Comparison of choroidal thickness in patients with active and stable thyroid eye disease / Comparação da espessura da coroide em pacientes com doença ocular tireoidiana ativa e estável

ABSTRACT Purpose: To compare the choroidal thickness in active and stable phases of thyroid eye disease. Methods: Forty-seven eyes of 47 patients with thyroid eye disease were prospectively studied. Patients were evaluated on the basis of their clinical activity scores, with scores 33 defined as active disease. Subfoveal, temporal macular, nasal macular, temporal peripapillary, and nasal peripapillary choroidal thickness measurements were performed with Cirrus enhanced depth imaging spectral-domain optical coherence tomography, and the results in the two groups were compared. Results: Twenty-four patients were int he active group, whereas 23 patients were in the stable group. Choroidal thickness was significantly higher in the subfoveal and temporal macular regions in the active group. Although the nasal macular and peripapillary values were also higher in the active group, the difference was insignificant. Conclusions: Subfoveal choroidal thickness was significantly higher in patients with thyroid eye disease in the active phase than in those with stable phase disease.

RESUMO Objetivo: Comparar a espessura da coroide nas fases ativa e estável da doença ocular tireoidiana. Métodos: Quarenta e sete olhos, de 47 pacientes com doença ocular tireoidiana foram estudados prospectivamente. Os pacientes foram avaliados com base em seus escores de atividade clínica, com escore de 33 definidos como doença ativa. As medidas subfoveais, maculares temporais, maculares nasais, peripapilares temporais e da espessura da coroide peripapilar foram realizadas com tomografia de coerência óptica de domínio espectral Cirrus EDI, e os resultados nos dois grupos foram comparados. Resultados: Vinte e quarto pacientes estavam no grupo ativo, enquanto 23 pacientes estavam no grupo estável. A espessura da coroide foi significativamente maior nas regiões macular subfoveal e temporal no grupo ativo. Embora os valores maculares e peripapilares nasais também fossem maiores no grupo ativo, a diferença foi insignificante. Conclusões: A espessura da coroide subfoveal foi significativamente maior em pacientes com doença ocular tireoidiana na fase ativa do que naqueles com doença na fase estável.

Graves' ophthalmopathy: low-dose dexamethasone reduces retinoic acid receptor-alpha gene expression in orbital fibroblasts

ABSTRACT Objective: Graves' ophthalmopathy (GO) is an autoimmune disease that leads to ocular proptosis caused by fat accumulation and inflammation, and the main treatment is corticosteroid therapy. Retinoid acid receptor-alpha (RARα) seems to be associated with inflammation and adipocyte differentiation. This study aimed to assess the effect of glucocorticoid treatment on orbital fibroblasts of GO patient treated or not with different glucocorticoid doses. Materials and methods: Orbital fibroblasts collected during orbital decompression of a female patient with moderately severe/severe GO were cultivated and treated with 10 nM and 100 nM dexamethasone (Dex). rRARα gene expression in the treated and untreated cells was then compared. Results: Fibroblast RARα expression was not affected by 100 nM Dex. On the other hand, RARα expression was 24% lower in cells treated with 10 nM Dex (p < 0.05). Conclusions: Orbital fibroblasts from a GO patient expressed the RARα gene, which was unaffected by higher, but decreased with lower doses of glucocorticoid.

Isolated primary amyloidosis of the inferior rectus muscle mimicking Graves’ orbitopathy / Amiloidose primária isolada do músculo reto inferior simulando orbitopatia de Graves

ABSTRACT The diagnosis of Graves’ orbitopathy is usually straightforward. However, orbital diseases that mimick some clinical signs of Graves’ orbitopathy may cause diagnostic confusion, particularly when associated to some form of thyroid dysfunction. This report describes the rare occurrence of localized inferior rectus muscle amyloidosis in a patient with autoimmune hypothyroidism, who was misdiagnosed as Graves’ orbitopathy. A 48-year-old man complained of painless progressive proptosis on the left side and intermittent vertical diplopia for 6 months. The diagnosis of Graves’ orbitopathy was entertained after magnetic resonance imaging revealing a markedly enlarged, tendon-sparing inferior rectus enlargement on the left side, and an autoimmune hypothyroidism was disclosed on systemic medical workup. After no clinical improvement with treatment, the patient was referred to an ophthalmologist and further investigation was performed. The presence of calcification in the inferior rectus muscle on computed tomography, associated with the clinical findings led to a diagnostic biopsy, which revealed amyloid deposition. This report emphasizes that a careful evaluation of atypical forms of Graves’ orbitopathy may be crucial and should include, yet with rare occurrence, amyloidosis in its differential diagnosis.

RESUMO O diagnóstico de orbitopatia de Graves usualmente é fácil de ser estabelecido. No entanto, doenças da órbita que simulam alguns sinais clínicos da orbitopatia de Graves podem levar à confusão diagnóstica, particularmente quando associada à alguma forma de disfunção tireoidiana. Relatamos a ocorrência rara de amiloidose localizada no músculo reto inferior em paciente com hipotireoidismo autoimune, que recebeu inicialmente o diagnóstico errôneo de orbitopatia de Graves. Paciente masculino, 48 anos, com queixa de proptose progressiva e indolor do lado esquerdo e diplopia vertical intermitente há 6 meses. O diagnóstico de orbitopatia de Graves foi considerado após a realização de ressonância magnética, que revelou aumento importante do músculo reto inferior esquerdo, sem acometimento do tendão, e uma propedêutica sistêmica detectou hipotireoidismo autoimune. Como não houve melhora com o tratamento clínico, o paciente foi encaminhado a um oftalmologista, que realizou nova investigação. A presença de calcificação no músculo reto inferior na tomografia computadorizada, associada aos achados clínicos, levou a uma biópsia da lesão, que demonstrou a deposição de material amiloide. Este relato enfatiza como uma avaliação minuciosa das formas atípicas de orbitopatia de Graves é essencial e deve incluir a ocorrência, embora rara, de amiloidose no diagnóstico diferencial da orbitopatia de Graves.

Clinical Profile and Visual Outcomes after Treatment in Patients with Dysthyroid Optic Neuropathy

PURPOSE: To report the clinical data and visual outcomes after treatment of patients with dysthyroid optic neuropathy (DON). METHODS: We retrospectively reviewed the medical records and orbital images of 40 patients (65 eyes) with DON and analyzed the visual outcomes after treatment with intravenous steroids pulse therapy, radiotherapy and orbital decompression. RESULTS: The study included 21 men and 19 women, with 10 (25%) being diabetic patients. Visual field test results revealed defects in 88.7% of DON eyes; afferent pupillary defects in 63.2%; reduced color vision in 78.5%; and abnormal visual evoked potentials in 84%. Orbital imaging showed moderate to severe apical crowding in 95% of the orbits and intracranial fat prolapse in 24.2%. Median best corrected visual acuity improved from 0.4 to 1.0 after one year of treatment (p < 0.001). We noted more improvement in vision with the use of decompressive surgery than with non-surgical methods (p < 0.05). Recurrences occurred in 7 patients who had not received orbital radiotherapy. CONCLUSIONS: Visual field defects and apical crowding seen on orbital imaging were the most sensitive indicators for the detection of DON. Treatment with intravenous steroids pulse therapy, radiotherapy and orbital decompression effectively improved visual outcomes in cases of DON.

Comparative evaluation of oculometric variables in graves' ophthalmopathy

OBJECTIVES: To estimate oculometric parameters of Graves' ophthalmopathy in comparison to healthy eyes using digital photography and digital image analysis. INTRODUCTION: Graves' ophthalmopathy is the main cause of eye proptosis. Because these protrusions cause clinically perceived distortions in orbital architecture, digital photographs can be used to detect and quantify these changes. METHODS: We carried out a cross-sectional study comprising 12 healthy volunteers and 15 Graves' ophthalmopathy patients with the purpose of evaluating the use of simple, non-invasive digital photography to estimate oculometric parameters of Graves' ophthalmopathy and compare them with the parameters of unaffected eyes. Facial photographs of cases and controls were taken in a standardized manner. Oculometric parameters were compared between the groups and then correlated to proptometer measures. RESULTS: All estimated oculometric variables showed significant differences between the groups, in particular with regard to mediopupilar aperture, lateral height, distance from the iris edge to the lateral boundary of the palpebral fissure, and distance from the higher point of the iris to the lateral limit of the palpebral fissure. The product of medial aperture and horizontal palpebral fissure also revealed greater discrepancy between the groups. Proptometer measures showed significant linear correlation between the distance from the iris edge to the lateral boundary of the palpebral fissure and between the distance from the higher point of the iris to the lateral limit of palpebral fissure (p<0.05). CONCLUSIONS: Comparative analysis of oculometric parameters in Graves' ophthalmopathy suggests that eye proptosis is related to an asymmetric increase in lateral oculometric measures. Standardized digital photographs can be used in clinical practice to objectively estimate oculometric parameters of Graves' ophthalmopathy patients.

Análise morfométrica da fenda palpebral de pacientes com oftalmopatia distireóidea antes e após aplicação de toxina botulínica tipo A / Morphometric analysis of the palpebral fissure in patients with thyroid-related disfunction before and after application of botulinum toxin / Morphometric analysis of the palpebral fissure in patients with thyroid-related disfunction before and after application of botulinum toxin

INTRODUÇÃO: A toxina botulínica tem sido usada como opção terapêutica para retração palpebral em pacientes com oftalmopatia distireóidea. Os objetivos deste trabalho foram apresentar dados morfométricos da fenda palpebral, avaliar o efeito da medicação sobre a função do músculo elevador da pálpebra superior e em relação à exposição ocular. MÉTODOS: Foram incluídos 7 pacientes com retração palpebral. A propedêutica foi realizada com o registro de imagens através de câmera filmadora digital. Foram utilizados programas para edição dos vídeos e para análise da fenda palpebral. Também foi realizada a medida da função do tendão do músculo elevador da pálpebra superior e a propedêutica do filme lacrimal. RESULTADOS: Os dados morfométricos mostraram uma diminuição da fenda palpebral e da distância entre a margem da pálpebra superior e o reflexo luminoso no centro da córnea, a função do músculo elevador da pálpebra superior apresentou uma diminuição de seu valor e a propedêutica do filme lacrimal evidenciou uma maior estabilidade do filme lacrimal após o uso da medicação. DISCUSSÃO: A toxina pode ser uma opção de tratamento para pacientes com retração palpebral, amenizando o problema estético e os sinais de exposição corneana.

INTRODUCTION: Botulinum toxin is an alternative treatment for retraction of ocular thyroid related dysfunction. The aim of this study was to evaluate the effects of this medication on upper lid position, levator palpebrae superioris muscle function and corneal exposure. METHODS: Seven patients were enrolled into the study. The palpebral fissure images were acquired by a digital camera and transferred to a computer video edition program in order to be processed and analyzed. The levator palpebrae superioris muscle function and lacrimal film tests were also studied. RESULTS: The distance between upper eyelid superior margin and light reflection on the center of the cornea had a significantly reduction in its measurements after toxin injection. The muscle function was diminished and there were improvement in corneal exposure after treatment. DISCUSSION: Botulinum toxin injection could be an alternative treatment for upper eyelid retraction; it may relieve symptoms and improve eye appearance.