Thyroid-related Ophthalmopathy Research Articles

Assessment of retinal and choroidal vessel density and nerve fibre layer thickness changes after orbitotomy in patients with severe non-active thyroid orbitopathy: a prospective study.

To evaluate the optical coherence tomography angiogram changes in non-active severe thyroid-related ophthalmopathy patients after cosmetic bone decompression. Eighteen patients (25 eyes) with severe not active not compressive (NANC) TED who were candidates for decompression surgery for cosmetic reasons were included in this study, and a 3 × 3mm macular scan was used to measure vessel density and RNFL thickness. Whole macular vessel density in its superficial, deep and choriocapillaris layers was evaluated. The following data were extracted for each of layers: superior and inferior hemispheres, fovea, parafoveal vessel density, its superior and inferior hemispheres, and temporal, superior, nasal and inferior quadrant. The mean RPC increased postoperatively, which was statistically significant in small vessels of peripapillary area (p-value = 0.045). The mean RNFL thickness decreased after surgery and it was statistically significant in the peripapillary (p-value = 0.032) and Inferior-Hemifield area (p-value = 0.036). The choriocapillaris changes were significant in Superior-Hemifield (p-value = 0.031) and Fovea (p-value = 0.03). Thyroid-associated orbitopathy patients have a tendency to decrease vascular density and correlated with disease activity more than stage of orbitopathy. There was not a strong and even discrepant result in linkage of RNFL thickness and other optic nerve function tests and TED patient status and it is needed to do studies with more epidemiologic power and same methodology of study to be more comparable.

Graves' ophthalmopathy and dry eye syndrome

Graves ophthalmopathy present different signs and symptoms, in particular ocular surface disease that is the most frequent cause of ocular discomfort. This pathology can lead to increased ocular surface exposure and evaporative dry eye disease, tear-film changes and ocular surface expression of pro-inflammatory cytokines. Patients with ocular surface disease complain of several symptoms from foreign body sensation, blurred vision, dryness, or conjunctival injection, at an estimated prevalence of 65-95%. The most useful assessment is the Ocular Surface Disease Index, which has been shown to be significantly increased in active thyroid-related ophthalmopathy patients. Every increase in clinical activity score of one, double the index values. A careful ocular examination should be performed to assess the severity of the pathology. Superior limbic keratoconjunctivitis, superficial keratopathy and obstructive Meibomian gland disease represent the structural pathological changes; tear break-up time, increase in lacrimal osmolarity and presence of inflammatory cytokines represent the functional changes. Management of dry eye syndrome associated to Graves ’ophthalmopathy can be challenging. Moderate disease may be handled with artificial tears, ointments, and night-time moisture chambers. Topical or oral steroids can be considered to treat the inflammatory component. Surgical intervention consists of early punctual occlusion with temporary punctual plugs. If the patient progresses to sight-threatening ophthalmopathy, surgical intervention may become necessary to reduce exophthalmos and lagophthalmos. Standardized treatment guidelines are not available, and the management depends on patient’s disease activity and severity. A stepwise approach must be applied, ranging from conservative management to surgical intervention combined with topical or systemic therapy.

IL-38 gene expression: A new player in Graves’ ophthalmopathy patients in Iraq

Introduction and Aim: Thyroid eye illness is widely recognized as one of the most significant concerns confronting the medical profession today. The thyroid-related ophthalmopathy also known as Graves’ ophthalmopathy is an autoimmune disorder that cannot be reversed and hence, research pertaining to the identification of novel markers that can explain both the prognosis and the recovery of the condition is needed. In this study, we aimed to investigate the IL-38 gene expression levels among Graves’ ophthalmopathy patients in Iraq. Methodology: The TSH levels were measured with an enzyme-linked immunosorbent assay (ELISA). The level of IL-38 gene expression in patient blood samples and normal healthy controls was measured qualitatively using RT-PCR. Results: Patients who were diagnosed with Graves’ ophthalmopathy were observed to have abnormally low levels of thyrotropin (TSH) in their serum. In these patients, the interleukin IL-38 gene expression was observed to be significantly greater compared to healthy controls (P<0.01), the tendency of which continued even after one year of therapy with anti-thyroid drugs. Conclusion: The findings of this study indicate that the IL-38 transcript is important in the autoimmune response. The identification of IL-38 expression levels could contribute in the early clinical diagnosis and treatment of thyroid eye disease

Relationship between ocular signs and quality of life in patients with thyroid-related ophthalmopathy

Relationship between ocular signs and quality of life in patients with thyroid-related ophthalmopathy

Role of Radiotherapy in Thyroid-Related Ophthalmopathy: A Case Series

Purpose To explore the role of radiotherapy (RT) in management of moderate to severe thyroid-related eye disease in terms of efficacy, treatment outcome, and response. Material and methods A case series of 5 patients with moderate to severe Graves Ophthalmopathy treated with orbital RT between July 2020 and March 2021. Patient symptoms and ophthalmic findings prior to RT and after 6 months post RT were analyzed. Computed tomography was performed before and after RT to compare orbital (muscles) volume change. Endpoints including improvement in ocular symptoms such as diplopia, proptosis, extraocular movement were compared. Acute and long-term complications were documented to assess its safety and treatment response. Results Addition of RT improved diplopia, visual acuity, proptosis, and color vision significantly. RT also decreased upper lid edema, optic nerve compression, and reduced intraocular muscle bulk. Extraocular muscles diameter reduced significantly. Patients experienced relief of symptoms and significant reduction in diplopia clinically. Conclusion External beam radiation is a safe and effective intervention in thyroid ophthalmopathy. Our study demonstrated that radiation is effective in decreasing inflammatory signs, symptoms, and muscle bulk. This treatment modality is well tolerated, and long-term complications are tolerable.

Is differential diagnosis of thyroid-associated ophthalmopathy easy

Thyroid-related ophthalmopathy is the most common orbital disease in adulthood. It is an autoimmune disease with diverse and complex clinical manifestations and is easily confused with various ophthalmic diseases. In order to improve the diagnosis of thyroid-related ophthalmology, this article lists a variety of ophthalmic diseases that need to be differentiated according to the characteristics of clinical manifestations, and introduces the main differentiation methods and principles of diagnosis and treatment, providing reference for ophthalmologists and endocrinologists. (Chin J Ophthalmol, 2021, 57: 809-813).

Thyroid-related ophthalmopathy development in concurrence with growth hormone administration

BackgroundThyroid stimulating hormone (TSH) receptor and local infiltrate lymphocytes have been considered as major pathological factors for developing thyroid-related ophthalmopathy. Overexpression of insulin-like growth factor-I (IGF-I) receptor has emerged as a promising therapeutic target for refractory patients. However, the relationship between activation of growth hormone (GH)/IGF-I receptor signaling and development or exacerbation of thyroid ophthalmopathy has not been elucidated. Herein we describe a case that provides further clarification into the association between thyroid-related ophthalmopathy and GH/IGF-I receptor signaling.Case presentationA 62-year-old Japanese female diagnosed with thyroid-related ophthalmopathy was admitted to Kurume University Hospital. She had received daily administration of GH subcutaneously for severe GH deficiency; however, serum IGF-I levels were greater than + 2 standard deviation based on her age and sex. She exhibited mild thyrotoxicosis and elevation in levels of TSH-stimulating antibody. Discontinuation of GH administration attenuated the clinical activity scores of her thyroid-related ophthalmopathy. Additionally, concomitant use of glucocorticoid and radiation therapies resulted in further improvement of thyroid-related ophthalmopathy. The glucocorticoid administration was reduced sequentially, followed by successful termination. Thereafter, the patient did not undergo recurrence of thyroid-related ophthalmopathy and maintained serum IGF-I levels within normal physiological levels.ConclusionsWe describe here a case in which development of thyroid-related ophthalmopathy occurred upon initiation of GH administration. GH/IGF-I signaling was highlighted as a risk factor of developing thyroid-related ophthalmopathy. Additionally, aberrant TSH receptor expression was suggested to be a primary pathophysiological mechanism within the development of thyroid-related ophthalmopathy. Physicians should be aware of the risks incurred via GH administration, especially for patients of advanced age, for induction of thyroid-related ophthalmopathy.

Study on the Correlation Between ANCA and Thyroid-related Ophthalmopathy

Background The pathogenesis of thyroid associated ophthalmopathy (TAO) is still unclear. Studies have proved that there are several autoantibodies in TAO patients, and ANCA, as one of the autoantibodies, is positive in some TAO patients, but its correlation with the occurrence, development and outcome of TAO is still unclear. Objective To study the correlation between ANCA and Thyroid Associated Ophthalmopathy. Methods Prospective observational cohort study was designed. This study was approved by the Ethic Commission of Hunan Provincial People’s Hospital/the First Affiliated Hospital of Hunan Normal University, and written informed consent was obtained from each Subject before entering this trial. 120 patients diagnosed as TAO and visited our hospital from January 2016 to June 2018 were enrolled in the study, including 30 cases in inactive group and 90 cases in active group [According to the criteria of clinical activity score (CAS)], 42 cases in Mild group and 78 cases in Moderate-to-severe and Sight-threatening group (According to the criteria of EUGOGO). The differences in ANCA positive rate among above groups and Active group after transferred to Inactive were compared. Results The overall positive rate of ANCA in TAO patients was 16.7%. The positive rates in the Inactive group and Active group were respectively 3.33% and 21.11%, and the difference was statistically significant (P 0.05). The positive rates of Active group reduced to 5.5%, and the difference was statistically significant (P<0.05). Conclusion ANCA can reflects the activity of TAO to some extent, which is helpful to guide clinical treatment and prognosis judgment.

Research progress of IGF-1R in ophthalmology

Insulin-like growth factor 1 receptor (IGF-1 R),a member of the family of tyrosine protein kinase,mediates the activity of the IGF-1.IGF-1R can promote the proliferation and migration of cells and inhibit the apoptosis of cells.IGF-1R shows a high level expression and presents a close relationship with a variety of biological characteristics such as invasion and metastasis of choroid melanoma,and it influences the pathogenesis and progress of thyroid related ophthalmopathy,working together with thyroid stimulating hormone receptor (TSHR) through different signaling pathways.Also IGF-1 R,targeting vascular endothelial growth factor (VEGF),may promote the pathogenesis and development of new retinal vascular diseases through the insulin receptor substrate 1 (IRS-1).Other IGF-1R related biological effects were found in eye diseases,such as refractive error and cataract,ect.,hinting us that as a molecular targete,IGF-1R will become a new topic of gene therapy for eye diseases. Key words: Insulin-like growth factor 1 receptor; Choroid melanoma; Thyroid associated opthalmopathy; Macular degeneration; Refractive error

Strabismus Surgery in Thyroid-Related Ophthalmopathy

Background: Restrictive strabismus is a common feature of Thyroid-Related Ophthalmopathy (TRO) causing intractable diplopia. We reviewed the surgical outcome for TRO patients. Methods: We retrospectively reviewed patients of TRO who underwent strabismus surgery from January, 1998 to September, 2012. Preoperative characteristics were recorded such as age, sex, disease severity, presence of compressive optic neuropathy or elevation of intraocular pressure, symmetry of orbitopathy, duration between onset of TRO and surgery, smoking status, and treatment. The length of muscle recession and the numbers of strabismus surgeries was recorded for further analysis. Results: Twenty-four patients were enrolled with twelve female and twelve male in a mean age of 55.5 years (SD + 10.71). The mean number of surgery was 1.29 (SD + 0.46). Patients with asymmetric involvement at onset, presence of elevated intraocular pressure, and longer intervals between the onset of TRO and first surgery needed significantly more surgeries to correct strabismus. Factors such as age, gender, smoking status, medical treatment before surgery, presence of compressive optic neuropathy or previous orbital decompression procedure had no statistically significant effect on the number of surgery required. Conclusion: Strabismus surgery showed favorable outcomes in correcting diplopia induced by thyroid-related ophthalmopathy. The average number of surgery needed is 1.29 (±0.46) in this study, and the mean surgical effect we got was 4.09+0.26 PD/mm of rectus muscle recession.

Orbital lymphoma associated with Graves’ disease: A case report

The presence of bilateral exophthalmos and palpebral, periorbital edema associated with hyperthyroidism is most often considered as an initial sign of Graves' ophthalmopathy. However, in up to 20% of cases, Graves' ophthalmopathy might precede the occurence of hyperthyroidism, which is very important to be considered in the differential diagnosis, especially if it is stated as unilateral. Among other less common causes of non-thyroid-related orbitopathy, orbital lymphoma represents rare conditions. We presented of a patient with Graves' disease, initially manifested as bilateral orbitopathy and progressive unilateral exophthalmos caused by the marginal zone B-cell non-Hodgkin lymphoma of the orbit. A 64-year-old man with the 3-year history of bilateral Graves' orbitopathy and hyperthyroidism underwent the left orbital decompression surgery due to the predominantly left, unilateral worsening of exophthalmos resistant to the previously applied glucocorticoid therapy. A year after the surgical treatment, a substantial exophthalmos of the left eye was again observed, signifying that other non-thyroid pathology could be involved. Orbital ultrasound was suggestive of primary orbital lymphoma, what was confirmed by orbital CT scan and the biopsy of the tumor tissue. Detailed examinations indicated that the marginal zone B-cell non-Hodgkin lymphoma extended to IV - B-b CS, IPI 3 (bone marrow infiltration: m+ orbit+). Upon the completion of the polychemiotherapy and the radiation treatment, a complete remission of the disease was achieved. Even when elements clearly indicate the presence of thyroid-related ophthalmopathy, disease deteriorating should raise a suspicion and always lead to imaging procedures to exclude malignancy.

Dysthyroid optic neuropathy (DON): diagnosis and associated features

Abstract Purpose To determine the frequency of occurence and severity of dysthyroid optic neuropathy (DON), in relation to the degree of inflammatory signs, exophthalmos, asymetrical disease and diplopia, among patients with newly diagnosed inflammatory thyroid related ophthalmopathy (TAO) or suffering from the recurrence of the inflammatory phase of previously inactive/fibrotic stage of the disease. Methods 400 subjects with TAO, 76% women and 24% men aged 29.0 to 88.0 (mean 55.5 +/‐ 9.8) years with Clinical activity scores between 2 and 9 ( mean 4.6 +/‐ 2.3) were included into the study. 30 healthy age and sex matched patients served as control. Diagnosis of DON was based on the presence of at least two features related to the optic nerve involvement, different than reduction of visual acuity. Results Two or more clinical features of DON werefound in 27 patients with inflammatory TAO. 20 of whom displayed asymmetrical involvement ( &gt; 2mm difference in exophthalmos and &gt; 2 in CAS scale). There was slight statistical association between neuropathy and diplopia with neuropathy patients being more likely to suffer from constant double vision. There was no correlation between CAS and DON. Visual acuity was reduced from 2 to 7 Snellen lines in patients with DON and from 2 to 6 lines in TAO and not DON. Conclusion Clinical features of DON occour in 6.75% of patients with inflammatory TAO. There is no correlation between the degree of inflammatory involvement and DON, therefore it must be carefully excluded in all patients even with apparently mild ophthalmopathy. Thera numerous other, than DON,causes of visual loss related to TAO. Majority of patients present with mild and moderate visual loss only, which is reversible on immunomodulatory treatment.

Orbital steroid injection versus oral steroid therapy in management of thyroid‐related ophthalmopathy

The aim of this study was to evaluate the efficacy, safety and complications of orbital steroid injection versus oral steroid therapy in the management of thyroid-related ophthalmopathy. A total of 29 patients suffering from thyroid ophthalmopathy were included in this study. Patients were randomized into two groups: group I included 15 patients treated with oral prednisolone and group II included 14 patients treated with peribulbar triamcinolone orbital injection. Only 12 patients in both groups (16 female and 8 male) completed the study. Both groups showed improvement in symptoms and in clinical evidence of inflammation with improvement of eye movement and proptosis in most cases. Mean exophthalmometry value before treatment was 22.6 ± 1.98 mm that decreased to 18.6 ± 0.996 mm in group I, compared with 23 ± 1.86 mm that decreased to 19.08 ± 1.16 mm in group II. Mean initial clinical activity score was 4.75 ± 1.2 and 5 ± 1.3 for group I and group II before treatment, respectively, which dropped to 0.83 ± 1.2 and 0.83 ± 1.02, 6 months after treatment, respectively. There was no change in the best-corrected visual acuity in both groups. There was an increase in body weight, blood sugar, blood pressure and gastritis in group I in 66.7%, 33.3%, 50% and 75%, respectively, compared with 0%, 0%, 8.3% and 8.3% in group II. No adverse local side effects were observed in group II. Orbital steroid injection for thyroid-related ophthalmopathy is effective and safe. It eliminates the adverse reactions associated with oral corticosteroid use.

Some Unanswered Questions in Thyroid-Related Ophthalmopathy

Some Unanswered Questions in Thyroid-Related Ophthalmopathy

Modulation of HLA-DR Expression on Retroocular Fibroblasts from Patients with Active Thyroid-Related Ophthalmopathy: In vitro Effects of Agents Used in the Management of Hyperthyroidism and Ophthalmopathy

Modulation of HLA-DR Expression on Retroocular Fibroblasts from Patients with Active Thyroid-Related Ophthalmopathy: In vitro Effects of Agents Used in the Management of Hyperthyroidism and Ophthalmopathy

Normalization of Upper Eyelid Height and Contour After Bony Decompressionin Thyroid-Related Ophthalmopathy: A Digital Image Analysis

Normalization of Upper Eyelid Height and Contour After Bony Decompressionin Thyroid-Related Ophthalmopathy: A Digital Image Analysis

Use of stereotactic intensity-modulated radiotherapy in thyroid-related ophthalmopathy

✓ Thyroid-related ophthalmopathy (TRO), a debilitating condition involving a range of visual and orbital symptoms, occurs in up to 40% of patients with Graves disease. The goals of treatment include correcting thyroid dysfunction, relieving ocular pain, preserving vision, and improving cosmetic appearance. Options for therapy include symptomatic treatment, glucocorticoid medication, radiation therapy, and surgery. Traditional radiation treatment uses small opposed bilateral fields consisting of retrobulbar volumes and customized blocks to shield periorbital structures. The combination of intensity-modulated radiotherapy (IMRT) and stereotactic technology facilitates the administration of radiation to patients suffering from TRO and provides greater safety and efficacy than traditional treatment. The authors present the case of a patient with severe TRO whose symptoms resolved rapidly after treatment with stereotactic IMRT. The outcome in this case supports stereotactic IMRT as an effective treatment option for patients with TRO who also undergo radiation therapy.

Use of stereotactic intensity-modulated radiotherapy in thyroid-related ophthalmopathy

✓ Thyroid-related ophthalmopathy (TRO), a debilitating condition involving a range of visual and orbital symptoms, occurs in up to 40% of patients with Graves disease. The goals of treatment include correcting thyroid dysfunction, relieving ocular pain, preserving vision, and improving cosmetic appearance. Options for therapy include symptomatic treatment, glucocorticoid medication, radiation therapy, and surgery. Traditional radiation treatment uses small opposed bilateral fields consisting of retrobulbar volumes and customized blocks to shield periorbital structures. The combination of intensity-modulated radiotherapy (IMRT) and stereotactic technology facilitates the administration of radiation to patients suffering from TRO and provides greater safety and efficacy than traditional treatment. The authors present the case of a patient with severe TRO whose symptoms resolved rapidly after treatment with stereotactic IMRT. The outcome in this case supports stereotactic IMRT as an effective treatment option for patients with TRO who also undergo radiation therapy.

Cine magnetic resonance imaging of eye movements.

Cine magnetic resonance imaging (MRI) is a technique in which multiple sequential static orbital MRI films are taken while the patient fixates a series of targets across the visual field. These are then sequenced to give a graphic animation to the eyes. The excellent soft tissue differentiation of MRI, combined with the dynamic imaging, allows rapid visualisation, and functional assessment of the extraocular muscles. Good assessment of contractility can be obtained, but the technique does not allow study of saccadic or pursuit eye movements. We have used this technique in 36 patients with a range of ocular motility disorders, including thyroid-related ophthalmopathy, blow-out fracture, post-operative lost or slipped muscle, and Duane's syndrome.

Pathophysiology, management, and surgical review of thyroid-related ophthalmopathy

Thyroid-related ophthalmopathy continues to receive worldwide attention. The pathophysiology is now clearly linked to autoimmune mechanisms although their precise relationship with dysthyroid disease remains illusive. Management considerations are becoming better defined and greater attention is being directed toward the treatment of the patient's thyroid dysfunction. Systemic corticosteroids, orbital radiotherapy, and thyroid-related orbital decompression continue to be the mainstay of orbitopathy treatment. Surgical innovations in the treatment of thyroid-related muscle imbalance, eyelid retraction, and orbital decompression techniques continue to evolve. The increased use of computed tomography and magnetic resonance imaging may provide further insight into the pathophysiology and future treatment of thyroid-related ophthalmopathy.