Advances in treatment of active, moderate-to-severe Graves' ophthalmopathy.
Wiersinga Wilmar M
The lancet. Diabetes & endocrinology
Graves' ophthalmopathy is defined as autoimmune inflammation of extraocular muscles and orbital fat or connective tissue, usually in patients with Graves' disease. About one in 20 patients with Graves' hyperthyroidism has moderate-to-severe Graves' ophthalmopathy. Corticosteroids have been the mainstay of treatment, but new evidence about immune mechanisms has provided a basis to explore other drug classes. Intravenous methylprednisolone pulses are more effective and better tolerated than oral prednisone in the treatment of active, moderate-to-severe Graves' ophthalmopathy. Rituximab has also been suggested as a possible replacement for intravenous corticosteroids. Two randomised controlled trials of rituximab reached seemingly contradictory conclusions-rituximab was not better with respect to the primary outcome (clinical activity score) than placebo in one trial (which, however, was confounded by rather long Graves' ophthalmopathy duration), but was slightly better than intravenous methylprednisolone pulses in the other (disease flare-ups occurred only in the latter group). On the basis of evidence published so far, rituximab cannot replace intravenous methylprednisolone pulses, but could have a role in corticosteroid-resistant cases. Open-label studies of tumour-necrosis-factor-α blockade had limited efficacy, but other studies showed that interleukin-6 receptor antibodies were effective. Results of randomised controlled trials investigating the efficacy of the IGF-1 receptor antibody teprotumumab and the interleukin-6 receptor antibody tocilizumab are expected shortly. Approaches that target the causal mechanism of Graves' ophthalmopathy (antibodies or antagonists that block thyroid-stimulating-hormone receptors) also look promising.
10.1016/S2213-8587(16)30046-8
Using morphologic parameters of extraocular muscles for diagnosis and follow-up of Graves' ophthalmopathy: diameters, areas, or volumes?
Szucs-Farkas Zsolt,Toth Judit,Balazs Erzsebet,Galuska Laszlo,Burman Kenneth D,Karanyi Zsolt,Leovey Andras,Nagy Endre V
AJR. American journal of roentgenology
OBJECTIVE:The objective of this study was to find the most appropriate, accurate, and convenient muscle parameter that can be used as a substitute for volume in monitoring the effectiveness of therapy of patients with Graves' ophthalmopathy. SUBJECTS AND METHODS:The four rectus muscles in 110 orbits (35 patients and 20 control subjects) were evaluated with MR imaging. The diameter at the largest extent of the muscle belly, as well as the long and the short diameters and the cross-sectional areas in a preselected coronal scan, were measured for each muscle and were compared with the corresponding muscle volume measured on contiguous T1-weighted transverse slices. RESULTS:The measured coronal area correlated well with the volume of the superior (r = 0.694, p < 0.0001) and inferior (r = 0.783, p < 0.0001) recti, and the largest transverse diameter showed strong correlation with the volume of the lateral (r = 0.868, p < 0.0001) and medial (r = 0.869, p < 0.0001) recti. For the latter muscle, the coronal area also exhibited a good correlation with the volume (r = 0.838, p < 0.0001). Coronal cross-sectional areas can be well estimated by measuring both the short and long coronal muscle diameters (r values were between 0.914 and 0.966; p < 0.0001). CONCLUSION:In Graves' ophthalmopathy, the volume of three of the rectus muscles can be well estimated by simple measurements on a single coronal slice, and the largest transverse diameter of the lateral rectus is suitable for the same purpose.
10.2214/ajr.179.4.1791005
Computed Tomography-Based Prediction of Exophthalmos Reduction After Deep Lateral Orbital Wall Decompression for Graves' Orbitopathy.
Kitaguchi Yoshiyuki,Takahashi Yasuhiro,Kakizaki Hirohiko
Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie
PURPOSE:To examine the predictability of exophthalmos reduction using preoperative computed tomography (CT) in deep lateral orbital wall decompression for Graves' orbitopathy. METHODS:This was a retrospective, observational, case-control study conducted at a single institution. Forty-three patients (43 orbits) who were treated with deep lateral decompression with (27 patients) and without (16 patients) fat removal. Multivariate linear regression analyses were used to identify factors influencing exophthalmos reduction 3 months postoperatively. Variables investigated included age; smoking history; history of corticosteroid therapy and/or radiotherapy; preoperative diplopia; width, depth, and height of the greater wing of the sphenoid bone (trigone); and volume of fat removed. The influence of these parameters on the area of the orbital opening was also analyzed. RESULTS:Trigone width and amount of fat removed were positively correlated with exophthalmos reduction (both, P < .050); none of the other variables exhibited significant correlations. The predictive equation for postoperative reduction in Hertel exophthalmometric values was 0.57 + 0.15 × trigone width (mm) + 1.1 × fat removed (cm). Depth and height were positively correlated (both, P < .050) and width was negatively correlated (P = .0045) with orbital opening area. CONCLUSIONS:Trigone width and amount of fat removed were positive predictors of exophthalmos reduction after deep lateral decompression. Trigone width was inversely associated with orbital width, and results showed that larger exophthalmos reductions could be achieved in narrower orbits. This CT-based prediction method will assist preoperative decision-making regarding additional fat removal and/or removal of another orbital wall.
10.1007/s00417-019-04500-1
Imaging of the medial rectus muscle predicts the development of optic neuropathy in thyroid eye disease.
Scientific reports
Goal of the study was to evaluate bony orbit remodeling and extraocular muscle (EOM) volume in thyroid eye disease (TED) and their role as predicting factors for development of dysthyroid optic neuropathy (DON). Orbital computed tomography of 92 patients with TED with (76 orbits) or without DON (98 orbits) were retrospectively evaluated. Orbits (n = 40) of subjects without TED served as controls. Measurements of the bony orbit as well as EOM volume were incorporated into a generalized linear mixed model to predict DON. The angle of the medial orbital wall was significantly smaller (p < 0.001) in patients with TED (- 2.3 ± 3.6°) compared to patients with TED + DON (1.0 ± 4.1°). Both groups differed significantly from controls (- 4.2 ± 2.7°). Bowing of the medial orbital wall correlated positively with muscle volume (r = 0.564; p < 0.001). Total EOM volume was significantly larger in TED + DON (7.6 ± 2.5cm) compared to TED only (5.6 ± 3.0cm; p < 0.001) or controls (2.6 ± 0.5cm). Multivariate analysis revealed the medial rectus muscle volume (TED: 1.06 ± 0.48cm vs. TED + DON: 2.16 ± 0.84cm) as the strongest predictor, achieving a specifity of 86.7% and a sensitivity of 73.7% in diagnosing DON in univariate analysis. Though characterized by a wide range of variability, increased medial rectus muscle volume is the strongest predictor for DON in our patient cohort with TED when analyzing a single muscle.
10.1038/s41598-022-10043-z
Peribulbar injection of glucocorticoids for thyroid-associated ophthalmopathy and factors affecting therapeutic effectiveness: A retrospective cohort study of 386 cases.
Wang Yujiao,Du Baixue,Yang Mei,Zhu Yanyan,He Weimin
Experimental and therapeutic medicine
Thyroid-associated ophthalmopathy (TAO) is common in Graves' disease. However, to date, no standard treatment has been established for TAO. The present study aimed to assess peribulbar injection of corticosteroids for TAO treatment as well as factors affecting therapeutic effectiveness. A retrospective cohort study was performed at West China Hospital, Sichuan University (Chengdu, China). Patients with TAO were administered peribulbar injection of triamcinolone acetonide and dexamethasone monthly. Ocular signs after each injection were assessed until the end of treatment. All patients were followed up for at least six months. Best corrected visual acuity, proptosis values, eye motility assessed by the Hess chart, as well as eyelid width and downward movement were determined. In addition, clinical data were retrospectively reviewed to explore factors affecting therapeutic effectiveness by logistic regression analysis. In the present study, 386 patients with TAO (515 eyes) were evaluated; 71.37% of cases of eyelid swelling were relieved and upper eyelid retraction was improved in 47.58% of affected patients. Eye movement disorders, diplopia and strabismus were all alleviated to varying degrees, with few adverse reactions. Logistic regression analysis demonstrated that therapeutic effectiveness was relatively lower in males [odds ratio (OR)=0.32, P=0.001] and patients with thyroid dysfunction (OR=0.41, P=0.002), and that non-smokers had a higher odds of substantial improvement (OR=4.62, P=0.008). The duration of TAO was not significantly associated with the clinical outcome. Patients with reduced disease severity and elevated clinical activity score exhibited higher effectiveness (all P<0.05). In conclusion, peribulbar injection of corticosteroids is effective in treating mild to moderate TAO, with the therapeutic response affected by gender, smoking and disease severity.
10.3892/etm.2020.8896
Intraorbital Steroid Injection for Active Thyroid Ophthalmopathy.
Journal of ophthalmic & vision research
PURPOSE:To evaluate the effect of orbital steroid injections in patients with active thyroid ophthalmopathy resistant to or dependent on systemic steroids, or with complications related to systemic steroid use. METHODS:This prospective non-comparative case series includes 31 eyes of 17 patients with active thyroid ophthalmopathy and clinical activity score (CAS) of 3 or more, without compressive optic neuropathy or overt exposure keratopathy. All subjects had a history of previous systemic steroid use (with steroid resistance or dependence) or had developed complications related to steroids. A combination of steroids including triamcinolone acetonide 20 mg and dexamethasone 4 mg was injected in the upper and lower retroseptal orbital spaces three or four times at one-month intervals. The patients were examined periodically after each injection and at least three months after the last injection. RESULTS:Mean pre-injection CAS was 5.2 1.3 which was improved to 1.6 1 after the fourth injection ( 0.001). Upper and lower lid retraction improved in 100% and 68.2% of the affected eyes, respectively. Strabismus completely resolved in one of five affected patients and the most significant improvement was observed in supraduction. Mean improvement in exophthalmos was 1.2 1.1 mm. Visual acuity did not significantly change after the injections. Eyelid ecchymosis and/or subconjunctival hemorrhage was observed in 7.1% and intraocular pressure rise occurred in 8.8% of eyes. CONCLUSION:Orbital steroid injections can be used for the treatment of active thyroid ophthalmopathy when the patient is resistant to or dependent on systemic steroids or has developed complications of systemic steroids.
10.18502/jovr.v15i1.5948
Risk prediction of dysthyroid optic neuropathy based on CT imaging features combined the bony orbit with the soft tissue structures.
Frontiers in medicine
Purpose:To analyze computed tomographic (CT) imaging features of patients with dysthyroid optic neuropathy (DON) retrospectively and deduce a more appropriate predictive model. Methods:The CT scans and medical records of 60 patients with clinically proven Graves' ophthalmopathy (GO) with (26 women and 10 men) and without DON (16 women and 8 men) were retrospectively reviewed, and 20 age- and sex-matched control participants (12 women and 8 men) were enrolled consecutively. The bony orbit [orbital rim angle (ORA), medial and lateral orbital wall angles (MWA and LWA), orbital apex angle (OAA), and length of the lateral orbital wall (LWL)], and the soft tissue structures [maximum extraocular muscle diameters (Max EOMD), muscle diameter index (MDI), medial and lateral rectus bulk from inter-zygomatic line (MRIZL and LRIZL), proptosis, intraorbital optic nerve stretching length (IONSL), superior ophthalmic vein diameter (SOVD), apical crowding, and presence of intracranial fat prolapse] were assessed on a clinical workstation. The CT features among groups were compared, and a multivariate logistic regression analysis was performed to evaluate the predictive features of DON. Results:All bony orbital angle indicators, except ORA ( = 0.461), were statistically different among the three groups (all < 0.05). The values of MWA, LWA, OAA, and LWL were larger in the orbits with the DON group than in the orbits without the DON group (all < 0.05). The MDI, MRIZL, proptosis, IONSL, and SOVD were statistically significantly different among the three groups (all < 0.05), in which the orbits with the DON group were significantly higher than the orbits without the DON group and control group. The apical crowding was more severe in the orbits with the DON group than in the orbits without the DON group ( = 0.000). There were no significant differences in the LRIZL and the presence of intracranial fat prolapse (all > 0.05). The multivariate regression analysis showed that the MWA, MDI, and SOVD were the independent factors predictive of DON. The sensitivity and specificity for the presence of DON by combining these three indicators were 89 and 83%, respectively. Conclusion:Bone and soft tissue CT features are useful in the risk prediction of DON, especially the MWA, MDI, and SOVD were the independent factors predictive of DON.
10.3389/fmed.2022.936819
Graves ophthalmopathy: the bony orbit in optic neuropathy, its apical angular capacity, and impact on prediction of risk.
Chan L-L,Tan H-E,Fook-Chong S,Teo T-H,Lim L-H,Seah L-L
AJNR. American journal of neuroradiology
BACKGROUND AND PURPOSE:Optic neuropathy (ON), a serious complication of Graves ophthalmopathy, is often subclinical and masked by symptoms of orbitopathy. We examined herein bony and soft-tissue CT features associated with ON, including an angular assessment of orbital apex capacity, and their usefulness in the risk prediction of ON. MATERIALS AND METHODS:The CT scans of 41 patients with Graves ophthalmopathy (17 men, 24 women; mean age, 49.1 years) clinically diagnosed with (19 patients, 32 orbits) or without ON were evaluated by 2 independent raters. Quantitative linear and angular measurements of the orbital structures and bony walls and categoric scores of apical crowding and intracranial fat prolapse were assessed on a clinical workstation. Inter- and intrarater variability of these features was determined. The CT features of the 2 patient groups were compared, and multivariate logistic regression analysis was performed to evaluate the predictive features of ON. RESULTS:Bony orbital angles (P < .005), length of the lateral orbital wall (P < .05), muscular diameters (P < .0005), muscular bulk of the medial rectus muscle relative to the bony orbit (P < .05), and apical crowding (P < .0005) were associated with clinical ON. Stepwise multivariate logistic regression analysis revealed the muscle diameter index and medial and lateral wall angles to be independent predictors. Combining these in a single multivariate equation yielded sensitivity, specificity, and positive and negative predictive values of 73%, 90%, 82%, and 85%, respectively. CONCLUSIONS:Orbital wall angles, especially the medial wall, and muscular enlargement are independent risk predictors.
10.3174/ajnr.A1413
Orbital measurement in black and white populations.
Barretto R L,Mathog R H
The Laryngoscope
OBJECTIVE:Obtain measurements of globe projection, intercanthal distance (ICD), interpupillary distance (IPD), palpebral fissure width (PFW), and palpebral fissure height (PFH) in a population of presumably normal white and black adults to determine if any significant differences exist between these groups. STUDY DESIGN:Prospective direct measurement of cohorts regarding orbital and globe measurements in a tertiary medical center. METHODS:Measurements of globe projection, ICD, IPD, PFW, and PFH were taken in 61 black adults and directly compared with measures taken from 65 white adults in an outpatient setting. Mean values and ranges were calculated and compared between races and sexes using an unpaired t test. RESULTS:A significant difference was found between races for globe projection, with black males demonstrating a mean projection of 18.23+/-2.26 mm as compared with 17+/-2.65 mm for white males (P < .025). Black females demonstrated a mean projection of 17.27+/-1.44 mm as compared with 15.98+/-2.22 mm for white females (P < .01). Similar differences were seen for measures of IPD and PFW, with greater mean values for black as compared with white adults. No racial differences existed for ICD or PFH. CONCLUSIONS:These findings suggest that racial differences exist for certain measures of globe and orbital position, i.e., projection, IPD, and PFW. Racial background should be considered when evaluating orbital anatomy.
Measurement of orbital volume by computed tomography: especially on the growth of the orbit.
Furuta M
Japanese journal of ophthalmology
PURPOSE:Using reconstructed x-ray computed tomography (CT) images of serial coronal sections, we measured the orbital volume and studied its changes with age. METHODS:The subjects consisted of 109 patients (74 male, 35 female) who had undergone x-ray CT. After the reproducibility of orbital volume measurements and laterality in individuals were confirmed, the relation between the orbital volume and age, sex, weight, and interlateral orbital rim distance were examined. RESULTS:The difference between two measurements in the same patient stood at 0.4% for measured volume, which showed good reproducibility of this measurement. The laterality in individuals stood at 0.06 cm(3); the difference was very small and no significant difference was found. Moreover, the orbital volume did not show any imbalance between the right and left eyes in any stage of growth. Both the height and the interlateral orbital rim distance had a strong correlation with the orbital volume. CONCLUSION:Referring to the relation between age and orbital volume, a strong correlation with an almost identical approximate equation was obtained for both sexes until the age of 12. Presumably, the rapid growth of the orbit comes to an end by 15 years of age in boys and by 11 years in girls. This means that more than 95% of the growth of the adult orbit has already been completed by the first half of the teens. The mean orbital volume in adult Japanese is 23.6 +/- 2.0 cm(3) in men and 20.9 +/- 1.3 cm(3) in women.
10.1016/s0021-5155(01)00419-1
Quantitative computed tomographic predictors of compressive optic neuropathy in patients with thyroid orbitopathy: a volumetric analysis.
Weis Ezekiel,Heran Manraj K S,Jhamb Ashu,Chan Andy K,Chiu Jack P,Hurley Michael C,Rootman Jack
Ophthalmology
PURPOSE:To evaluate the relationship between orbital bony geometry and the volume of the intraorbital structures in predicting compressive dysthyroid optic neuropathy (DON). DESIGN:Retrospective, consecutive case series. PARTICIPANTS:Images of 198 orbits from 99 patients suffering from thyroid-related orbitopathy were reviewed. METHODS:Clinical examination and computed tomography of the orbits, including volumetric analysis, were performed on all patients. MAIN OUTCOME MEASURES:Clinical and radiologic predictors of DON. RESULTS:Significant volumetric univariate predictors of compressive optic neuropathy included medial rectus volume (P = 0.005), lateral rectus volume (P = 0.011), superior muscle group volume (P = 0.04), and total rectus muscle volume (P = 0.015). Inferior rectus muscle volume, orbital volume, bony orbital apex angle, globe diameter, and bony medial wall contour were not associated with optic neuropathy. Multivariate modeling found medial rectus volume the only independently significant predictor. Univariate modeling of simple rectus diameter measurements found medial rectus axial diameter (P = 0.003) and total recti diameter (P = 0.016) predictive of optic neuropathy. Lateral rectus, superior rectus, and inferior rectus diameters were not predictive. Multivariate modeling found only medial rectus diameter to be a significant independent predictor of optic neuropathy. The area under the receiver operating characteristic curve was not different between the volumetric and rectus diameter curves. CONCLUSIONS:Medial rectus size was found to be the most important quantifiable predictor of compressive optic neuropathy in patients with optic neuropathy. In this study, simple maximum medial rectus diameter, as measured on axial scans, was equally predictive of compressive optic neuropathy as the more involved volumetric calculation. Assessment of orbital geometry, including bowing of the medial wall, orbital apex angle, globe diameter, and orbital volume, were not found to be predictive of DON.
10.1016/j.ophtha.2012.04.021
Graves orbitopathy: correlation of CT and clinical findings.
Nugent R A,Belkin R I,Neigel J M,Rootman J,Robertson W D,Spinelli J,Graeb D A
Radiology
The clinical and high-resolution computed tomographic (CT) findings in 71 patients (142 orbits) with Graves orbitopathy and 20 healthy patients (40 orbits) were retrospectively reviewed. The orbits with orbitopathy were subgrouped at clinical examination into those with (n = 18) and those without (n = 124) optic neuropathy. Mean extraocular muscle diameters and the calculated muscle diameter index were significantly increased in all orbits with ophthalmopathy, particularly in those with optic neuropathy. Graves orbitopathy affected the superior muscle group (63.4%) more than the medial (61.3%) or inferior (57%) recti. The most common pattern of muscle involvement involved all five measured extraocular muscles. Solitary muscle involvement most frequently involved the superior muscle group (6.3%). Significant enlargements of the retrobulbar optic nerve sheath and superior ophthalmic vein were noted only in orbits with optic neuropathy. Anterior displacement of the lacrimal gland at CT correlated with clinical palpability and occurred more frequently in patients with optic neuropathy. Severe apical crowding was the most sensitive indication of optic neuropathy at CT.
10.1148/radiology.177.3.2243967
Clinical criteria for the assessment of disease activity in Graves' ophthalmopathy: a novel approach.
Mourits M P,Koornneef L,Wiersinga W M,Prummel M F,Berghout A,van der Gaag R
The British journal of ophthalmology
Patients with serious inflammatory Graves' ophthalmopathy should be treated with anti-inflammatory drugs or radiotherapy to prevent complications like fibrosis, while those with non-inflammatory ophthalmopathy may be treated by surgery immediately. It is often difficult, however, to distinguish inflammatory from non-inflammatory Graves' disease. We therefore present a simple clinical classification here to differentiate between these two conditions. This classification is based on the classical signs of inflammation--pain, redness, swelling, and impaired function. After two consecutive clinical examinations an 'activity score' can be determined, ranging from 0 to 10 points. In a retrospective study testing the efficacy of this classification we found that patients with an activity score of 3 or more at the beginning of therapy responded well to anti-inflammatory drugs, while those with a lower activity score mostly did not. Comparing the pretreatment activity score with the degree of enlargement of the extraocular muscles on the CT scan, we found a significant correlation between these two parameters: the higher the activity score, the more the enlargement of the muscles. We conclude that this classification facilitates the proper selection of patients for treatment.
10.1136/bjo.73.8.639
Consensus statement of the European group on Graves' orbitopathy (EUGOGO) on management of Graves' orbitopathy.
Bartalena Luigi,Baldeschi Lelio,Dickinson Alison J,Eckstein Anja,Kendall-Taylor Pat,Marcocci Claudio,Mourits Maarten P,Perros Petros,Boboridis Kostas,Boschi Antonella,Currò Nicola,Daumerie Chantal,Kahaly George J,Krassas Gerasimos,Lane Carol M,Lazarus John H,Marinò Michele,Nardi Marco,Neoh Christopher,Orgiazzi Jacques,Pearce Simon,Pinchera Aldo,Pitz Susanne,Salvi Mario,Sivelli Paolo,Stahl Matthias,von Arx Georg,Wiersinga Wilmar M
Thyroid : official journal of the American Thyroid Association
10.1089/thy.2007.0315
Prevalence and natural history of Graves' orbitopathy in the XXI century.
Piantanida E,Tanda M L,Lai A,Sassi L,Bartalena L
Journal of endocrinological investigation
Graves' orbitopathy (GO) is an autoimmune disorder and the main extrathyroidal expression of Graves' disease. There is a spectrum of ocular involvement in Graves' disease, from complete absence of symptoms and signs to sight-threatening conditions. The prevalence of GO varies in different published series of Graves' patients, due to confounding factors (new diagnosis vs long-lasting disease, way of defining and assessing ocular involvement, treatment of hyperthyroidism with potentially GO-modifying treatments, such as radioiodine). Recent studies, however, suggest that most Graves' patients have mild or no GO at presentation, while moderate-to-severe GO is rare, and sight-threatening GO (mostly due to dysthyroid optic neuropathy) is exceptional in non-tertiary referral centers. The natural course of GO is incompletely defined, particularly in patients with moderate- to-severe GO, because these patients require prompt and disease-modifying therapies for orbital disease. In patients with mild GO at presentation, progression to severe forms is rare, while partial or complete remission is frequent. Progression of pre-existing GO or de novo occurrence of GO is more likely in smokers. There seems to be a trend towards a decline in progression of GO, possibly due to a better control of risk factors (cigarette smoking, thyroid dysfunction, etc.) and a closer interaction between endocrinologists and ophthalmologists allowing an improved integrated management of thyroid and orbital disease.
10.3275/8937
Repeated peribulbar injections of triamcinolone acetonide: a successful and safe treatment for moderate to severe Graves' ophthalmopathy.
Bordaberry Marcela,Marques Daniela L,Pereira-Lima Julio C,Marcon Italo M,Schmid Helena
Acta ophthalmologica
PURPOSE:In this study, we aimed to evaluate the efficacy of peribulbar triamcinolone injections to treat inflammatory signs of Graves' ophthalmopathy (GO) in patients with moderate to severe GO and associated optic neuropathy (ON). METHODS:Twenty-one patients with active GO [clinical activity score (CAS) > or = 4] and systemic thyroid disease under control were enrolled in this prospective pilot study. Peribulbar triamcinolone acetonide was injected in each orbit (42 eyes), in four doses of 20 mg at 2-week intervals. Ophthalmological examination including CAS evaluation, visual field, computerized tomography (CT) scan and digital photography were performed before and after treatment. RESULTS:Twenty-one patients (11 with moderate disease, 10 with ON) were enrolled in this study and followed for at least 14 months. Initial mean CAS was 6.38 +/- 1.49, which dropped to 1.8 +/- 1.12 after 6 months of treatment (P = 0.01; mean difference of 4.57 +/- 1.56; range 1-8 score points). ON was diagnosed in 10 patients. Of these, 66% improved with peribulbar triamcinolone exclusively. A transitory increase in intraocular pressure in two patients was controlled with topic medication. CONCLUSION:Peribulbar triamcinolone injections reduce the inflammatory signs of moderate GO, as measured by the CAS, and could also be used as an alternative treatment for ON. Randomized clinical trials are needed to compare the results of triamcinolone peribulbar injections to those of other treatment modalities.
10.1111/j.1755-3768.2008.01171.x
Localization of local anesthetic solution by magnetic resonance imaging.
Niemi-Murola Leila,Krootila Kari,Kivisaari Riku,Kangasmäki Aki,Kivisaari Leena,Maunuksela Eeva-Liisa
Ophthalmology
PURPOSE:The aim of this study was to examine the distribution of local anesthetic solution by magnetic resonance imaging (MRI) after combined peribulbar and retrobulbar, superomedial retrobulbar, and sub-Tenon's injection in relation to clinical akinesia. DESIGN:Randomized clinical trial. PARTICIPANTS:Fifteen patients scheduled for cataract surgery, 5 patients in each group. METHODS:Five patients received combined peribulbar and retrobulbar anesthesia, 5 patients received superomedial retrobulbar injection, and 5 patients had sub-Tenon's injection, all with a combination of bupivacaine 0.75%, lidocaine 2%, and hyaluronidase. The MRI scans were performed before the injection and up to 35 minutes after the injection. RESULTS AND CONCLUSIONS:Reliable anesthesia is achieved using a combined peribulbar and retrobulbar block and a relatively great volume of local anesthetic solution, which spreads throughout the orbit, as evidenced by MRI. After superomedial retrobulbar and sub-Tenon's injection, the local anesthetic solution accumulates behind the globe. Sub-Tenon's injection gives good analgesia and slight akinesia with a very small volume. Superomedial retrobulbar injection and combined peribulbar and retrobulbar block provide a similar degree of exophthalmos, which seems to be the result of the volume injected behind the globe.
10.1016/j.ophtha.2003.05.026
Comparison of retrobulbar and periocular injections of lignocaine by computerised tomography.
Ropo A,Nikki P,Ruusuvaara P,Kivisaari L
The British journal of ophthalmology
Ten patients undergoing cataract surgery were given a local anaesthetic with lignocaine solution which was mixed with iohexol contrast medium. The location of the needle and the substance injected was determined by computerised tomography following retrobulbar or periocular anaesthesia. The retrobulbarly inserted needles were within the muscle cone, directed towards the optic foramen. The periocular needles were outside the muscle cone, tangentially along the orbital floor or pointing slightly upwards. After the retrobulbar injection the contrast medium was seen within the cone immediately after the injection and outside the cone as early as 3 minutes after the injection. With the periocular technique, however, diffusion of the anaesthetic in the opposite direction (that is, into the muscle cone) was rapid. The contrast medium was identified inside the muscle cone 2 minutes after the injection. Compression with an intraocular pressure reduction device after both of these techniques prevented exophthalmos. It is concluded that retrobulbar-like anaesthesia can also be induced by an appropriate periocular technique.
10.1136/bjo.75.7.417
Ultrasonic localization of anesthetic fluid in sub-Tenon's, peribulbar, and retrobulbar techniques.
Winder S,Walker S B,Atta H R
Journal of cataract and refractive surgery
PURPOSE:To determine the distribution of anesthetic fluid during 3 regional anesthetic techniques routinely used for phacoemulsification. METHODS:Patients having routine cataract extraction by phacoemulsification were studied after informed consent had been obtained. B-scan ultrasonography was performed on the eye before administration of the anesthetic agent. Kinetic echography was used to scan the eye during administration of the anesthesia to show the needle position and location of fluid in the orbit during the injection. Ten minutes after injection, another scan was performed to outline the pattern of fluid distribution. RESULTS:In all patients, the needle and the anesthetic fluid were seen on ultrasonography, with sub-Tenon's the most easily seen. In the sub-Tenon's group, fluid tracked behind the globe in the retrobulbar space, appearing as a dark outline during the injection. The fluid around the optic nerve developed a characteristic T sign. In the retrobulbar technique, the needle was less easily identifiable and fluid localized within the cone. The fluid distributed in the intraconal fat. Identification of the peribulbar needle and fluid was also more difficult; the fluid was, however, seen in the extraconal fat. After 10 minutes, fluid was seen within the cone. CONCLUSION:B-scan ultrasonography was a suitable method of identifying the needle position and the distribution of anesthetic fluid in regional ocular anesthesia. The sub-Tenon's technique appears to be the safest method of introducing anesthetic fluid into the retrobulbar space without the potential complications of sharp-needle techniques.
Orbital steroid injection versus oral steroid therapy in management of thyroid-related ophthalmopathy.
Alkawas Ayman A,Hussein Atef M,Shahien Ezzat A
Clinical & experimental ophthalmology
BACKGROUND: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. METHODS: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. RESULTS: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. CONCLUSION:Orbital steroid injection for thyroid-related ophthalmopathy is effective and safe. It eliminates the adverse reactions associated with oral corticosteroid use.
10.1111/j.1442-9071.2010.02332.x
Treatment of thyroid associated ophthalmopathy with periocular injections of triamcinolone.
The British journal of ophthalmology
AIM:To evaluate the efficacy of periocular triamcinolone acetonide for the treatment of thyroid associated ophthalmopathy (TAO), and the presence of ocular or systemic adverse effects. METHODS:A multicentre prospective pilot study was performed on patients diagnosed with Graves' ophthalmopathy less than 6 months before entry to the study. Patients were admitted to the study and were randomised into two groups: treatment and control. The treatment group received four doses of 20 mg of triamcinolone acetate 40 mg/ml in a peribulbar injection to the inferolateral orbital quadrant. Both groups were evaluated by measuring the area of binocular vision without diplopia on a Goldmann perimeter and the size of the extraocular muscles on computed tomography (CT) scans. Ophthalmological and systemic examinations were done to rule out ocular and systemic adverse effects. Follow up was 6 months for both groups. RESULTS:50 patients were eligible for the study. 41 patients completed the study. There was an increase in the area of binocular vision without diplopia in the treatment group (Sigma initial: mean 231.1 (SD 99.9) and final absolute change, mean 107.1 (SD 129.0)) compared to the control group (Sigma initial: mean 350.7 (SD 86.5) and final absolute change, mean -4.5 (SD 67.6)). The sizes of the extraocular muscles were reduced in the treatment group (mean (inferior rectus initial values): 1.3 (0.7), final percentage change: -13.2 (25.7), medial rectus initial values: 1.2 (0.6), final percentage change: -8.2 (20.7), superior rectus-levator palpebrae initial values: 1.2 (0.6), final percentage change: -9.5 (29.1), lateral rectus initial values: 1.0 (0.4), final percentage change: -11.5 (20.6)) compared to the control group (inferior rectus initial values: 0.9 (0.3), final percentage change: -4.0 (21.5), medial rectus initial values: 0.9 (0.3), final percentage change: 0.6 (22.4), superior rectus-levator palpebrae initial values: 0.9 (0.3), final percentage change: 12.5 (37.5), lateral rectus initial values: 0.9 (0.4), final percentage change: -0.5 (31.6)). Both measurements (degree of diplopia and muscle thickness) were statistically significant between groups (initial - final). No systemic or ocular adverse effects were found. CONCLUSIONS:Triamcinolone administered as a periocular injection is effective in reducing diplopia and the sizes of extraocular muscles in TAO ophthalmopathy of recent onset. This form of treatment is not associated with systemic or ocular side effects.
10.1136/bjo.2004.046193
MiRNA-21 promotes fibrosis in orbital fibroblasts from thyroid-associated ophthalmopathy.
Tong Bo-ding,Xiao Man-Yi,Zeng Jie-Xi,Xiong Wei
Molecular vision
PURPOSE:This study aimed to determine the role of miR-21 in orbital fibroblasts obtained from donors with thyroid-associated ophthalmopathy (TAO) and to elucidate the regulation of fibrosis by miR-21 in the pathological process of TAO. METHODS:The expression of miR-21 was investigated in orbital tissues from 26 donors with TAO and 10 donors without TAO. Human orbital fibroblasts were cultivated from TAO donors, and the role of miR-21 in orbital fibroblast proliferation, apoptosis, and differentiation was analyzed. Moreover, the effect of transforming growth factor-beta1 (TGF-β1) on miR-21 expression was also analyzed. In addition, the regulation of miR-21 in TGF-β1-induced collagen production was determined. RESULTS:The expression of miR-21 in orbital fibroblasts from TAO was higher than in donors without TAO. Additional experiments demonstrated that miR-21 enhanced proliferation, decreased apoptosis, and promoted differentiation in TAO orbital fibroblasts. Moreover, this study also showed that TGF-β1 induced miR-21 expression in a time- and dose-dependent manner and miR-21 promoted collagen I mRNA expression and total collagen production induced by TGF-β1. Additionally, miR-21 activated the TGF-β1/Smad signaling pathway by enhancing Smad3 phosphorylation. CONCLUSIONS:The present study shows that miR-21 regulates cell proliferation, apoptosis, and differentiation in orbital fibroblasts from TAO, and acts as a mediator in TGF-β1-induced collagen production. These data predict a close association between miR-21 and orbital muscle fibrosis, and provide a novel therapeutic target for TAO.
Evaluating Graves' orbitopathy.
Dolman Peter J
Best practice & research. Clinical endocrinology & metabolism
Graves' Orbitopathy (GO) is an immune-mediated disorder causing inflammation and expansion of orbital fat and muscle. The resulting spectrum of ocular and orbital changes may cause significant visual and cosmetic morbidity and are graded as disease severity. The disease follows a biphasic course with an active or progressive phase followed by a quiescent or stable phase: the temporal status is graded as disease activity. Grading systems for GO include Werner's NO SPECS and European Group on Graves' Orbitopathy (EUGOGO)'s severity scales, the Clinical Activity Score (CAS) and the VISA Classification (for severity and activity). Diagnosis of GO is based on recognition of clinical features and may be supported by thyroid function and immune testing, and orbital imaging. The endocrinologist or internist may play an important role in early recognition and diagnosis of GO, in grading severity and activity, and in arranging appropriate referral to an ophthalmologist based on this evaluation.
10.1016/j.beem.2011.11.007
Thyroid eye disease.
Scott I U,Siatkowski M R
Seminars in ophthalmology
Thyroid eye disease is the most common cause of unilateral and bilateral proptosis in adults. It occurs most frequently in women aged 30 to 50 years. Clinical features include eyelid retraction, periorbital edema, conjunctival injection and chemosis, proptosis, extraocular muscle restriction, exposure keratopathy, and optic nerve compromise. Thyroid eye disease differs from idiopathic orbital myositis in that the latter is characterized by a more acute onset, more severe pain, and a rapid response to systemic corticosteroid therapy. Echography and computed tomography in thyroid eye disease reveal enlarged extraocular muscle bellies with relative sparing of the tendons. Despite evidence of an immune-mediated cause, the precise pathophysiologic mechanisms of thyroid eye disease remain unknown.
10.3109/08820539909056064