Christopher Neoh

Consensus statement of the European Group on Graves' orbitopathy (EUGOGO) on management of GO

Summary of consensus a. All patients with GO should (Fig. 1):Be referred to specialist centers;Be encouraged to quit smoking;Receive prompt treatment in order to restore andmaintain euthyroidism.b. Patients with sight-threatening GO should be treatedwith i.v. GCs as the first-line treatment; if the responseis poor after 1–2 weeks, they should be submitted tourgent surgical decompression.c. The treatment of choice for moderate-to-severe GO isi.v. GCs (with or without OR) if the orbitopathy isactive;surgery(orbitaldecompression,squintsurgery,and/or eyelid surgery in this order) should beconsidered if the orbitopathy is inactive.d. In patients with mild GO, local measures and anexpectant strategy are sufficient in most cases, buttreatment may be justified if QoL is affectedsignificantly. In memoriam This document is dedicated to the memory of MarkPrummel (1956–2005), one of the founders ofEUGOGO, who greatly contributed to expanding ourunderstanding of clinical and therapeutic aspects of GO.

Consensus statement of the European group on Graves' orbitopathy (EUGOGO) on management of Graves' orbitopathy.

Luigi Bartalena, Lelio Baldeschi, Alison J. Dickinson, Anja Eckstein, Pat Kendall-Taylor, Claudio Marcocci, Maarten P. Mourits, Petros Perros, Kostas Boboridis, Antonella Boschi, Nicola Curro, Chantal Daumerie, George J. Kahaly, Gerasimos Krassas, Carol M. Lane, John H. Lazarus, Michele Marino, Marco Nardi, Christopher Neoh, Jacques Orgiazzi, Simon Pearce, Aldo Pinchera, Susanne Pitz, Mario Salvi, Paolo Sivelli, Matthias Stahl, Georg von Arx, and Wilmar M. Wiersinga

Clinical Features of Dysthyroid Optic Neuropathy: A European Group on Graves Orbitopathy (EUGOGO) Survey

Background: This study was performed to determine clinical features of dysthyroid optic neuropathy (DON) across Europe. Methods: Forty seven patients with DON presented to seven European centres during one year. Local protocols for thyroid status, ophthalmic examination and further investigation were used. Each eye was classified as having definite, equivocal, or no DON. Results: Graves’ hyperthyroidism occurred in the majority; 20% had received radioiodine. Of 94 eyes, 55 had definite and 17 equivocal DON. Median Clinical Activity Score was 4/7 but 25% scored 3 or less, indicating severe inflammation was not essential. Best corrected visual acuity was 6/9 (Snellen) or worse in 75% of DON eyes. Colour vision was reduced in 33 eyes, of which all but one had DON. Half of the DON eyes had normal optic disc appearance. In DON eyes proptosis was > 21 mm (significant) in 66% and visual fields abnormal in 71%. Orbital imaging showed apical muscle crowding in 88% of DON patients. Optic nerve stretch and fat prolapse were infrequently reported. Conclusion: Patients with DON may not have severe proptosis and orbital inflammation. Optic disc swelling, impaired colour vision and radiological evidence of apical optic nerve compression are the most useful clinical features in this series.

Outcome of orbital decompression for disfiguring proptosis in patients with Graves' orbitopathy using various surgical procedures

Aim: To compare the outcome of various surgical approaches of orbital decompression in patients with Graves’ orbitopathy (GO) receiving surgery for disfiguring proptosis. Method: Data forms and questionnaires from consecutive, euthyroid patients with inactive GO who had undergone orbital decompression for disfiguring proptosis in 11 European centres were analysed. Results: Eighteen different (combinations of) approaches were used, the swinging eyelid approach being the most popular followed by the coronal and transconjunctival approaches. The average proptosis reduction for all decompressions was 5.0 (SD 2.1) mm. After three-wall decompression the proptosis reduction was significantly greater than after two-wall decompression. Additional fat removal resulted in greater proptosis reduction. Complications were rare, the most frequent being worsening of motility, occurring more frequently after coronal decompression. The average change in quality of life (QOL) in the appearance arm of the GO-QOL questionnaire was 20.5 (SD 24.8) points. Conclusions: In Europe, a wide range of surgical approaches is used to reduce disfiguring proptosis in patients with GO. The extent of proptosis reduction depends on the number of walls removed and whether or not fat is removed. Serious complications are infrequent. Worsening of ocular motility is still a major complication, but was rare in this series after the swinging eyelid approach.

Thyroid eye disease

Thyroid eye disease is a relatively rare condition, with an incidence of 2.9 to 16.0 cases per 100 000 population per year.1 The disease mainly affects women. Many patients experience distressing symptoms, and a few develop sight threatening complications. Patients are often young or middle aged and at the peak of their career. Most patients are very aware of their altered appearance. Sight loss can be prevented by appropriate management, yet it still occurs even in countries with advanced healthcare systems. This problem is largely due to delays in starting treatment, because health professionals are not always aware of the remarkable difference that treatment can make in restoring visual function and appearance.2 For example, treatment can reverse blindness and help a reclusive patient to become socially reintegrated. Referral to specialist centres is appropriate for all but the mildest cases.3 Thyroid eye disease is an autoimmune disorder, with associated thyroid autoimmunity always discernible.4 The presence of one or more shared autoantigens between the thyroid and the orbit may explain why retro-orbital tissues are affected.5 6 Extraocular muscles and retro-ocular connective tissue are infiltrated by lymphocytes, leading to activation of cytokine networks and inflammation and interstitial oedema of the extraocular muscles.7 8 Excess secretion of glycosaminoglycans by orbital fibroblasts seems to be an important contributor. The end result is expansion of the volume of extraocular muscles, retro-orbital fat, and connective tissue. Similar changes affect the eyelids and anterior periorbital tissues. Smoking increases the risk of developing thyroid eye disease by seven to eight fold.9 Apart from visible swelling and redness of the eyelids and conjunctiva, the other clinical features of thyroid eye disease can also be accounted for by the expansion of inflammatory soft tissue within the constraints of the rigid bony orbit. Anterior displacement of …

Clinical outcome of endonasal KTP laser assisted dacryocystorhinostomy

BackgroundTo evaluate the clinical outcome of primary endonasal laser assisted dacryocystorhinostomy (ENL-DCR) using the potassium-titanyl-phosphate laser.MethodsWe retrospectively reviewed all primary ENL-DCRs performed within a period of twelve months by the same combined Ophthalmology and Otorhinolaringology team in Freeman Hospital, Newcastle upon Tyne, UK. The main outcome measure for success was resolution or significant improvement of epiphora. Details of surgery, intraoperative and postoperative complications, as well as pathology associated with failure were also studied. Patients were followed up for at least 12 months.ResultsA total of 41 consecutive ENL-DCRs on 29 patients (22 females, 7 males, mean age 75 years) were analysed. All patients had bicanalicular silicone intubation for at least 4 months. The success rate at 12 months postoperatively was 78.1%. Pathology associated with failure included: intranasal pathology (12.2%), mucocele (7.3%), and systemic sarcoidosis (2.4%). No significant intra-operative complications were recorded.ConclusionThe ENL-DCR with potassium-titanyl-phosphate laser can be considered as a safe and efficient primary procedure for the treatment of nasolacrimal duct obstruction.

PREGO (presentation of Graves’ orbitopathy) study: changes in referral patterns to European Group On Graves’ Orbitopathy (EUGOGO) centres over the period from 2000 to 2012

Background/aims The epidemiology of Graves’ orbitopathy (GO) may be changing. The aim of the study was to identify trends in presentation of GO to tertiary centres and initial management over time. Methods Prospective observational study of European Group On Graves’ Orbitopathy (EUGOGO) centres. All new referrals with a diagnosis of GO over a 4-month period in 2012 were included. Clinical and demographic characteristics, referral timelines and initial decisions about management were recorded. The data were compared with a similar EUGOGO survey performed in 2000. Results The demographic characteristics of 269 patients studied in 2012 were similar to those collected in the year 2000, including smoking rates (40.0% vs 40.2%). Mild (60.5% vs 41.2%, p<0.01) and inactive GO (63.2% vs 39.9%, p<0.01) were more prevalent in 2012. The times from diagnosis of thyroid disease to being seen in EUGOGO centres (6 vs 16 months) and from first symptoms of GO (9 vs 16 months) or from diagnosis of GO (6 vs 12 months) to first consultation in EUGOGO centres were shorter in 2012 (p<0.01). The initial management plans for GO were no different except surgical treatments for patients with mild inactive disease were more frequently offered in the 2012 cohort than in 2000 (27.3% vs 17%, p<0.05), and selenium supplements were offered only in the 2012 cohort (21.2% vs 0%, p<0.01). Conclusions These findings suggest that the clinical manifestations of patients with GO may be changing over time in Europe.

Novel Thermal Imaging Analysis Technique for Detecting Inflammation in Thyroid Eye Disease

CONTEXT The disease phase in thyroid eye disease (TED) is commonly assessed by clinical investigation of cardinal signs of inflammation and using the clinical activity score (CAS). Although CAS is the current gold standard, the clinical assessment would benefit if a more objective tool were available. OBJECTIVE The aim of this work was to explore the clinical value of a novel thermal imaging analysis technique to objectively quantify the thermal characteristics of the eye and peri-orbital region and determine the disease phase in TED. DESIGN This was a cross-sectional study comparing consecutive patients with active TED (CAS ≥ 3/7) attending a tertiary center, with a group of consecutive patients with inactive TED (CAS <3). PATIENTS Thermal images were acquired from 30 TED patients, 17 with active disease and 13 with inactive disease. INTERVENTIONS Patients underwent standard ophthalmological clinical assessments and thermal imaging. MAIN OUTCOME MEASURES Five novel thermal eye parameters (TEP) were developed to quantify the thermal characteristics of the eyes in terms of the highest level of inflammation (TEP1), overall level of inflammation (TEP2), right-left asymmetry in the level of inflammation (TEP3), maximum temperature variability across the eyes (TEP4), and right-left asymmetry in the temperature variability (TEP5). RESULTS All five TEP were increased in active TED. TEP1 gave the largest accuracy (77%) at separating the two groups, with 65% sensitivity and 92% specificity. A statistical model combining all five parameters increased the overall accuracy, compared to using only one parameter, to 93% (94% sensitivity and 92% specificity). All five of the parameters were also found to be increased in patients with chemosis compared to those without. CONCLUSIONS The potential diagnostic value of this novel thermal imaging analysis technique has been demonstrated. Further investigation on a larger group of patients is necessary to confirm these results.

Declaración de consenso del Grupo europeo sobre la orbitopatía de Graves (EUGOGO) sobre el tratamiento de la orbitopatía de Graves (OG)

LUIGI BARTALENAa, LELIO BALDESCHIb, ALISON DICKINSONc, ANJA ECKSTEINd, PAT KENDALL-TAYLORe, CLAUDIO MARCOCCIf, MAARTEN MOURITSg, PETROS PERROSh, KOSTAS BOBORIDISi, ANTONELLA BOSCHIj, NICOLA CURROk, CHANTAL DAUMERIEl, GEORGE J. KAHALYm, GERASIMOS E. KRASSASn, CAROL M. LANEo, JOHN H. LAZARUSp, MICHELE MARINOf, MARCO NARDIq, CHRISTOPHER NEOHc, JACQUES ORGIAZZIr, SIMON PEARCEs, ALDO PINCHERAf, SUSANNE PITZt, MARIO SALVIu, PAOLO SIVELLIv, MATTHIAS STAHLw, GEORG VON ARXx Y WILMAR M. WIERSINGAy

Uno studio prospettico sugli effetti della terapia con radioiodio nei pazienti con oftalmopatia basedowiana minimamente attiva

RiassuntoPREMESSE: La terapia dell’ipertiroidismo con radioiodio è efficace e sicura, ma è stata indicata come potenziale fattore di rischio per il peggioramento o la comparsa ex novo della oftalmopatia basedowiana (OB). SCOPO: Lo scopo di questo studio era di determinare l’andamento della OB dopo terapia con radioiodio. DISEGNO: Studio prospettico osservazionale. I pazienti venivano valutati prima della terapia e 2, 4, 6, e 12 mesi dopo il radioiodio. SETTING: Lo studio veniva condotto in un Centro di riferimento terziario. PAZIENTI: 72 pazienti con OB minimamente attiva partecipavano allo studio. A tutti veniva somministrata una dose prefissata di radioiodio e dopo due settimane veniva iniziata la terapia con L-tiroxina per prevenire l’ipotiroidismo. PRINCIPALI OBIETTIVI:Valutazione delle variazioni della attività e della gravità della OB. RISULTATI: La misurazione della proptosi, l’apertura palpebrale, la diplopia e il Clinical Activity Score miglioravano significativamente. Utilizzando un criterio di rilevanza clinica, si verificava un miglioramento sostanziale della OB in 4 pazienti (solo transitorio in 3 casi), verosimilmente attribuibile alla storia naturale della malattia. In nessun caso la OB peggiorava. CONCLUSIONI: la terapia con radioiodio non è associata ad un peggioramento della OB se l’ipotiroidismo post-radioiodio viene prevenuto.