worst in the group with sight-threatening active TED (0.29 ± 0.33 logarithm of the minimum angle of resolution, p = 0.01). The MBR-overall was the highest in the group with mild active TED (28.5 ± 2.7), followed by that in the moderate to severe (23.6 ± 3.2), and in the sight-threatening (20.2 ± 4.3) active TED groups (p < 0.001). The MBR-vessel was 57.1, 47.0, and 39.3 in the mild, moderate to severe, and sight-threatening active TED groups, respectively (p < 0.001). The MBR-tissue was 16.9, 14.4, and 12.0 in the mild, moderate to severe, and sight-threatening active TED groups, respectively (p < 0.001). Conclusions This study demonstrates that optic nerve blood flow is lower with more severe active TED. In addition, LSFG is an effective, objective, and noninvasive method for evaluating the severity of TED.

Clinical relevance of thyroid-stimulating immunoglobulin as a biomarker of the activity of thyroid eye disease.

Although it has been reported that thyroid-stimulating immunoglobulin (TSI) is associated with the clinical characteristics of thyroid eye disease (TED), there is a paucity of literature regarding the role of TSI in diagnosing active TED. This study investigated the relationship between the level of TSI and the activity of TED and assessed the cut-off value of TSI discriminating active TED from inactive TED. This cross-sectional study included 101 patients with TED. TSI was quantitatively measured with a cell-based bioassay using a chimeric TSH receptor and a cyclic adenosine monophosphate response element-dependent luciferase. The association between TSI and a variety of demographic and clinical features of TED was analysed. Multivariate regression analysis was performed to determine possible independent factors affecting the level of TSI. TSI level was higher in males than in females (p = 0.023) and smokers than in nonsmokers (p = 0.004). TSI level was inversely correlated with the duration of ocular symptoms (r = -0.295, p = 0.003). The level of TSI was also significantly different when compared to the thyroid function (p = 0.003), TED activity (p < 0.001), and TED severity (p = 0.001). Multivariate regression analysis revealed a significant relationship between TED activity and thyroid function jointly and the TSI level. The cut-off level of TSI for predicting active TED was a specimen-to-reference ratio of 406.7 (p < 0.001, area under the curve = 0.847, sensitivity 77.4%, specificity 81.3%). TSI was a functional biomarker strongly associated with TED activity even after being adjusted by other clinical characteristics. Serum TSI level may help identify patients with active TED in clinics.

Medical and surgical treatment of thyroid eye disease.

Thyroid eye disease is an autoimmune inflammatory disease strongly associated with thyroid disease, principally Graves disease. It can range from mild disease requiring observation or symptomatic treatments only, through to sight-threatening disease requiring major drug therapy and orbital surgery. Severity is graded by the NOSPECS system and activity by the clinical activity score (CAS) to assist in treatment selection. Non-surgical management can extend from observation alone to minor therapy such as oral selenium, then glucocorticoid therapy, cyclosporin, mycophenolate, rituximab, immunoglobulin, teprotumumab, and orbital radiotherapy. High-dose intravenous methylprednisolone therapy is used in active vision-threatening disease with early use of tarsorrhaphy and orbital decompression. Inactive but moderate to severe disease may be treated by orbital decompression, strabismus and eyelid surgery. Systematic assessment and management by both an endocrinologist and ophthalmologist to achieve and maintain euthyroidism and select and sequence treatments according to activity and severity of thyroid eye disease gives the best results for quality of life and vision.

Orbital decompression for thyroid eye disease: surgical treatment outcomes in endocrinological assessment.

Surgical orbital decompression involves removal of one or more of the orbital bony walls in order to gain space for overgrown muscles and adipose tissue, which results in a reduction in pressure on the eye. This observational study aims to perform an endocrinological assessment of the surgical treatment outcomes of thyroid eye disease (TED) patients before and after orbital decompression. This retrospective study included 51 TED patients (84 orbits) who underwent endoscopic orbital decompression (EOD) or balanced orbital decompression. The effect of surgical treatment was evaluated via the clinical activity score (CAS), and modified NOSPECS and EUGOGO classification. Before orbital decompression, the average CAS index was 3.83 ± 1.86 points, whereas the modified NOSPECS score was 3.31 ± 0.97 points. After surgical intervention, the values were as follows: 2.07 ± 1.84 points for CAS and 2.5 ± 0.97 points for modified NOSPECS. The EUGOGO classification before surgery showed that Graves' orbitopathy (GO) was mild, moderate to severe, and sight-threatening in 1%, 25%, and 74% of the orbits, respectively. After surgery, GO was determined to be mild, moderate to severe, and sight-threatening in 24%, 57%, and 19% of the orbits, respectively. Statistical analysis was performed using the R 3.6.2 statistical environment. Inference about the statistical reliability of the parameter was made by calculating the mean and the 95% credibility interval (CI). The severity of TED decreased after orbital decompression. The CAS, and modified NOSPECS and EUGOGO classification showed a statistically reliable postoperative reduction. The drop in activity of the disease after orbital surgery requires careful follow-up.

Relationship between Serum Thyroid-stimulating Hormone Receptor Autoantibodies and Activity and Severity of Thyroid Eye Disease

Purpose: To study the relationship between the levels of serum thyroid-stimulating hormone (TSH)-receptor autoantibodies (TRAbs) and thyroid eye disease (TED) activity and severity scores.Methods: A cross-sectional study was performed. The medical records of 315 patients diagnosed with TED between March 2014 and December 2019 were reviewed. The clinical activity score (CAS) was used to assess TED activity and a modified NOSPECS score was used for severity grading. The serum TRAb level was measured using two assays: a TSHR binding inhibitory immunoglobulin (TBII) assay and thyroid stimulating immunoglobulin (TSI) bioassay.Results: The TBII and TSI assay results were significantly positively correlated with the CAS (R = 0.113 and 0.211, respectively; &lt;i&gt;p&lt;/i&gt; &lt; 0.05), modified NOSPECS score (R = 0.173 and 0.316, respectively; &lt;i&gt;p&lt;/i&gt; &lt; 0.05), and proptosis (R = 0.136 and 0.167, respectively; &lt;i&gt;p&lt;/i&gt; &lt; 0.05). Both assays demonstrated significant differences in the level of TRAb between patients with and without compressive optic neuropathy or corneal epithelial defects.Conclusions: The levels of TRAbs according to both TBII and TSI assays showed significant correlations with clinical signs of corneal involvement, optic neuropathy, and TED activity and severity.

The Efficacy of Teprotumumab for Chronic, Progressive Thyroid Eye Disease Greater Than 9 Months

Abstract Purpose: To evaluate the efficacy of teprotumumab for the treatment of patients with chronic, progressive Thyroid Eye Disease (TED) who do not meet the inclusion and exclusion criteria used in prior clinical trials. Methods: This is a prospective case series of patients with chronic, progressive TED, defined as ocular symptoms of more than 9 months prior to treatment initiation with teprotumumab, an insulin-like growth factor I receptor inhibitor (10 mg/kg for the first infusion then 20 mg/kg for subsequent infusions, every three weeks for a total 8 infusions). This study included patients with a Clinical Activity Score (CAS) greater than or equal to 4. Data collected included patients’ age, sex, race, baseline thyroid status, thyroid stimulating immunoglobulin, CAS, smoking status, best corrected visual acuity, intraocular pressure, Schirmer’s, pupil exam, extraocular motility, Gorman diplopia score, and exophthalmometer measurements. Pre-infusion and post-infusion external photos in all 9 gazes, orbital imaging (CT or MRI), Humphrey visual fields and optical coherence tomography were obtained when possible. Results: Ten patients with chronic TED were treated with teprotumumab either as a primary treatment or following other interventions including oral prednisone, intravenous methylprednisolone, orbital radiation, orbital decompression and/or eyelid surgery. The age range was 55 to 79, with 5 female patients and 5 male patients. Four of the patients were African American and 6 of the patients were White/Non-Hispanic. The number of years the patients had been diagnosed with Graves’ disease ranged from 4 to 33 years, with ocular involvement spanning 4 to 15 years. Patients had CT scans of the orbits to document muscle size prior to initiation, and external photos were taken at each visit. All patients improved subjectively after the first infusion and objectively by the fourth infusion. We will report the long-term follow-up after 8 infusions at ENDO2021. Discussion: Teprotumumab is a fully human monoclonal IgG1 antibody that blocks the IGF-1 receptor, disrupting the cell-to-cell signaling of the immunologic cascade and is independent of the duration or severity of TED. At this time, FDA approval for teprotumumab is for the treatment of TED without any specific restrictions. However, our teprotumumab-treated patients included those who would have been excluded in the phase 2 and 3 clinical trials due to: (1) poor thyroid control, (2) previous orbital surgery, (3) previous therapeutic interventions including steroids and radiation, (4) visual loss due to compressive optic neuropathy or exposure keratopathy and (5) chronic TED greater than 9 months. In our series, we found that teprotumumab was as effective in a wider population of chronic TED patients than included in the clinical trials.

Prospective Correlation of Risk of Obstructive Sleep Apnea With Severe Clinical Features of Thyroid Eye Disease.

To evaluate the association between risk of obstructive sleep apnea (OSA) and severity of thyroid eye disease (TED) using a validated OSA screening tool. A prospective, observational cohort study was performed. New adult TED patients were offered OSA screening with the Snoring Tired Observed Pressure (STOP)-Bang survey during their initial evaluation. Clinical examination and treatment for TED were standard of care and utilized the International Thyroid Eye Disease Society Vision Inflammation Strabismus Appearance system. At the conclusion of the study period, analysis was performed correlating maximum severity of TED signs and symptoms between high- and low-risk OSA groups. Multivariate logistic and linear regression analyses were also performed to analyze the association between the numerical STOP-Bang score and maximum severity of the potentially actionable clinical features of TED (compressive optic neuropathy, vertical prism deviation, horizontal prism deviation, exophthalmos, vertical fissure height). Eighty-five patients met inclusion criteria. Twenty-eight percent were at high risk of OSA (STOP-Bang score of 3 or higher). When comparing the low- and high-risk cohorts, increased risk of OSA was significantly associated with the development of TED compressive optic neuropathy (p = 0.014), conjunctival injection (p = 0.027), chemosis (p = 0.013), upper eyelid edema (p = 0.024), lower eyelid edema (p = 0.003), eyelid erythema (p = 0.037), and vertical strabismus (p = 0.047). In the multivariate regression analyses, higher STOP-Bang scores correlated with increased risk of TED compressive optic neuropathy (p = 0.006), vertical strabismus (p = 0.019), and higher subjective diplopia scores (p = 0.045). Increased risk of OSA, as determined by the STOP-Bang survey, is associated with increased severity of multiple clinical features of TED, including TED compressive optic neuropathy and strabismus.

The changes of retinal nerve fibre layer and ganglion cell layer with different severity of thyroid eye disease.

To evaluate the changes of retinal nerve fibre layer (RNFL) and ganglion cell layer/inner plexiform layer (GCL/IPL) with the severity of thyroid eye disease (TED). One hundred and forty-five eyes of 75 patients with TED and 70 eyes of 35 healthy controls were included. The eyes with TED were divided into mild group (35 eyes), moderate-to-severe group (42 eyes) and DON group (68 eyes). The thickness of RNFL and GCL/IPL were measured by optic coherence tomography (OCT). Clinical activity score (CAS), best corrected visual acuity (BCVA), intraocular pressure (IOP), proptosis and mean deviation (MD) by Humphrey perimetry were assessed. The CAS had significant difference between the three groups (p < 0.001). The proptosis and IOP were significantly higher in DON group and moderate-to-severe group than mild group (p < 0.05). The MD and BCVA were significantly worse in DON group compared with mild group and moderate-to-severe group (p < 0.001). The mean GCL/IPL thickness was thinnest in DON group (p < 0.001). The mean RNFL thickness had significant difference between moderate-to-severe group and DON group (p = 0.036). The mean GCL/IPL thickness had a significant correlation with MD (r = 0.449, p < 0.001) and VA (r = -0.388, p < 0.001), whereas the mean RNFL thickness had no significant correlation with MD (p = 0.082) or VA (p = 0.226). Subclinical optic neuropathy might progress in the patients with moderate-to-severe TED. OCT measurements of GCL/IPL and RNFL are useful to detect the early changes of optic nerve. The thinning of GCL/IPL might be a strong suggestion for closer vision follow-up and earlier decompression surgery.

Physician-Perceived Impact of Thyroid Eye Disease on Patient Quality of Life in the United States.

IntroductionThyroid eye disease (TED) is an autoimmune disease that causes retro-orbital inflammation and subsequent proptosis, corneal exposure, strabismus, and variable vision changes. European studies have shown that TED can severely impact quality of life (QOL), but little is known about the QOL of patients with TED in the USA. Given that patient QOL influences TED severity classifications and subsequent treatment, understanding physician-perceived patient QOL is extremely important.MethodsThis retrospective chart review (conducted in 2018) examined QOL in US patients with moderate-to-severe TED, as reported by treating physicians who regularly manage patients with TED (≥ 5 patients in prior 12 months). The physicians graded patients’ overall QOL (7-point Likert scale; 1 = “not at all impaired”, 7 = “extremely impaired”), assessing mental health, vision changes, and ocular structural signs/symptoms. Patient demographics and clinical findings were examined to understand the impact of disease presentation on physician-perceived QOL.ResultsMedical record data of 714 US patients with moderate-to-severe TED were provided by 181 physicians (73 endocrinologists, 108 ophthalmologists). Patients had a mean age of 49.4 (standard deviation [SD] 13.6) years, and 102 cases (14%) were severe. Anxiety and/or depression was reported in 36% of patients (an increase from the 18.9% prevalence reported for the USA in 2017 by the US National Institute of Mental Health; P < 0.001). The mean physician-reported QOL impact score was 4.1 (SD 1.5). Furthermore, 62 and 89% of patients with moderate and severe TED, respectively, had a high physician-perceived QOL impact (≥ 4). The higher QOL impact group had significantly higher rates of pain symptoms, visual disturbances (including diplopia), and orbito-facial structural changes. Higher disease activity and severity were associated with lower physician-perceived QOL.ConclusionPatients’ QOL, as evaluated by US physicians, is highly impacted by the activity and severity of TED. Additionally, mental health issues were more frequently reported by patients with TED than in the general US population. Ocular pain, strabismus, and diplopia appear to be main drivers of physician-perceived QOL impairment in this sample of US patients with TED.

Non-EPI-DWI for Detection, Disease Monitoring, and Clinical Decision-Making in Thyroid Eye Disease.

The Clinical Activity Score is widely used to grade activity of thyroid eye disease and guide treatment decisions, but as a subjective measurement and being confined to the anterior orbit, it has limitations. Non-EPI-DWI of the extraocular muscles may offer advantages as a functional imaging technique with reduced skull base artifacts, but the correlation with the Clinical Activity Score and patient outcome is unknown. Our aim was to establish the correlation between the Clinical Activity Score and non-EPI-DWI and to describe the additional value provided by adjunctive non-EPI-DWI in making clinical decisions. This was a retrospective longitudinal study of 31 patients seen in a multidisciplinary thyroid eye disease clinic during 5 years who had at least 1 ophthalmic and endocrine assessment including the Clinical Activity Score and a non-EPI-DWI ADC calculation. The Spearman rank correlation coefficient was used to determine the relationship between the Clinical Activity Score and non-EPI-DWI. A patient flow chart was constructed to evaluate clinical decision-making, and receiver operating characteristics were generated. From 60 non-EPI-DWI scans, 368 extraocular muscles were selected for analysis. There was a significant positive correlation between the Clinical Activity Score and ADC (r s = 0.403; 95% CI, 0.312-0.489; P < .001). ADC values were significantly higher in the Clinical Activity Score ≥ 3 group compared with the Clinical Activity Score < 3 group (P < .001). Our patient flow chart identified a third intermediate-severity cohort in which the non-EPI-DWI was particularly useful in guiding clinical decisions. The non-EPI-DWI correlated well with the Clinical Activity Score in our patients and was a useful adjunct to the Clinical Activity Score in making clinical decisions, especially in patients with intermediate activity and severity of thyroid eye disease.