High-dose intravenous steroid pulse therapy in thyroid-associated ophthalmopathy.
ABSTRACT To evaluate the efficacy of high-dose intravenous steroid pulse followed by oral steroids in the treatment of thyroid-associated ophthalmopathy, we performed clinical assessment and measurement of retroorbital muscle enlargement in 27 patients before and after the therapy, and followed them up longitudinally. The mean duration of follow up is (mean +/- SD) 29.8 +/- 23.8 months (range 4-92). Diplopia disappeared in 10 patients and ameliorated in 11 patients. The degree of proptosis decreased in 15 patients and the fall in visual acuity improved in a third of the patients. The total ophthalmopathy index (OI) decreased from 7.0 +/- 1.9 to 3.0 +/- 1.5. The extraocular muscle enlargement (EME), expressed as the maximal ratio of extraocular muscle thickness to the diameter of the optic nerve, decreased from 2.33 +/- 0.56 to 1.27 +/- 0.26. No major side effects were found in any patient. The improvement in the eye disease was found immediately after the pulse therapy, prior to the start of the following therapy by oral steroids and/or orbital irradiation. Both of OI and EME decreased with time after the therapy and did not get worse after withdrawing oral steroids. The efficacy of the therapy evaluated by degrees of improvement in OI and in EME was significantly greater in females than in males. Although there was a significant positive correlation between initial OI and EME values and initial TBII and TSAb activities, a significant correlation was seen only between the degrees of improvement in EME and changes in TBII activity due to the therapy. The duration of eye disease, thyroid status, treatment with anti-thyroid drug, smoking and experience of previous treatment did not affect the efficacy of the present therapy. We conclude that high-dose intravenous steroid pulse therapy is effective and safe for thyroid-associated ophthalmopathy.
Article: Endokrine Orbitopathie 1998[Show abstract] [Hide abstract]
ABSTRACT: □ HintergrundDie häufigste extrathyreoidale Manifestation der autoimmunen Thyreopathie ist die endokrine Orbitopathie. □ Klinisches BildDas Charakteristikum dieser Autoimmunerkrankung ist die entzündliche Volumenzunahme des peri- und retrobulbären Gewebes, die zur klinischen Symptomatik nichtinfiltrativer Lidaffektionen, Protrusio bulbi, Augenmuskelparesen und bis hin zum Visusverlust führen kann. Die pathologischen Veränderungen der endokrinen Orbitopathie sind gekennzeichnet durch immunologisch vermittelte Entzündungsreaktionen im Retrobulbärraum, in deren Verlaufes zur lymphozytären Infiltration und Einlagerung von Glykosaminoglykanen in das orbitale Muskel-, Binde- und Fettgewebe kommt. □ Diagnose und TherapieTrotz verschiedener neuer diagnostischer Möglichkeiten und therapeutischer Ansätze bietet das adäquate Vorgehen bei der enkokrinen Orbitopathie häufig Schwierigkeiten, vor allem bei rezidivierenden und schweren Verläufen. Mit neuen Erkenntnissen in der Pathogenese und weiteren klinischen Studien sind neue diagnostische und therapeutische Ansätze bei der Behandlung der endokrinen Orbitopathie entstanden. □ SchlußfolgerungEine interdisziplinäre Zusammenarbeit ist für eine effiziente Diagnostik, adäquate Therapie und eine kontinuierliche Nachsorge bei der endokrinen Orbitopathie von entscheidender Bedeutung. □ BackgroundOphthalmopathy is the most common extrathyroidal manifestation of Graves’ disease, also called thyroid-associated ophthalmopathy. □ ClinicsThis autoimmune disorder is characterized by a lymphocyte infiltration of the retrobulbar space. Activated T cells react with the target organ and secrete cytokines, leading to accumulation of glycosaminoglycans, interstitial edema of the peri- and retrobulbar tissue and enlargement of the extraocular muscles. During the inflammatory stage, the increased orbital pressure results in the clinical manifestation of the eye disease. □ Diagnosis and TreatmentThus, therapeutic immunosuppression is often used initially, and by suppressing inflammatory changes, it can result in subjective and objective improvement of the thyroid eye disease. In recent years, new pathogenetic aspects and clinical randomized trials led to modified therapy concepts. □ ConclusionInterdisciplinary management is recommended for rapid diagnosis and effective therapy of patients with thyroid-associated ophthalmopathy.93(6):365-373.
Article: Thyroid eye disease[Show abstract] [Hide abstract]
ABSTRACT: The treatment of thyroid eye disease is very complex, owing to the varied nature of the symptoms and the variable course of the disease. The first step in treatment should be achieving an euthyroid state or monitoring for the development of hyperthyroidism if the patient is euthyroid at presentation. The second step is local measures (artificial tears and ointment, cessation of smoking) along with careful visual follow-up (acuity, color vision, automated visual fields, fundus examination, ocular motility, and external examination) to assess for the development of optic neuropathy, proptosis, diplopia, and lid abnormalities. If external irritation or orbital discomfort cannot be managed with conservative local measures, then a trial of oral corticosteroids or orbital radiation can be considered. If optic neuropathy develops without proptosis, corticosteroids—starting with an intravenous course, then oral medication —should be used. If there is either an initial improvement in optic neuropathy with corticosteroids, but worsening with subsequent tapering of corticosteroids or no initial improvement, radiation treatment or orbital decompression can be done. If optic neuropathy develops with proptosis, corticosteroids—starting with an intravenous course, then oral medication—should be used for rapid visual improvement. Orbital decompression should then be done to resolve both the optic neuropathy and the proptosis. If for medical reasons the patient with optic neuropathy and proptosis is not a surgical candidate, then radiation treatment can be done, but there will be little change in the proptosis. Proptosis without optic neuropathy can be treated with orbital decompression both for cosmetic reasons and for comfort. Occasionally, this will also resolve lid retraction, and return the lids to an acceptable position in terms of cosmesis and corneal exposure. Diplopia is best treated initially with press-on prisms or patching. Once the disease is stable (ie, no variation in proptosis or change in ocular motility measurements for at least 6 months), eye muscle surgery can be planned. Eye muscle surgery should follow orbital decompression because there is a reasonable possibility that decompression will change ocular motility. If there is corneal exposure or unacceptable lid position and proptosis is not an issue, eyelid surgery, at times on both upper and lower lids, can be done. Eyelid surgery should follow eye muscle surgery because a change in eye position, particularly with vertical muscle surgery, can change eyelid position. Finally, the patient should be made aware at the time of diagnosis that there is unlikely to be a return to normal appearance (ie, appearance before the development of thyroid eye disease).Current Treatment Options in Neurology 04/2012; 2(5):401-405. · 1.94 Impact Factor
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ABSTRACT: Several trials have proved the efficacy of intravenous (IV) steroids in Graves' orbitopathy (GO). However, the impact of administered dose and therapy schedule has not been assessed yet. Nine randomized and 14 non-randomized controlled trials of IV steroids in GO were evaluated according to the applied single and cumulative doses with respect to outcome, efficacy on clinically relevant issues and adverse events. High single (1 g per day) and cumulative (>6 g) doses of IV steroids are superior to lower single (0.5 g/d) and cumulative (<5 g) doses with respect to therapy response (84 vs 75%; p=0.034 and 83 vs 77%; ns, respectively), improvement of eye symptoms (87 vs 75%, p=0.052 and 85 vs 71%; ns, respectively) and disappearance of diplopia (32 vs 27%; ns and 48 vs 27%; p=0.08, respectively). Decrease of both clinical activity score (3 vs 2.5 points and 2.5 vs 3, ns) as well as proptosis (-1.4 vs -1.2 mm, ns and 1.5 vs 1.2, ns) are similar in both groups. However, high single and/or cumulative doses are accompanied with a 2-fold higher rate of adverse events (56 vs 28%; p<0.001 and 52 vs 33%; p=0.034, respectively). Tailoring the IV steroid dose to severity of GO can be concluded and implies that a prospective randomized trial comparing different doses of IV steroids in active/severe GO is keenly warranted.Journal of endocrinological investigation 12/2011; 34(11):876-80. · 1.65 Impact Factor