New insights into the pathogenesis and nonsurgical management of Graves orbitopathy

Abstract

Graves' orbitopathy, also known as thyroid eye disease or thyroid-associated orbitopathy, is visually disabling, cosmetically disfiguring and has a substantial negative impact on a patients' quality of life. There is increasing awareness of the need for early diagnosis and rapid specialist input from endocrinologists and ophthalmologists. Glucocorticoids are the mainstay of treatment; however, recurrence occurs frequently once these are withdrawn. Furthermore, in >60% of cases, normal orbital anatomy is not restored, and skilled rehabilitative surgery is required to reduce disfigurement, double vision and occasionally, to preserve vision. Clinical trials from over the past decade [Au: edits to define "recent" OK? Please edit my changes if I have misunderstood you This is fine] have shown that considerable benefit can be derived from the addition of anti-proliferative agents (such as mycophenolate or azathioprine) in preventing deterioration after steroid cessation. In addition, targeted biologic therapies have shown promise, including teprotumumab (anti-IGF-1R), which seems to substantially reduce proptosis, rituximab (anti-CD20), which reduces inflammation, and tocilizumab, which potentially benefits both of these parameters. Other strategies such as orbital radiotherapy have had their widespread role in combination therapy called into question. In the last decade, the pathophysiology of Graves' orbitopathy has also been revised with identification of new potential therapeutic targets. In this review we provide an up-to-date overview of the field, [Au: addition of linking text OK? This is fine] outline the optimal management of Graves' orbitopathy and summarise the research developments in this area to highlight future research questions and direct future clinical trials.

Histopathologic study of extraocular muscles in thyroid-associated ophthalmopathy coexisting with ocular myasthenia gravis: a case report

“…Previous studies have unveiled several histopathologic features of extraocular muscles in TAO and in OMG patients. In TAO, the extraocular muscles are characterized by lymphocytic infiltration, myofiber hypertrophy, hyaluronan accumulation, and deposition of collagen fibrils [11]. Our findings in the TAO samples are consistent with these typical changes.…”

Recomendaciones para el manejo del paciente con enfermedad tiroidea en el escenario de contingencia por COVID-19

“…Algunos pacientes con oftalmopatía tiroidea llevan tratamiento con glucocorticoides a dosis que inhiben el sistema inmunitario o con otros fármacos inmunosupresores, como micofenolato, rituximab, tocilizumab, metotrexato o azatioprina; el uso de estos medicamentos conlleva incremento del riesgo de infecciones 21,22 .…”

Shining a light on thyroid eye disease

“…TED is a rare autoimmune condition that predominantly affects women, in whom the cosmetic effects have at least the same negative effect on quality of life as vision disturbance 1 . A major strength of the study is that recruitment at 13 sites enabled the required number of patients to be randomized in less than a year.…”

“…Current TED treatment depends on whether the disease is mild, moderate to severe or sight threatening. Sight-threatening TED is due to compression of the optic nerve, occurs in <5% of patients and requires immediate surgical decompression 1 . In all patients with TED, restoring and maintaining euthyroidism should be a priority and smokers should be advised to stop smoking.…”

“…In moderate to severe disease the anti-inflammatory actions of intravenous glucocorticoids improve most of the signs and symptoms; however, relapse upon withdrawal is common but can be mitigated by the addition of an anti-proliferative such as mycophenolate 10 . Immunologics, such as tocilizumab (an anti-IL6 receptor) and rituximab (an anti-CD20 that depletes B cells) and orbital radiotherapy have all been trialled with varying success 1 . Even when a stable inactive disease phase is reached, most people with TED require rehabilitative surgery, for example to improve cosmetic appearance and correct squint, the whole process requiring several years to complete.…”