Características clínico-oftalmológicas y evolución de los pacientes con oftalmopatía tiroidea activa moderada severa tratados con bolos de metilprednisolona que acuden al Hospital Central del Instituto de Previsión Social, Paraguay / Clinical-ophthalmological characteristics and evolution of patients with moderately severe active thyroid ophthalmopathy treated with methylprednisolone boluses who attended the Central Hospital of the Instituto de Previsión Social, Paraguay

Introducción: La oftalmopatía tiroidea (OT) es un trastorno debilitante en pacientes con enfermedad tiroidea autoinmune, principalmente enfermedad de Graves, que se desarrolla entre el 30 a 50% de los casos. Objetivos: Describir las características clínico-oftalmológicas y la evolución de los pacientes con oftalmopatía tiroidea activa moderada severa tratados con bolos de metilprednisolona que acuden al Hospital Central del Instituto de Previsión Social en el tiempo comprendido entre enero de 2018 y setiembre de 2021. Materiales y métodos: Investigación de diseño observacional, con estudio descriptivo, retrospectivo. Resultados: Se revisaron fichas de 34 pacientes con OT activa moderada severa que recibieron bolos de metilprednisolona basado en las guías EUGOGO 2016, de los cuáles se excluyeron 3 pacientes por tener fichas incompletas y otros 3 pacientes ya que requirieron tratamiento de segunda línea previo al término del esquema de 12 sesiones. De los 28 pacientes estudiados, la edad promedio fue de 43,6 ±13,1 años, el 89% de sexo femenino y el 28,5%, fumadores. En cuanto a la función tiroidea de la población previo al tratamiento, se constató hipertiroidismo en el 82%, hipotiroidismo en el 11% y eutiroidismo en el 7%; y posterior al tratamiento, se constató hipertiroidismo en el 78,6% (subclínico), eutiroidismo en el 17,9% e hipotiroidismo en el 3,5%. La mayoría (92.6%) contaba con anticuerpos contra el receptor de TSH positivo, con un promedio de 18 ± 9,9 mIU/Ml. Respecto a la actividad de la oftalmopatía según la escala CAS, se constató un promedio de 4,1 ±1,0 previo al tratamiento y posterior 1,2 ±1,4; de ellos el 46,4% presentó un estado leve según escala de gravedad, 39% sin criterios de gravedad y 14 % persistió en moderada -severa. Se constató mejoría de la agudeza visual tras el tratamiento (57,1%), el promedio de exoftalmía previo al tratamiento fue 22,2 mm y posterior 21,1 mm; se presentó diplopía en el 7,1% previo al tratamiento y en el 3,6% posterior al tratamiento. Conclusión: El tratamiento con glucocorticoides endovenosos en la oftalmopatía de Graves moderada-severa (esquema EUGOGO 2016) fue muy efectivo, revirtiendo la actividad y consecuentemente ayudando a disminuir la gravedad, en la gran mayoría de nuestros pacientes. Esto podría explicarse porque la oftalmopatía era incipiente y por el alto grado de adherencia de los pacientes en el contexto de un manejo multidisciplinar bien protocolizado.

Introduction: Graves' orbitopathy (GO) is a debilitating disorder in patients with autoimmune thyroid disease, mainly Graves' disease, which develops in 30 to 50% of cases. Objectives: To describe the clinical-ophthalmological characteristics and evolution of patients with moderate-to- severe active GO treated with methylprednisolone boluses who attended the Central Hospital of the Institute of Social Security between January 2018 and September 2021. Materials and methods: Observational design research, descriptive, retrospective study. Results: Records of 34 patients with active moderate-to-severe GO who received boluses of methylprednisolone based on the EUGOGO 2016 guidelines, were reviewed, of which 3 patients were excluded due to having incomplete records and another 3 patients since they required second-line treatment prior to end the 12-session scheme. Of the 28 patients studied, the average age was 43.6 ±13.1 years, 89% were female and 28.5% were smokers. Regarding the thyroid function of the population prior to treatment, hyperthyroidism was found in 82%, hypothyroidism in 11% and euthyroidism in 7%; and after treatment, hyperthyroidism was found in 78.6% (subclinical), euthyroidism in 17.9% and hypothyroidism in 3.5%. The majority (92.6%) had positive thyrotropin receptor antibodies, with an average of 18 ± 9.9 mIU/Ml. Regarding the activity of orbitopathy according to the CAS scale, an average of 4.1 ±1.0 was found before treatment and 1.2 ±1.4 after; Of them, 46.4% presented a mild condition according to the severity scale, 39% without severity criteria and 14% persisted in moderate-severe. Improvement in visual acuity was noted after treatment (57.1%), the average exophthalmia before treatment was 22.2 mm and after 21.1 mm; Diplopia occurred in 7.1% before treatment and in 3.6% after treatment. Conclusion: Treatment with intravenous glucocorticoids in moderate-severe Graves' orbitopathy (EUGOGO 2016 scheme) was very effective, reversing the activity and consequently helping to reduce the severity, in the vast majority of our patients. This could be explained because the orbitopathy was incipient and by the high degree of patient adherence in the context of well-protocolized multidisciplinary management.

Técnicas de imagen en la orbitopatía asociada al tiroides

La orbitopatía asociada al tiroides es la primera causa de afección inflamatoria orbitaria y de exoftalmo en adultos. Su progresión puede generar complicaciones, las cuales, ante un manejo inoportuno u omisión diagnóstica, pueden conllevar a disfunción visual irreversible. De aquí la importancia de garantizar un diagnóstico y tratamiento adecuados, para lo cual es fundamental un correcto manejo imagenológico. Con el propósito de actualizar y sistematizar el conocimiento sobre el diagnóstico por imágenes de la orbitopatía asociada al tiroides, se realizó una revisión de las publicaciones relacionadas con el tema de las últimas dos décadas. La búsqueda y la localización de la información se apoyaron en la elección de palabras clave/descriptores que configuraron su perfil. Además, se analizaron las ecografías, tomografías computarizadas y resonancias magnéticas de los pacientes diagnosticados con esta enfermedad en el Instituto Cubano de Oftalmología Ramón Pando Ferrer, durante los últimos 10 años. Todo lo investigado confirma que las técnicas de imagen son claves para establecer el diagnóstico de la oftalmopatía asociada al tiroides, pero jamás sustituirán a la historia clínica detallada y el examen físico minucioso. El médico se equivoca gravemente cuando pretende obviar la importancia del juicio clínico. La omisión de este principio, en el mejor de los casos, solo conducirá a diagnósticos casuales.

Thyroid-associated orbitopathy is the leading cause of orbital inflammatory disease and exophthalmos in adults. Its progression can generate complications, which, in case of inopportune management or diagnostic omission, can lead to irreversible visual dysfunction. Hence the importance of guaranteeing an adequate diagnosis and treatment, for which a correct imaging management is essential. With the purpose of updating and systematizing the knowledge on the imaging diagnosis of thyroid associated orbitopathy, a review of the publications related to the subject of the last two decades was carried out. The search and localization of the information was supported by the choice of keywords/descriptors that configured its profile. In addition, ultrasound scans, CT scans and MRI scans of patients diagnosed with this disease at the Cuban Institute of Ophthalmology Ramón Pando Ferrer, during the last 10 years, were analyzed. All that has been investigated confirms that imaging techniques are key to establish the diagnosis of thyroid-associated ophthalmopathy, but they will never replace a detailed clinical history and a thorough physical examination. The physician is seriously mistaken when he pretends to ignore the importance of clinical judgment. The omission of this principle will, at best, only lead to casual diagnoses.

Inhibitory effect of phloretin on inflammation and oxidative stress in IL-1β induced orbital fibroblasts in Graves orbitopathy and its mechanism / 中华实验眼科杂志

Objective:To investigate the inhibitory effect of phloretin on inflammation and oxidative stress in interleukin (IL)-1β induced orbital fibroblasts (OFs) from Graves orbitopathy (GO) patients and its mechanism.Methods:The orbital fat and connective tissue from 6 eyes of 6 patients diagnosed as inactive GO who underwent orbital decompression in Henan Eye Hospital from January 2019 to December 2020 were collected.Primary OFs were isolated and passaged by explant culture and were identified by cell immunofluorescence assay.OFs were divided into control group, IL-1β induced group, and groups of various phloretin concentrations (25, 50, 75, 100 and 200 μmol/L). The viability of OFs after 24- and 48-hour treatment of the various phloretin concentrations was determined by cell counting kit-8 (CCK-8). OFs were induced by IL-1β to simulate an inflammatory environment of GO in vitro.Intracellular reactive oxygen species (ROS) levels of the normal control group, IL-1β induced group, 50 μmol/L phloretin group and 100 μmol/L phloretin group were detected by fluorescent probe (H 2DCF-DA). The concentrations of pro-inflammatory cytokines IL-6, IL-8 and monocyte chemoattractant protein-1 (MCP-1) in cell culture supernatant of the normal control group, IL-1β induced group and phloretin treated groups (25, 50, 75, and 100 μmol/L) were examined by enzyme-linked immunosorbent assay (ELISA). The expressions of heme oxygenase-1 (HO-1), nuclear factor erythroid 2-related factor (Nrf2) proteins, as well as P38, extracelluar regulated protein kinase (ERK) and c-Jun N-terminal kinase (JNK) proteins as well as their phosphorylated proteins in the MAPK signal pathway of the normal control group, IL-1β induced group and 100 μmol/L phloretin group, were detected by Western blot.The purpose and methods of the study were explained to the patients and their family members.Written informed consent was obtained.The study protocol was approved by the Ethics Committee of Henan Provincial People's Hospital (No.HNEECKY-2020[07]). Results:For cultured OFs, the mesenchymal origin was confirmed by positive expression of vimentin and fibroblasts were identified by negative expression of desmin, S-100 and cytokeratin-18.CCK-8 showed that there was no significant difference in absorbance value after 24- and 48-hour treatment between 25 μmol/L, 50 μmol/L, 75 μmol/L and 100 μmol/L phloretin groups and control group (all at P>0.05). The ROS levels of 50 μmol/L and 100 μmol/L phloretin groups were 21.95±1.71 and 10.01±1.03, respectively, which were significantly lower than 39.27±4.01 of IL-1β induced group (both at P<0.01). ELISA showed that IL-6 concentrations in 25 μmol/L, 50 μmol/L, 75 μmol/L and 100 μmol/L phloretin groups were (4 544.25±572.98), (1 000.25±133.96), (724.25±98.63), (519.50±118.02)pg/ml, respectively, which were all significantly lower than (7 581.75±565.93)pg/ml in IL-1β induced group (all at P<0.01). IL-8 concentrations in 50 μmol/L, 75 μmol/L and 100 μmol/L phloretin groups were (3 679.50±676.76), (2 143.75±616.20), (1 174.75±284.18)pg/ml, respectively, which were all significantly lower than (8 411.00±939.67)pg/ml in IL-1β induced group (all at P<0.01). The concentrations of MCP-1 in 50 μmol/L, 75 μmol/L and 100 μmol/L phloretin groups were (3 783.25±610.24), (1 565.75±457.89), (745.75±227.01)pg/ml, respectively, which were all significantly lower than (5 533.00±602.87)pg/ml in IL-1β induced group (all at P<0.01). The relative expression levels of HO-1 and Nrf2 were significantly higher and the relative expression levels of p-P38, p-ERK, and p-JNK were significantly lower in 100 μmol/L phloretin group than IL-1β induced group (all at P<0.01). Conclusions:Phloretin reduces the oxidative stress level of IL-1β induced OFs from GO patients and inhibits the production of pro-inflammatory cytokines.The mechanism is related to the activation of Nrf2/HO-1 and the inhibition of the MAPK signal pathway.

Dysthyroid optic neuropathy: Demographics, risk factors, investigations, and management outcomes

Purpose: To analyze the clinical presentations, risk factors, and management outcomes in patients presenting with dysthyroid optic neuropathy (DON). Methods: This is a retrospective, single?center study carried out on consecutive patients presenting with DON over a period of 4 years (2013–2016). The VISA classification was used at the first visit and subsequent follow?ups. The diagnosis was based on optic nerve function tests and imaging features. Demographic profiles, clinical features, risk factors, and management outcomes were analyzed. Results: Thirty?seven eyes of 26 patients diagnosed with DON were included in the study. A significant male preponderance was noted (20, 76.92%). Twenty patients (76.9%, P = 0.011) had hyperthyroidism, and 15 (57.69%, P = 0.02) were smokers. Decreased visual acuity was noted in 28 eyes (75.6%). Abnormal color vision and relative afferent pupillary defects were seen in 24 (64.86%) eyes, and visual field defects were seen in 30 (81.01%) eyes. The visual evoked potential (VEP) showed a reduced amplitude in 30 (96.77%, P = 0.001) of 31 eyes and delayed latency in 20 (64.51%, P = 0.0289) eyes. Twenty?six (70.27%) patients were treated with intravenous methyl prednisolone (IVMP) alone, whereas 11 (29.72%) needed surgical decompression. The overall best?corrected visual acuity improved by 0.2 l logMARunits. There was no statistically significant difference in outcome between medically and surgically treated groups. Four patients developed recurrent DON, and all of them were diabetics. Conclusion: Male gender, hyperthyroid state, and smoking are risk factors for developing DON. VEP, apical crowding, and optic nerve compression are sensitive indicators for diagnosing DON. Diabetics may have a more defiant course and are prone to develop recurrent DON.

Guideline interpretation: the 2021 European Group on Graves′ Orbitopathy Clinical Practice Guidelines for the Medical Management of Graves′ Orbitopathy / 中华内分泌代谢杂志

The 2021 European Group on Graves′ Orbitopathy (EUGOGO) Clinical Practice Guidelines for the Medical Management of Graves′ Orbitopathy was released in July, 2021. Based on the 2016 version, the new guidelines updated the first-line management algorithm for patients with Graves′ orbitopathy in moderate-to-severe and active period, provided multiple second-line treatment pathways and made detailed recommendations from aspects of clinical assessment, general measures, and management of specific conditions, etc. At the same time, efficacy evaluation and management during COVID-19 period were explained in detail. The new guidelines also mentioned some novel treatment strategies of GO which still need further efficacy and safety verification.

Pacientes con compromiso orbitario y renal: Diagnósticos diferenciales poco frecuentes / Patients with orbitary and kidney commitment: Rare differential diagnoses

Se comunica una serie de tres casos clínicos que consultaron al servicio de Reumatología por compromiso orbitario y renal. Uno de ellos presentó pseudotumor orbitario con proteinuria en rango nefrótico; se realizó biopsia y se encontró infiltrado linfoplasmocitario denso y fibrosis estoriforme con inmunohistoquímica: 15 células IgG4+ por campo de alto poder y relación IgG/IgG4 ≤40%, concluyendo diagnóstico de enfermedad relacionada por IgG4. El segundo y tercer caso presentaron compromiso ocular con "ojos de mapache" y lesiones amarillentas en párpados, ambos con proteinuria >500 mg/24 h, con biopsia de piel rojo Congo positiva y birrefringencia verde manzana con luz polarizada. Se discuten distintos diagnósticos diferenciales poco frecuentes a tener en cuenta en estos pacientes.

A series of three cases that consulted the rheumatology service due to orbital and renal involvement is reported. One of them presented orbital pseudotumor with proteinuria in the nephrotic range, a biopsy was performed, finding dense lymphoplasmacytic infiltrate and storiform fibrosis with immunohistochemistry: 15 IgG4 positive cells per HPF and IgG/IgG4 ratio ≤40%, concluding diagnosis of IgG4 related disease. The second and third cases presented ocular involvement with raccoon eyes and yellowish lesions on the eyelids, both with proteinuria greater than 500 mg/24 h, with apple-green birefringence of amyloid on congo red staining. Different rare differential diagnoses to take into account in these patients are discussed.

Características de orbitopatía asociada al tiroides y tasa de requerimiento de cirugía / Thyroid-associated orbitopathy characteristics and surgery requirement rate

RESUMO Objetivo: Conheça as características demográficas e clínicas da Órbita Associada da Tiroide (OAT), bem como a taxa de exigência da cirurgia orbital em pacientes do Centro Médico Nacional do Oeste. Métodos. Estudo observacional, transversal, descritivo e retrospetivo realizado analisando os registos de pacientes diagnosticados com OAT tratados num centro de cuidados de terceiro nível de janeiro de 2005 a julho de 2016. Os resultados. Um total de 236 órbitas de 118 pacientes foram avaliados, com uma idade média de 47,3 (13,2 anos, 74,6% eram do sexo feminino e 25,4% masculinos. 4,2% dos doentes foram tratados com hipotiroidismo, 94,1% com hipertireoidismo e 1,7% com goiter tóxico difuso. 44,9% dos doentes estudados com restrição de movimento ocular,10,2% com queratopatia de exposição e 51,7% com hipertensão intraocular. 34,7% dos doentes avaliados no serviço necessitaram de descompressão orbital, 16,1% de cirurgia palpebral e 8,5% de correção do hatrabisma. Na gestão conservadora destes doentes, 48,3% exigiam o uso de lubrificantes tópicos dos olhos, enquanto 52,5% dos pacientes necessitavam do uso de hipotensivos oculares em número variável. As conclusões. A OAT foi associada principalmente ao hipertiroidismo, sendo mais comum em pacientes do sexo feminino entre os 40 e os 59 anos; mais de 50% dos pacientes necessitaram do uso de hipotensivos oculares. Da mesma forma, a gestão cirúrgica foi realizada em mais de 50% dos pacientes, sendo a descompressão orbital a intervenção mais frequente.

ABSTRACT Objective. To know the demographic and clinical characteristics of Thyroid Associated Orbitopathy (TAO), as well as the requirement rate of orbital surgery in patients of the Orbit Service in the National Medical Center of the West, IMSS. Methods. Observational, cross-cutting, descriptive and retrospective study carried out analyzing the records of patients diagnosed with TAO and treated at a third-level care center from January 2005 to July 2016. Results. A total of 236 orbits of 118 patients were valued, with an average age of 47.3 ± 13.2 years, 74.6% were female and 25.4% male. 4.2% of patients were treated with hypothyroidism, 94.1% with hyperthyroidism and 1.7% with diffuse toxic goiter. 44.9% of patients studied had eye movement restriction,10.2% exposure keratopathy and 51.7% intraocular hypertension. 34.7% of patients valued in the service required orbital decompression, 16.1% palpebral surgery and 8.5% strabism correction. In the conservative management of these patients 48.3% required the use of topical eye lubricants, while 52.5% required the use of eye hypotensives in variable numbers. Conclusions. TAO was mainly associated with hyperthyroidism, being more common in female patients between the age of 40 and 59; more than 50% of patients required the use of eye hypotensives. Likewise, surgical management was performed in more than 50% of patients, with orbital decompression being the most frequent intervention.

El ojo: Un rompecabezas diagnóstico: Estudio observacional descriptivo y revisión / The Eye: A Diagnostic Puzzle: Descriptive observational study and review

Se comunica una serie de casos, multicéntricos de la cual participaron cinco instituciones. La muestra fue de 17 pacientes, de los cuales 11 pertenecían al Hospital Dr. J.M. Cullen. Todos consultaron por compromiso orbitario y/o periorbitario. El compromiso en hombres fue de 23.4% y un 76.6% en mujeres. La edad media en años fue de 45.4 (17-69 años). Dentro de los diagnósticos encontrados, cinco casos fueron Enfermedad Relacionada con IgG4 (ER-IgG4), dos casos de Enfermedad de Erdheim Chester (EEC), dos Xantogranuloma, dos xantelasmas, un caso de metástasis de cáncer de mama, un caso de orbitopatía tiroidea, un caso de Amiloidosis con mieloma múltiple, y tres sin diagnóstico. Se revisan los diagnósticos diferenciales encontrados.

A series of multicentric cases is reported, of which five institutions participated. The sample was of 17 patients, of which 11 belonged to our Hospital, the Dr. J.M. Cullen Hospital. All consulted for orbital and/or periorbital commitment. The commitment in men was 23.4% and 76.6% in women. The average age in years was 45.4 (17-69 years). Among the diagnoses found, five cases were IgG4-Related Disease, two cases of Erdheim Chester Disease, two Xantogranuloma, two xanthelasmas, a case of breast cancer metastases, a case of thyroid orbitopathy, a case of Amyloidosis with multiple myeloma, and three without diagnosis. Differential diagnoses found are reviewed.

The change in the clinical presentation of Graves disease: a 30 years retrospective survey in an academic Brazilian tertiary center

ABSTRACT Objective Graves' disease (GD) is the main cause of hyperthyroidism among adults. It is an autoimmune condition classically marked by the Merserburg Triad (goiter, thyrotoxicosis, and orbitopathy), but the change in presentation of GD over time has rarely been studied. To determine changes in the clinical presentation of patients with GD in the last 30 years. Subjects and methods The study evaluated 475 patients diagnosed with GD between 1986 and 2016 in a single center. Patients were evaluated regarding epidemiological aspects, thyroid function, inflammatory activity of the eyes evaluated by the Clinical Activity Score; CAS, severity evaluated by NOSPECS classification and thyroid volume estimated by ultrasonography. Results Patients assessment identified an increase in the mean age of diagnosis of GD (p < 0.02), a reduction in thyroid volume (p < 0.001) and less intense orbital involvement from 2007-2016 compared to 1986-2006 (p = 0.04). The number of smoking patients was smaller from 2007 to 2016 (28.7%) than 1986 to 2006 (42.8% p = 0.001). The TSH and TRAb values did not had significant changes. Conclusion GD presentation appears to be changed in the last years compared to the typical initial presentation. There is a less frequent inflammatory involvement of orbital tissue, smaller goiters, a lower number of smokers and diagnosis at older age.

Thyroid-Associated Orbitopathy: Evaluating Microstructural Changes of Extraocular Muscles and Optic Nerves Using Readout-Segmented Echo-Planar Imaging-Based Diffusion Tensor Imaging

OBJECTIVE: We aimed to investigate the ability of readout-segmented echo-planar imaging (rs-EPI)-based diffusion tensor imaging (DTI) in assessing the microstructural change of extraocular muscles (EOMs) and optic nerves in patients with thyroid-associated orbitopathy (TAO) as well as in evaluating disease activity.MATERIALS AND METHODS: We enrolled 35 TAO patients and 22 healthy controls (HCs) who underwent pre-treatment rs-EPI-based DTI. Mean, axial, and radial diffusivity (MD, AD, and RD) and fractional anisotropy (FA) of the medial and lateral EOMs and optic nerve for each orbit were calculated and compared between TAO and HC groups and between active and inactive TAO groups. Factors such as age, sex, disease duration, mediation, and smoking history between groups were also compared. Logistic regression analysis was used to evaluate the predictive value of significant variables for disease activity.RESULTS: Disease duration was significantly shorter in active TAOs than in inactive ones (p < 0.001). TAO patients showed significantly lower FA and higher MD, AD, and RD than HCs for both medial and lateral EOMs (p < 0.001), but not the AD value of lateral EOMs (p = 0.619). Active patients had significantly higher FA, MD, and AD than inactive patients for medial EOMs (p < 0.005), whereas only FA differed significantly in the lateral EOMs (p = 0.018). The MD, AD, and RD of optic nerves were significantly lower in TAO patients than HCs (p < 0.05), except for FA (p = 0.129). Multivariate analysis showed that the MD of medial EOMs and disease duration were significant predictors for disease activity. The combination of these two parameters showed optimal diagnostic efficiency for disease activity (area under the curve, 0.855; sensitivity, 68.4%; specificity, 96.9%).CONCLUSION: rs-EPI-based DTI is promising in assessing microstructural changes of EOMs and optic nerves and can help to indicate the disease activity of TAO, especially through the MD of medial EOMs.

Clinical Study of Ocular Manifestations of Thyroid Disease in Tertiary Eye Care Center

Introduction: Thyroid eye disease (TED), Graves’ ophthalmopathy, or Thyroid associated orbithopathy (TAO) are an immunemediated inflammatory disorder that produces expansion of the extraocular muscles and fat in the orbit. TED is most commonlyassociated with Graves’ hyperthyroidism but can also be noted in hypothyroid and euthyroid states.Aim: The aim of the study is to evaluate the ocular manifestation of thyroid dysfunction (TD).Materials and Methods: A prospective non-randomized observational study was carried out on 106 patients of TD. They wereexamined in detail for demography, systemic, and ocular examination and laboratory investigation. Period of study was 1 year.Results: In this study, average age of presentation of TD was 42.54 years. Female-to-male ratio was 3.1:1. Lid retractionwas the most common (82.4%) lid sign in patients of hyperthyroidism while in patients of hypothyroidism, it was lid edema(28.9%). The second most common lid sign was lid lag which was present 70.6% cases. Proptosis was present in 52.9%hyperthyroid patients. Three patients had unilateral proptosis. Corneal ulcer (due to exposure keratopathy) was present in17.6% of hyperthyroid patients.Conclusion: Females were more commonly affected. However, ocular manifestations were more severe in male. Hence, it isimportant to rule out TD in patient with other ocular symptom.

Descompresión orbitaria endoscópica transnasal en orbitopatía tiroidea severa / Transnasal endoscopic orbital decompression in severe thyroid orbitopathy

RESUMEN La orbitopatía tiroidea es una enfermedad autoinmune, en la que una reacción inflamatoria genera aumento de la presión orbitaria con protrusión de su contenido. A menudo es autolimitada y sus síntomas más frecuentes son retracción palpebral, exoftalmo y diplopía. Existen casos severos con compromiso de la agudeza visual por compresión del nervio óptico. El diagnóstico es clínico, pero debe complementarse con una tomografía computarizada. Su tratamiento depende de la gravedad y actividad de la enfermedad, siendo los procedimientos quirúrgicos, como la descompresión orbitaria, de elección en exoftalmo y neuropatía óptica compresiva. El pilar de tratamiento en la orbitopatía tiroidea severa es la cirugía descompresiva. Se han descrito múltiples técnicas, pero con limitaciones. La descompresión endoscópica transnasal, es considerada actualmente el procedimiento de elección, ya que permite una buena visualización de la pared medial, con resultados comparables y menores complicaciones, respecto a métodos tradicionales. Describimos un caso de oftalmopatía tiroidea severa, con exoftalmo, diplopía y disminución de la agudeza visual, en la que se realizó una descompresión endoscópica con muy buenos resultados.

ABSTRACT Thyroid orbitopathy is an autoimmune disease in which an inflammatory reaction generates increased orbital pressure with protrusion of its contents. It is often self-limiting and its most frequent symptoms are eyelid retraction, exophthalmos and diplopia. There are severe cases with compromised visual acuity due to compression of the optic nerve. The diagnosis is clinical, but must be complemented with a computed tomography scan. Its treatment depends on the severity and activity of the disease and the surgicals procedures such as orbital decompression is the best choice in exophthalmos and compressive optic neuropathy. The treatment in severe thyroid orbitopathy is decompressive surgery. Multiple techniques have been described, but with limitations. The transnasal endoscopic decompression is currently considered the gold standard, since it allows a good visualization of the medial wall with comparable results and less complications, compared to traditional methods. We present a case of severe thyroid ophthalmopathy, with exophthalmos, diplopia and decreased visual acuity, in which a transnasal endoscopic decompression was performed with very good outcomes.

The Clinical Result of Medial Orbital Decompression in Patients with Thyroid-associated Orbitopathy

PURPOSE: To evaluate the clinical effects of medial orbital decompression in patients with thyroid orbitopathy. METHODS: Forty-three orbits of 28 patients who underwent medial orbital decompression for cosmetic purposes between January 2014 to January 2017 were retrospectively reviewed. Changes in visual acuity, intraocular pressure, exophthalmos, strabismus, and diplopia were checked before, 3 months, and 1 year after surgery. RESULTS: The average exophthalmos reduction was −2.99 ± 0.96 mm at postoperative 3 months and −3.07 ± 1.24 mm after 1 year (both, p < 0.001). In patients who underwent unilateral orbital decompression, the mean difference in exophthalmometry between the two eyes was significantly reduced from 3.06 ± 0.78 mm to 0.38 ± 0.44 mm after 3 months, and to 0.50 ± 0.46 mm after 1 year (p = 0.011 and p = 0.012, respectively). After surgery, the final postoperative intraocular pressure decreased significantly at postoperative 3 months and 1 year (both, p < 0.001). The mean preoperative horizontal deviation was 0.88 ± 4.85 prism diopters (PD) and 5.50 ± 6.74 PD at postoperative 3 months, which demonstrated significant esodeviation postoperatively (p = 0.007). Three patients had new onset esotropia (8.33%), but no surgical treatment was needed. CONCLUSIONS: Medial orbital decompression is a less invasive and safe surgical procedure for patients with asymmetric or mild thyroid-associated orbitopathy, which can be beneficial for reducing proptosis.

Evaluation of quality of life in patients with Graves orbitopathy and its influencing factors / 中华内科杂志

Objective To evaluate life quality of Graves orbitopathy (GO) patients using Graves orbitopathy quality-of-life questionnaire (GO-QOL) and explore the influence factors of the quality of life of GO patients.Methods This was a cross-sectional study conducted at The Third Affiliated Hospital of Southern Medical University including 145 newly diagnosed GO patients.All the patient answered the GO-QOL and underwent ophthalmic and endocrine assessments.The main outcome measures were the scores on GO-QOL 2 subscales:visual functioning and appearance.Based on the classification in the guideline of European Group on Graves Orbitopathy (EUGOGO),the patients were divided into two groups:mild and moderate to severe groups.Then the scales between these two groups were compared and influencing factors were analyzed.Finally,the floor and ceiling effects were assessed.Results The GO-QOL scores for the subscales of visual functioning and appearance were 70.91±27.83 and 61.29±26.37 respectively in 145 GO patients.Visual functioning and appearance were lower in moderate to severe group (62.71 ±28.77 and 57.52 ± 26.49,respectively) than in mild group (85.58 ± 18.77 and 68.02 ±24.99,respectively).The GO-QOL scores for the visual functioning subscale were significantly correlated with age (P =0.002),clinical active score (P =0.011) and the degree of diplopia (P =0.00,R2=0.373).The GO-QOL scores for the appearance were significantly correlated with sex (P =0.05) and thyroid-stimulating hormone levels (P =0.001,R2 =0.231).No significant ceiling or floor effects were observed for either subscale of the GO-QOL.Conclusions With the aggravation of the disease,the quality of life of GO patients is getting worse and worse.The main influencing factors of the quality of life of GO patients include age,gender,diplopia,clinical active score and thyroid-stimulating hormone levels.Close attention needs to be paid to the quality of life of GO patients.

Changes of immunoglobulins and CD series in patients with Graves' orbitopathy treated with high-dose methylprednisolone / 中华内分泌代谢杂志

Objective To study the effect of high-dose methylprednisolone intravenous pulse therapy on immunoglobulins and CD series in patients with active moderate-to-severe Graves' orbitopathy. Methods Twenty-seven patients with active moderate-to-severe Graves' orbitopathy were enrolled in this study. All the patients received iv methylprednisolone pulse therapy for 12 weeks according to the 2016 European Thyroid Association/European Group on Graves'Orbitopathy(EUGOGO) Guidelines. Serum thyroidal autoantibodies, such as thyroid-stimulating hormone receptor antibody ( TRAb) , anti-thyroperoxidase antibody ( TPOAb) , and serum immunoglobulins, such as IgG, IgE, IgA, IgM were evaluated at the baseline, at the end of 4th and 12th week. Percentages of CD3+ T cells, CD4+ T cells, CD8+T cells and CD19+ B cells, CD16+ or CD56+ NK cells were also evaluated at each time point. Results TRAb, TPOA and IgE, IgG, IgA were significantly decreased both after 4th week and after 12th week (all P<0.05). Percentages of CD3+ T cells, CD4+ T cells and CD4+/CD8+ ratio were gradually decreased after treatment. However, change of CD8+T cells was not significant (P>0.05). Conclusion High-dose methylprednisolone may exert an immunosuppressive effect not only by modifying humoral and cellular immune functions, but also by decreasing serum immunoglobulins.

Changes of immunoglobulins and CD series in patients with Graves′ orbitopathy treated with high-dose methylprednisolone / 中华内分泌代谢杂志

Objective@#To study the effect of high-dose methylprednisolone intravenous pulse therapy on immunoglobulins and CD series in patients with active moderate-to-severe Graves′ orbitopathy.@*Methods@#Twenty-seven patients with active moderate-to-severe Graves′ orbitopathy were enrolled in this study. All the patients received iv methylprednisolone pulse therapy for 12 weeks according to the 2016 European Thyroid Association/European Group on Graves′Orbitopathy(EUGOGO) Guidelines. Serum thyroidal autoantibodies, such as thyroid-stimulating hormone receptor antibody (TRAb), anti-thyroperoxidase antibody (TPOAb), and serum immunoglobulins, such as IgG, IgE, IgA, IgM were evaluated at the baseline, at the end of 4th and 12th week. Percentages of CD3+ T cells, CD4+ T cells, CD8+ T cells and CD19+ B cells, CD16+ or CD56+ NK cells were also evaluated at each time point.@*Results@#TRAb, TPOA and IgE, IgG, IgA were significantly decreased both after 4th week and after 12th week (all P<0.05). Percentages of CD3+ T cells, CD4+ T cells and CD4+ /CD8+ ratio were gradually decreased after treatment. However, change of CD8+ T cells was not significant (P>0.05).@*Conclusion@#High-dose methylprednisolone may exert an immunosuppressive effect not only by modifying humoral and cellular immune functions, but also by decreasing serum immunoglobulins.

A Demographic Profile And Awareness Study Of Hyperthyroidism Among Patients In A Tertiary Hospital In Western India

Background and objectives- To study the demographic profiling and awareness of hyperthyroidism among patients reporting to our hospital. Methods- A randomized retrospective study was done consisiting of 50 patients who were diagnosed with hyperthyroidism in the Out patient department of our hospital during two year period after approval by ethical committee. The data obtained were tabulated, analysed, assessed and formulated. Results- Females were more commonly affected, with age group of 60-69 being more commonly affected in the male and female category, with majority of patients belonging to the class III of kuppusamy socio-economic classification. On laterality males had more bilateral involvement with women having predominantly unilateral involvement. On treatment study, males were on a strict treatment regime as compared to their counterparts. In the socio-economic classification majority of class V category were not on any treatment. On awareness majority of male & female patients were equally unaware of the fact that they were suffering from hyperthyroidism. Conclusions- Our study showed that majority of female patients were affected, off treatment and unaware of the disease. Patients of lower socio-economic class were off treatment and unaware of the disease. As we found the group of 60-69 years were more commonly involved a thorough survey and screening of this age group is essential. With proper awareness, screening, check-ups, camps and education among we can make a remarkable difference in treatment in restoring visual function, appearance and help a reclusive patient to become socially reintegrated.

TSH-receptor antibodies may prevent bone loss in pre- and postmenopausal women with Graves' disease and Graves' orbitopathy

ABSTRACT Objective Thyrotoxicosis is established risk factor for osteoporosis due to increased bone turnover. Glucocorticoids often administered for Graves' orbitopathy (GO) have additional negative effect on bone mineral density (BMD). Our aim was to examine the influence of thyroid hormones, TSH, TSH-receptor antibodies (TRAb) and glucocorticoid treatment on bone in women with Graves' thyrotoxicosis and Graves' orbitopathy (GO). Subjects and methods Forty seven women with Graves' disease, mean age 55.6 ± 12.8 (23 women with thyrotoxicosis and 24 hyperthyroid with concomitant GO and glucocorticoid therapy) and 40 age-matched healthy female controls were enrolled in the study. We analyzed clinical features, TSH, FT4, FT3, TRAb, TPO antibodies. BMD of lumbar spine and hip was measured by DEXA and 10-year fracture risk was calculated with FRAX tool. Results The study showed significantly lower spine and femoral BMD (g/cm2) in patients with and without GO compared to controls, as well as significantly higher fracture risk. Comparison between hyperthyroid patients without and with orbitopathy found out significantly lower spine BMD in the first group (p = 0.0049). Negative correlations between FT3 and femoral neck BMD (p = 0.0001), between FT4 and BMD (p = 0.049) and positive between TSH and BMD (p = 0.0001), TRAb and BMD (p = 0.026) were observed. Fracture risk for major fractures and TRAb were negatively associated (p = 0.05). We found negative correlation of BMD to duration of thyrotoxicosis and cumulative steroid dose. Conclusions Our results confirm the negative effect of hyperthyroid status on BMD. TRAb, often in high titers in patients with GO, may have protective role for the bone, but further research is needed.

Descompresión orbitaria por vía endoscópica nasal en la orbitopatía tiroidea: nuestra experiencia / Endoscopic orbital decompression for the management of thyroid eye disease: our experience / Decompressão orbitaria por via nasal endoscópica na orbitopatia tírida: nossa experiência

INTRODUCCIÓN: La orbitopatía tiroidea es una de las manifestaciones extratiroideas más frecuentes de la enfermedad de graves. El diagnóstico es clínico y con estudios de imágenes. El tratamiento depende de la etapa en que se encuentre la enfermedad, pudiendo ser conservador o quirúrgico, siendo la descompresión orbitaria el pilar del tratamiento. OBJETIVOS: Describir la técnica quirúrgica y las complicaciones más frecuentes. Comprobar los beneficios en la reducción del exoftalmos, la mejoría de la agudeza visual y la descompresión del nervio óptico...

INTRODUCTION: Thyroid orbitopathy is one of the most frequent extra thyroid manifestations of Graves' disease. The diagnosis is clinical and with imaging studies. The treatment depends on the stage in which the disease is found; can be conservative or surgical, the orbital decompression is the pillar of the treatment. OBJECTIVES: Describe the surgical technique and the most frequent complications checking the benefits in the reduction of exophthalmos, the improvement of visual acuity and decompression of the optic nerve…

INTRODUÇÃO: A orbitopatia tireoidiana é uma das manifestações extra tireóides mais freqüentes da doença de graves. O diagnóstico é clínico e com estudos de imagem. O tratamento depende da fase em que a doença é encontrada; podendo ser conservador ou cirúrgico, sendo a descompressão orbital o pilar do tratamento. OBJETIVOS: Descreva a técnica cirúrgica e as complicações mais frequentes. Verificar os benefícios na redução do exoftalmos, a melhora da acuidade visual e descompressão do nervo óptico...

Related quality of life questionnaire specific to dysthyroid ophthalmopathy evaluated in a population of patients with Graves' disease

ABSTRACT Objective The aim of this study was to measure quality of life (QOL) impairment in individuals currently suffering from Graves' ophthalmopathy (GO) and to determine the correlation of GO-specific QOL scores with disease severity and activity. Subjects and methods Seventy three GO-specific QOL surveys were prospectively analysed and compared with GO status. The GO-specific QOL survey was translated into Spanish and applied to Argentine patients with Graves' disease (GD). Results were compared with presence or absence of GO, Clinical Activity Score (CAS), severity score, age, gender and thyroid function. Results Fifty-six patients answered the survey and underwent complete ophthalmic evaluation, 15 did not have GO and were considered to be a control group. Appearance QOL score for patients with GO (53 ± 31.4) was lower than the control group (88.3 ± 17) (p < 0,000), no difference was observed in functional QOL score. There was a negative correlation between GO severity and both functional (r = -0.575; p < 0.000) and appearance QOL (r = -0.577; p < 0.000). Functional QOL differed between patients with active GO vs control group (p = 0.043). Patients with active and inactive GO had lower appearance QOL scores than control group (p < 0.000, p < 0.001 respectively). Conclusions GO has significant impact on the life of these Argentine patients. QOL was worse in GO patients than in control group, functional QOL was mostly affected by the activity and appearance QOL was mainly altered by the effects of the disease. Patients with more severe GO had lower scores on both QOL scales.