Clinical assessment of thyroid related orbitopathy: a review.

This review follows the process of evaluation of thyroid related orbitopathy (TRO) patients from diagnosis to treatment decision. We will attempt to define the criteria for referring TRO patients to the ophthalmologist and establish a common basis for orbital examination and TRO patient assessment. This should help classify TRO patients and achieve the best treatment regime. Thyroid related orbitopathy (TRO) is an endocrine disorder with orbital manifestations. Though most patients are first seen by an endocrinologist because of thyroid function disturbance symptoms, approximately 10% will first be seen by an ophthalmologist due to orbitopathy symptoms and signs (1). In the majority of cases the time interval between the appearance of dysthyroid symptomatology and orbital signs is less than a year. Among patients with thyroid endocrine dysfunction, 25% to 50% will gradually develop TRO. Most will have mild orbital manifestations, 28% will develop moderate to severe signs and only 3-5% will have the severe form (2). In this review we will follow the TRO patient through his first steps in the orbital clinic and emphasize the importance of clinical assessment as a crucial phase in determining the appropriate therapeutic approach.

Graves' orbitopathy in a patient with adrenoleukodystrophy after bone marrow transplantation.

OBJECTIVE: For many years, the treatment of X-linked childhood cerebral adrenoleukodystrophy (XALD) consisted of hydrocortisone replacement and a mixture of short chain-fatty acids, known as 'Lorenzo's oil'. Recently, bone marrow transplantation (BMT) has also been used. CASE REPORT: We report the case of a patient affected by XALD who developed Graves' hyperthyroidism (GH) and Graves' orbitopathy (GO) after BMT and who we could follow-up for 6.5 years afterwards. EVIDENCE SYNTHESIS: A boy affected by XALD was treated at the age of 6 years, with a whole BMT from his sister. One year after BMT, the transplanted patient presented TSH at the lower normal value and 3 years later he developed thyrotoxicosis. After a further 2 years, the patient developed GO, which showed clinical evidence of reactivation 5 years after its onset as a consequence of an attempt to treat thyrotoxicosis by means of I(131) (300 MBq). Seven years after BMT, the donor showed alterations of thyroid autoimmunity and 1 year thereafter she developed GH. She never presented GO during a subsequent 5 year follow-up. CONCLUSIONS: This case illustrates that autoimmunity originating from a pre-symptomatic donor can be transferred into the host during allogeneic stem cell transplantation. In cases where autoimmune phenomena are recognized in the donor prior to donation, alternative donors or T-cell manipulation of the graft might be considered.

Favorable effects of lacrimal plugs in patients with an anophthalmic socket.

BACKGROUND: The use of punctal plugs in the treatment of dry eyes is well established. Anophthalmic patients have less tears in the anophthalmic socket in comparison to their normal side, due to an absent corneal reflex (Lee & Elsie, 1981a,b). Many of those patients complain of dry eye symptoms, even when they are treated with tear replacement therapy. The authors wished to examine whether they could improve their dry socket complaints with punctal plugs. PURPOSE: To evaluate the clinical efficacy and tolerability of punctal plug (Smart Plugs) insertion in anophthalmic patients with symptoms of dry eye. PATIENTS AND METHODS: Interventional case series. Fifteen anophthalmic patients with dry eye symptoms, a Schirmer test of less than 3 mm and an open lacrimal passage were examined before and after insertion of punctal plugs. The patients were asked for their subjective evaluation of the treatment and were examined to evaluate the change. Schirmer tests were compared. Bacterial cultures were taken at both visits. RESULTS: Schirmer results of less than 3 mm in the anophthalmic socket were obtained in 75% of patients with dry eyes symptoms; 87% of patients in whom punctal plugs were inserted reported an improvement in dry eye sensation. More than half of the patients demonstrated less discharge (p < or = 0.05). Schirmer tests improved from 1.4 mm to 1.9 mm (p < or = 0.05). Patients with a Schirmer outcome of 2 mm or more tended to have less pathogenic bacterial cultures (p = 0.11). CONCLUSION: Punctal plugs improve the symptoms and signs of dry socket. Punctal plugs seem to reduce the pathogenic bacterial growth in the anophthalmic socket.