Graves ’ Orbitopathy A Multidisciplinary Approach – Questions and Answers 3rd, revised and expanded edition Editors Wilmar M. Wiersiinnggaa George J. Kahaly Graves’ Orbitopathy A Multidisciplinary Approach – Questions and Answers 3rd, revised and expanded edition Graves’ Orbitopathy A Multidisciplinary Approach – Questions and Answers 3rd, revised and expanded edition Editors Wilmar M. Wiersinga Amsterdam George J. Kahaly Mainz 116 figures, 69 in color, and 52 tables, 2017 Basel · Freiburg · Paris · London · New York · Chennai · New Delhi · Bangkok · Beijing · Shanghai · Tokyo · Kuala Lumpur · Singapore · Sydney Wilmar M. Wiersinga, MD, PhD George J. Kahaly, MD, PhD Department of Endocrinology and Metabolism Department of Medicine I Academic Medical Center Gutenberg University Medical Center University of Amsterdam Langenbeckstrasse 1 Meibergdreef 9 DE–55131 Mainz (Germany) NL–1105 AZ Amsterdam (The Netherlands) Library of Congress Cataloging-in-Publication Data Names: Wiersinga, Wilmar M., editor. | Kahaly, George, editor. Title: Graves' orbitopathy : a multidisciplinary approach : questions and answers / editors, Wilmar M. Wiersinga, George J. Kahaly. Description: 3rd, revised and expanded edition. | Basel ; New York : Karger, 2017. | Includes bibliographical references and indexes. Identifiers: LCCN 2017031321| ISBN 9783318060843 (softcover : alk. paper) | ISBN 9783318060850 (electronic version) Subjects: | MESH: Graves Ophthalmopathy--diagnosis | Graves Ophthalmopathy--pathology | Graves Ophthalmopathy--therapy | Ophthalmologic Surgical Procedures | Diagnosis, Differential | Ophthalmologic Surgical Procedures Classification: LCC RE715.T48 | NLM WK 265 | DDC 617.7--dc23 LC record available at https://lccn.loc.gov/2017031321 Disclaimer. The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publisher and the editor(s). The appearance of advertisements in the book is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements. Drug Dosage. The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. © Copyright 2017 by S. Karger AG, P.O. Box, CH–4009 Basel (Switzerland) www.karger.com Printed on acid-free and non-aging paper (ISO 9706) ISBN 978–3–318–06084–3 e-ISBN 978–3–318–06085–0 Contents XV Preface to the Third, Revised and Expanded Edition Wiersinga, W.M. (Amsterdam); Kahaly, G.J. (Mainz) XVI Preface to the Second, Revised Edition Wiersinga, W.M. (Amsterdam); Kahaly, G.J. (Mainz) XVI Preface to the First Edition Wiersinga, W.M. (Amsterdam); Kahaly, G.J. (Mainz) Diagnosis and Pathogenesis 1 Clinical Manifestations Dickinson, A.J. (Newcastle upon Tyne); Hintschich, C. (Munich) 1 What Are the Common Signs and Symptoms of Early Graves’ Orbitopathy? 1 What Are Other Signs and Symptoms of Graves’ Orbitopathy? 3 What Signs Should Question the Diagnosis of Graves’ Orbitopathy? 3 Are There Racial Differences in How Graves’ Orbitopathy Manifests? 4 Is the Presentation of Graves’ Orbitopathy Different in Older Compared to Younger Patients? 4 Why Can the Clinical Presentation of Graves’ Orbitopathy Be So Variable? 5 Can You Give Me a Short Mechanistic Explanation for All These Clinical Manifestations? 6 What Do the Terms “Activity” and “Severity” Denote? 7 Why Is It Important to Distinguish Activity and Severity when Evaluating Patients? 7 What Signs and Symptoms Are Valuable for Assessing Activity? 7 How Are These Signs Assessed? 10 How Reproducible Are These Assessments? 11 What Value Does the “Clinical Activity Score” Have? 11 Do Patients without Signs of Activity Ever Have Active Disease? 12 What Should I Do if I Am Not Sure whether the Disease Is Active? 12 Are There Any Other Ways to Evaluate Activity other than Clinical Examination? 13 When Should These Other Methods for Assessing Activity Be Used in Routine Clinical Practice? 14 What Signs Are Helpful for Assessing Severity? 14 What Value Does the Mnemonic “NOSPECS” Have? 14 How Are Signs of Severity Assessed? 18 How Reproducible Are These Assessments? 19 How Is Severity Best Classified? 19 How Do You Decide whether a Patient Has Dysthyroid Optic Neuropathy? 21 Can Dysthyroid Optic Neuropathy Ever Be Present with Normal Vision? 21 Are Some Patients at Particular Risk? 21 What Other Assessments Are Useful in Evaluating Possible Dysthyroid Optic Neuropathy? 22 Should These Tests Be Performed in All Patients at Every Assessment? 22 Are There Any Other Assessment Systems in Common Use? 23 References V 26 Orbit-Thyroid Relationship Marinò, M. (Pisa) 26 Should This Condition Always Be Called Graves’ Orbitopathy? 26 Is Graves’ Orbitopathy Exclusively Occurring in Patients with Graves’ Hyperthyroidism? 28 Do All Patients with Graves’ Hyperthyroidism Have Graves’ Orbitopathy? 28 Are There Any Relationships between Hyperthyroidism, Hypothyroidism, and Graves’ Orbitopathy? 29 Is Graves’ Orbitopathy Related to Thyroid Autoimmunity? 29 Are There Other Extrathyroidal Manifestations of Graves’ Disease apart from Graves’ Orbitopathy? 31 References 33 Epidemiology Burlacu, M.-C.; Daumerie, C. (Brussels) 33 What Is the Estimated Incidence and Prevalence of Graves’ Orbitopathy? 34 Has the Occurrence of Graves’ Orbitopathy Changed over the Last Few Decades? 35 Is the Age and Sex Distribution of Graves’ Orbitopathy Similar to That of Graves’ Hyperthyroidism? 36 Are There Ethnic Differences? 36 What Are the Risk Factors for the Occurrence of Graves’ Orbitopathy? 37 Can Particular Drugs Trigger or Modify Graves’ Orbitopathy and Its Course? 38 Is Tobacco Bad for Graves’ Orbitopathy? 38 Has Nutrition an Effect on Graves’ Orbitopathy? 38 Does Total Thyroidectomy for Other Diseases than Graves’ Disease Preclude the Development of Graves’ Orbitopathy? 39 References 41 Pathogenesis Salvi, M. (Milan); Berchner-Pfannschmidt, U. (Essen); Ludgate, M. (Cardiff) 41 What Are the Pathological Changes in Orbital Tissue in Graves’ Orbitopathy? 43 How Do the Pathological Changes Give Rise to the Clinical Manifestations? 44 What Triggers Graves’ Orbitopathy? 45 Is Graves’ Orbitopathy Triggered by an Autoimmune Phenomenon? If So, What Is the Nature of the Autoantigen? 47 Why Is the Orbit Special and a Target for Thyroid Autoimmunity? 48 What Kind of Immune Reactions Take Place within the Orbit? 50 Does Thyroid-Stimulating Hormone Receptor Activation and/or Autoreactivity to Thyroid- Stimulating Hormone Receptor Play a Role in the Onset or Development of Graves’ Orbitopathy? 52 Is There a Familial Predisposition or a Specific Genetic Background for Graves’ Orbitopathy? 53 How Do Environmental Factors Increase the Risk and Severity of Graves’ Orbitopathy? 54 How May These Observations and Current Understanding Lead to More Effective Treatment of Graves’ Orbitopathy? 56 References 61 Orbital Imaging Pitz, S.; Müller-Forell, W. (Mainz) 61 Is Orbital Imaging Always Necessary? 61 What Are the Relative Benefits of Orbital CT and MRI? 65 What Is Apical Crowding? 68 What Is the Place of Orbital Ultrasound? 70 What Lessons Can We Learn from Orbital Octreoscan? 70 What Other Imaging Techniques May Be Useful? 71 References VI Contents 74 Diagnosis and Differential Diagnosis of Graves’ Orbitopathy Konuk, O. (Ankara); Anagnostis, P. (Thessaloniki) 74 Can You Give an Overall Scheme for the Diagnosis of Graves’ Orbitopathy? 75 Which Clinical Findings Are Helpful in Making a Diagnosis of Graves’ Orbitopathy? 81 Can One Make a Diagnosis of Graves’ Orbitopathy Based on Medical History and Clinical Picture Alone? 82 Do We Always Need to Order Thyroid Autoantibody and Thyroid Function Tests? 83 Which Imaging Technique Is Best to Make a Diagnosis of Graves’ Orbitopathy, and Is Imaging Always Requested? 84 Which Are the Most Frequent Conditions Mimicking Graves’ Orbitopathy? 91 References 93 Natural History Mamoojee, Y.; Pearce, S.H.S. (Newcastle upon Tyne) 93 Does Graves’ Orbitopathy Occur at the Same Time as Hyperthyroidism? 94 Does Restoring Euthyroidism Lead to Improvement in Graves’ Orbitopathy? 95 What Effect May Hypothyroidism Have? 95 What Is the Typical Course of the Disease? 96 What Happens to Orbital Fat during the Course of the Disease? 97 What Is the Difference between Activity and Severity? 99 How Do You Determine Which Phase of the Disease the Patient Is Displaying? 99 How Does the Phase of the Disease Influence the Choice of Treatment? 100 Will Graves’ Orbitopathy Eventually Burn Itself Out? 100 Will the Orbital Changes Return to Normal when the Condition Eventually Resolves? 100 How Long Is It Likely to Take before the Disease Becomes Inactive? 101 Once the Condition Has Become Inactive (whether Treated or Untreated), Is It Likely to Flare Up Again? 101 Are There Any Other Factors, Additional to Thyroid Status, That May Influence the Course of the Disease? 102 References Management 105 General Management Plan for Graves’ Orbitopathy Bartalena, L. (Varese) 105 Is There General Agreement among Specialists on How to Manage Graves’ Orbitopathy? 105 What Are the Priorities when Faced with a New Presentation of Graves’ Orbitopathy? 107 Should the Patient Be Informed about Risk Factors Affecting the Course of Graves’ Orbitopathy? 108 What Is the Evidence about the Role of Smoking on the Course of Graves’ Orbitopathy? 109 Does Thyroid Status Affect Graves’ Orbitopathy? 109 Are There Simple Measures That Can Help the Eyes? 110 Is Early Referral to Specialized Centres Important? 111 Can You Provide the Patient with an Overall Management Scheme? 111 References 113 Combined Thyroid-Eye Clinics Törüner, F.B.; Konuk, O.; Ayvaz, G. (Ankara) 113 What Are Combined Thyroid-Eye Clinics? 115 Why Is a Multidisciplinary Approach Recommended? Contents VII 115 Can Patient Support Groups Be Helpful? 117 I Have Heard of a Fast-Track Clinic for Graves’ Orbitopathy Patients: What Is That? 117 What Can I Expect when Starting a Combined Thyroid-Eye Clinic? 117 References 119 Thyroid Treatment Hegedüs, L.; Brix, T.H. (Odense) 120 Do the Eyes Care How Euthyroidism Is Obtained and Maintained? 123 Are There Criteria for Preferring One of the Treatment Options for Hyperthyroidism over the Others in Graves’ Orbitopathy? 124 Can Risk Factors Which Predict Appearance or Worsening of Graves’ Orbitopathy after Radioiodine Be Identified? 125 Should the Presence of Graves’ Orbitopathy Restrict Our Use of Radioiodine Therapy? 126 Does Avoiding Transient Hypothyroidism following Radioiodine Therapy Affect the Course of Graves’ Orbitopathy? 127 What Is the Role of Total Thyroid Ablation in the Management of Hyperthyroidism in Graves’ Orbitopathy? 128 Conclusions 128 References 131 Management of Mild Graves’ Orbitopathy Marcocci, C.; Rocchi, R. (Pisa) 131 Which Parameters Should Be Taken into Account to Define a Clinically Evident Graves’ Orbitopathy as Mild? 132 Are Mild Forms Likely to Progress to More Severe Graves’ Orbitopathy? 133 Is a “Wait-and-See” Policy Justified in Patients with Mild Graves’ Orbitopathy? 134 Are Low-Dosage Oral Steroids Advisable or Is Orbital Radiotherapy Preferable? 135 What Is the Rationale for Antioxidant Therapy like Selenium in Graves’ Orbitopathy? 138 References 140 Management of Moderately Severe Graves’ Orbitopathy Kahaly, G.J. (Mainz) 140 How Is Moderately Severe Graves’ Orbitopathy Defined? 140 Is Immunosuppression Indicated in Moderately Severe Graves’ Orbitopathy? 141 What Are the Cellular and Molecular Mechanisms of Steroid Anti-Inflammation and Immunosuppression? 145 What Are the Results of Randomized Trials with Steroids? 155 What Are the Results of Randomized Trials Using Orbital Radiotherapy? 159 Do You Favour Combined Steroid/Radiotherapy? 160 What Are the Results of Randomized Trials Using Non-Steroid Immunosuppressants? 165 What Are the Results of Randomized Trials Using Somatostatin Analogues? 167 How Should a Diabetic or Hypertensive Patient with Moderately Severe Graves’ Orbitopathy Be Treated? 168 What Should You Do if Steroids Fail? 168 What Is the Optimal Thyroid Treatment in Patients with Graves’ Hyperthyroidism and Moderately Severe Active Graves’ Orbitopathy? 169 What Are the Actual Evidence-Based Therapeutic Recommendations for Patients with Moderately Severe Graves’ Orbitopathy? 169 What Were the Recommendations of the EUGOGO Consensus Statement for the Management of Moderately Severe Graves’ Orbitopathy? VIII Contents 170 What Do the ETA/EUGOGO Guidelines for the Management of Graves’ Orbitopathy Recommend? 171 Acknowledgements 171 References 177 Novel Immunomodulatory Treatment Modalities Lane, L.C.; Perros, P.; Pearce, S.H.S. (Newcastle upon Tyne) 177 Why Look for New Immunomodulatory Treatments? 177 What Are the Targets for Potential Novel Therapies? 179 Rituximab 184 What Are the Most Likely Targets for Therapeutic Intervention? 189 Should Clinicians Be Cautious about Trying Novel Immunomodulators? 190 References 193 Management of Very Severe Graves’ Orbitopathy: Dysthyroid Optic Neuropathy and Corneal Breakdown Boschi, A. (Brussels); Currò, N. (Milan) 193 How Do You Define Dysthyroid Optic Neuropathy? What Is the Causative Mechanism? 194 Are There Specific Risk Factors for Dysthyroid Optic Neuropathy? 195 Which Symptoms Should Alert Me for Dysthyroid Optic Neuropathy? 196 What Are the Ophthalmological Signs of Dysthyroid Optic Neuropathy? 196 Are Additional Investigations Helpful? 197 How Fast Can Dysthyroid Optic Neuropathy Progress? Is Urgent Treatment Necessary? 197 What Is the Evidence Base for the Treatment of Dysthyroid Optic Neuropathy? 198 Are Predictive Factors for Response to Steroid Treatment in Dysthyroid Optic Neuropathy Patients Well Defined? 199 What Is the Role of Surgery in Dysthyroid Optic Neuropathy? 199 How Many Patients Become Blind due to Dysthyroid Optic Neuropathy? 199 How Can I Recognize Corneal Breakdown? 200 What Is the Recommended Treatment of Corneal Breakdown? 200 References 202 Local Treatment Modalities Boboridis, K.; Anagnostis, P. (Thessaloniki) 202 Is Graves’ Orbitopathy Related to Ocular Surface Pathology? 202 When and How Should We Support the Ocular Surface? 204 Can Local Measures Address Eyelid Retraction? 204 Can Local Measures Reduce Orbital Inflammation in Graves’ Orbitopathy? 205 Can Local Measures Improve the Visual Disturbance and Diplopia? 205 References 207 Rehabilitative Surgery Baldeschi, L. (Brussels) 207 Why Is This Chapter Called Rehabilitative Surgery and Not Cosmetic Surgery? 208 What Are the Steps and Timing of Rehabilitative Surgery? 209 How Should Patients Be Selected for Rehabilitative Surgery? 210 References Contents IX