Controversies in the clinical evaluation of active thyroid‐associated orbitopathy: use of a detailed protocol with comparative photographs for objective assessment

Abstract

SummaryDespite many learned publications over recent decades, the assessment of active thyroid-associated orbitopathy (TAO) remains difficult and controversial. There are no biochemical, immunological or imaging investigations which can identify active disease reliably, and clinical assessment is still of paramount importance. We therefore review the strengths and weaknesses of all methods of clinical assessment. A new atlas for clinical assessment of soft tissue signs has been developed, and its reproducibility assessed. It details a suggested protocol that could help standardize descriptions of TAO and allow more objective assessment of its activity and severity. This is relevant to general endocrinologists, who have a crucial role in the identification of patients who require ophthalmological assessment. Certain aspects are more relevant to ophthalmologists and endocrinologists who have a special clinical and research interest in TAO. Unless a reproducible system of assessment is devised and widely adopted, it will remain difficult to interpret research meaningfully, particularly if results appear to contradict.

Disease Activity in Graves' Ophthalmopathy: Diagnosis with Orbital MR Imaging and Correlation with Clinical Score

“…Patients with other orbit diseases such as trauma, optic neuropathy, other inflammatory diseases of unknown origin, previous orbital radiotherapy or surgery, previous immunosuppressive treatments with steroids and antithyroid treatment for more than 12 weeks before MR examination resolves [5][6][7] . Moreover, in Mourits et al's study, many patients with a CAS of 1 or 2 showed a significant response to immunosuppressive treatment 8,7 , and the CAS cut-off value of 3, as stated by European Groups, did not prove suitable for the Asian population [5][6][7] . So there is no exact correspondence between CAS alone and the real clinical condition of GO.…”

Multi-center study on the characteristics and treatment strategies of patients with Graves' orbitopathy: the first European Group on Graves' Orbitopathy experience

“…For all NOSPECS (7) categories at least one assessment was selected. NOSPECS class 2 (soft tissue involvement) was assessed using the color atlas (6). In addition, the lid aperture (in mm) was measured at the midline in primary gaze.…”

Orbital magnetic resonance imaging combined with clinical activity score can improve the sensitivity of detection of disease activity and prediction of response to immunosuppressive therapy for Graves' ophthalmopathy

“…ing, whereby improvement of any individual feature does not alter the score unless it completely resolves [3]. Furthermore, there is no evidence that the cutoff value of CAS, 3 points or over, is appropriate for the Asian population whose facial features tend to be less sculptured.…”