Planning health care for patients with Graves' orbitopathy.

BACKGROUND: To describe disease parameters of patients with Graves' orbitopathy in a tertiary referral center in order to plan health care resource allocations. To investigate whether the clinical activity and/or the severity of the disease can be used as a predictor of the duration of treatment. METHODS: Retrospective, observational, non-comparative case series. One hundred and seventeen charts of GO-patients, randomly chosen out of a pool of 1600, referred to the Orbital Unit of the University Medical Centre Utrecht between 1 January 1992 and 1 January 2002, were analysed. Relevant parameters, such as age, gender, race, disease duration, smoking habits, concomitant diseases, previous treatment, symptoms and signs, number and sort of investigations, severity and activity scores, number and sort of treatments, treatment duration and outcome of treatment were retrieved and analysed. Disease activity and severity at entry were tested as possible predictors of disease duration and extent of treatment. RESULTS: Clinical profile at presentation; duration of the disease; extent of treatment; predictors of disease duration and of number of treatment interventions were the main outcome measures. Three percent of patients had Only Signs, but No Symptoms (OSNS), 61% had mild, 27% had moderately severe and 9% had severe GO. Fifteen percent had inactive disease at presentation, 65% had borderline activity and only 20% had active orbitopathy. Sixty percent complained about eyelid swelling and/or proptosis. The average period of eye treatment was 2.5 years (range: 0-110 months), during which patients were seen at an average of 8 times. Twenty percent needed no treatment at all. Fifteen percent were treated with nothing but lubricants and/or prisms. Twenty-five percent were treated with immunosuppressive modalities. Fifty-six percent underwent one or more surgical corrections. The Clinical Activity Score (CAS) was found to be significantly related to the duration of the treatment (p < 0.001), to the number of visits (p < 0.001), and to the number of surgical interventions (p < 0.001). CONCLUSIONS: The majority of GO patients referred to a tertiary referral centre has no or borderline disease activity and 'mild' orbitopathy, disfiguring eyelids and proptosis being the most frequent complaints. The disease activity as assessed with the CAS can be used to predict the duration and extent of the treatment.

Methylprednisolone pulse therapy for patients with moderately severe Graves' orbitopathy: a prospective, randomized, placebo-controlled study.

OBJECTIVE: To assess whether methylprednisolone (MP) pulse therapy is efficacious in the treatment of moderately severe Graves' orbitopathy (GO). DESIGN: Prospective, placebo (PL)-controlled, double-blind, randomized study. METHODS: Fifteen previously untreated patients with active, moderately severe GO participated in the study; 6 patients received MP and 9 patients a PL. Moderately severe disease was defined using the NOSPECS classification of clinical signs of GO . Activity was measured with the clinical activity score (CAS). A dose of 500 mg MP or only solvent was administered intravenously, over three consecutive days, in four cycles at 4 weekly intervals (6 g of MP in total). Qualitatively, a successful treatment outcome was defined as an improvement in one major and/or two minor criteria in the worst eye at week 48. The major criteria were: improvement in diplopia grade; improvement in eye movement; a decrease in CAS of three points. The minor criteria were: decrease of eyelid retraction; decrease of proptosis; improvement in grade of soft tissue swelling; a decrease in CAS of two points. RESULTS: The qualitative treatment outcome was successful at the end of the trial in five out of six (83%) patients receiving MP and in one out of nine (11%) patients given the PL (relative risk=7.5; (95% confidence interval 1.1-49.3), P=0.005). The treatment was well tolerated. CONCLUSIONS: In spite of the small number of patients, a significant difference in outcome was observed between MP- and PL-treated patients. We conclude that MP pulse therapy appears to be an effective treatment for active, moderately severe GO.

Coronal or swinging eyelid decompression for patients with disfiguring proptosis in Graves' orbitopathy? Comparison of results in one center.

PURPOSE: To compare 2 different approaches for 3-wall orbital decompression in patients with disfiguring proptosis due to Graves' orbitopathy, and to determine which technique is preferable. DESIGN: Retrospective nonrandomized study with a concurrent comparison group. PARTICIPANTS: Charts of 74 consecutive patients with disfiguring proptosis due to Graves' orbitopathy who underwent coronal (46) or swinging eyelid (28) decompression between January 1, 2000 and January 1, 2004 were studied retrospectively. Patients with dysthyroid optic neuropathy were excluded. METHODS: We analyzed the following parameters: proptosis reduction, ocular motility, number of additional operations, number and kind of complications, patients' satisfaction, patients' estimation of numbness or abnormal sensations in the field of operation and surgical scars, and duration of hospitalization time. MAIN OUTCOME MEASURES: Reduction of proptosis, changes in eye motility, and duration of hospitalization. RESULTS: Mean proptosis reductions were 4.8 mm (range, 1-11) after coronal decompression and 5.6 mm (range, 0-8) after swinging eyelid decompression (P = 0.025). Patients who were operated by the swinging eyelid approach had no more deteriorated motility and a shorter hospitalization time. Complications were seen rarely. Both groups of patients showed high satisfaction scores. CONCLUSION: Relative to the coronal approach, swinging eyelid decompression results in at least the same proptosis reduction, no greater motility disturbance, and a shorter hospitalization time.

Methylprednisolone pulse therapy for patients with dysthyroid optic neuropathy.

purpose 1) To test the short- and long-term efficacy of Methylprednisolone Pulse Therapy (MPT) for patients with Dysthyroid Optic Neuropathy (DON). 2) To assess possible side-effects of MPT. 3) To assess whether a delay in decompressive surgery would influence the visual outcome. study design Retrospective, uncontrolled. method The records of 62 consecutive patients with DON, who received MPT between 1994 and 2000, were evaluated with special attention for pre- and post treatment ophthalmic and orthoptic parameters, Clinical Activity Score (CAS), visual fields and visual evoked potentials, and treatment complications. DON-patients were hospitalized and received four times 500 mg methylprednisolone intravenously. Immediately afterwards they were treated with oral prednisone (maximal dose 60 mg) and/or orbital irradiation (10 times 2 Gy). Evaluation was done one day after the last bolus (T1) and when the orbitopathy had been stable for at least six months (T2). results Visual acuity, proptosis, elevation and CAS all improved significantly at T1, whereas the lid aperture did not change. At T2, 24 out 62 (39%) DON-patients were stable with normal vision. The other 38 (61%) had undergone orbital decompression because of persistent or recurrent DON within one week to six months after MPT. Final visual acuity in the whole group (121 eyes) was less than 0.1 in 3 eyes, between 0.1 and 0.5 in 17 and more than 0.5 in 101 eyes. Treatment complications were: pylorus ulcer (n = 1), increased osteoporosis (n = 1), abcess formation (n = 1), and increase in insulin dosage (n = 1). conclusions 1) MPT is efficious as emergency treatment. 2) One-third of DON-patients are spared decompressive surgery. 3) MPT causes only rare and no serious side-effects. 4) The final visual outcome after MPT and orbital decompression is comparable to the results of immediate decompression.