Management of Graves’ ophthalmopathy – 2022 update
Authors:
Jan Jiskra
Authors‘ workplace:
3. interní klinika – klinika endokrinologie a metabolismu 1. LF UK a VFN v Praze
Published in:
Čas. Lék. čes. 2022; 161: 198-206
Category:
Review Article
Overview
Graves’ ophthalmopathy (GO) occurs in 25–50% cases of Graves’ disease. Most cases are just mild, only 5% represents eye threatening diseases. About 5–10% of cases could be euthyroid and 10% hypothyroid, respectively. All patients with GO should be assessed for activity (clinical activity score – CAS) and severity of the disease. Essential conditions of the successful treatment are well controlled thyroid dysfunction, smoking cessation and to refer patients with moderate to severe and sight threatening GO to specialized thyroid eye centers as soon as possible.
Local therapy to maintain wet eye (lubricants) and supplementation of selenium deficiency is adequate in mild cases of GO. In cases of moderate to severe and sight threatening GO, administration of intravenous glucocorticoids in thyroid eye centers is first line treatment and a combination with mycophenolate or radiotherapy could be considered. When the first-line treatment fails or a contraindication/intolerance to them is present, non-steroid immunosuppressive drugs (mycophenolate, ciclosporin), rituximab, or radiotherapy could be considered. In rare cases of sight threatening GO urge surgical orbital decompression or tarsorrhaphy is warranted.
Keywords:
radiotherapy – mycophenolate mofetil – rituximab – Graves’ orbitopathy – clinical activity score – dysthyroid optic neuropathy – intravenous glucocorticoids
Sources
- Soeters MR, van Zeijl CJJ, Boelen A et al. Optimal management of graves orbitopathy: a multidisciplinary approach. Netherland J Med 2011; 69: 302–308.
- Bahn RS. Graves’ ophthalmopathy. N Engl J Med 2010; 362: 726–738.
- Forbes G, Gorman CA, Brennan MD et al. Ophthalmopathy of Graves’ disease: computerized volume measurements of the orbital fat and muscle. Am J Neuroradiol 1986; 7: 651–656.
- Bartalena L, Baldeschi L, Boboridis K et al; European Group on Graves’ Orbitopathy (EUGOGO). The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves’ Orbitopathy. Eur Thyroid J 2016; 5: 9–26.
- Lipman LM, Green DE, Snyder NJ et al. Relationship of long-acting thyroid stimulator to the clinical features and course of Graves’ disease. Am J Med 1967; 43: 486–498.
- Gerding MN, van der Meer JW, Broenink M et al. Association of thyrotrophin receptor antibodies with the clinical features of Graves’ ophthalmopathy. Clin Endocrinol (Oxf) 2000; 52: 267–271.
- Eckstein AK, Plicht M, Lax H et al. Thyrotropin receptor autoantibodies are independent risk factors for Graves’ ophthalmopathy and help to predict severity and outcome of the disease. J Clin Endocrinol Metab 2006, 91: 3464–3470.
- Bartalena L, Baldeschi L, Dickinson A et al.; European Group on Graves’ Orbitopathy (EUGOGO). Consensus statement of the European Group on Graves’ orbitopathy (EUGOGO) on management of GO. Eur J Endocrinol 2008; 158: 273–285.
- Bartalena L, Kahaly GJ, Baldeschi L et al.; EUGOGO. The 2021 European Group on Graves’ orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves’ orbitopathy. Eur J Endocrinol 2021; 185: G43–G67.
- Jiskra J, Gabalec F, Diblík P a kol. Doporučený postup pro diagnostiku a léčbu endokrinní orbitopatie – novelizace 3/2022. Česká endokrinologická společnost, 2022. Dostupné na: www.endokrinologie.cz/cs/doporuceny-postup-pro-diagnostiku-a-lecbu-endokrinni-orbitopatie
- Mourits MP, Koornneef L, Wiersinga WM et al. Clinical criteria for the assessment of disease activity in Graves’ ophthalmopathy: a novel approach. Br J Ophthalmol 1989; 73: 639–644.
- Werner SC. Modification of the classification of the eye changes of Grave’s disease. Am J Ophthalmol 1977; 83: 725–7257.
- Česká endokrinologická společnost ČLS JEP. Dotazník kvality života pacientů s endokrinní orbitopatií. Dostupné na: www.endokrinologie.cz/cs/dotaznik-kvality-zivota-pacientu-s-endokrinni-orbitopatii
- Česká endokrinologická společnost ČLS JEP. Endokrinní orbitopatie – informační materiál pro endokrinology. Dostupné na: www.endokrinologie.cz/cs/endokrinni-orbitopatie-informacni-material-pro-endokrinology
- Bahn Chair RS, Burch HB, Cooper DS et al.; American Thyroid Association; American Association of Clinical Endocrinologists. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid 2011; 21: 593–646.
- Ross DS, Burch HB, Cooper DS et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26: 1343–1421.
- Marcocci C, Kahaly GJ, Krassas GE et al.; European Group on Graves’ Orbitopathy. Selenium and the course of mild Graves’ orbitopathy. N Engl J Med 2011; 364: 1920–1931.
- Zang S, Ponto KA, Kahaly GJ. Intravenous glucocorticoids for Graves’ orbitopathy: efficacy and morbidity. J Clin Endocrinol Metab 2011; 96: 320–332.
- Lendorf ME, Rasmussen AK, Fledelius HC, Feldt-Rasmussen U. Cardiovascular and cerebrovascular events in temporal relationship to intravenous glucocorticoid pulse therapy in patients with severe endocrine ophthalmopathy. Thyroid 2009; 19: 1431–1432.
- Ye X, Bo X, Hu X et al. Efficacy and safety of mycophenolate mofetil in patients with active moderate-to-severe Graves’ orbitopathy. Clin Endocrinol (Oxf) 2017; 86: 247–255.
- Kahaly GJ, Riedl M, König J et al.; European Group on Graves’ Orbitopathy (EUGOGO). Mycophenolate plus methylprednisolone versus methylprednisolone alone in active, moderate-to-severe Graves' orbitopathy (MINGO): a randomised, observer-masked, multicentre trial. Lancet Diabetes Endocrinol 2018; 6: 287–298.
- Rajabi MT, Rafizadeh SM, Mohammadi A et al. Mycophenolate mofetil (CellCept®) in combination with low dose prednisolone in moderate to severe Graves’ orbitopathy. Front Med (Lausanne) 2022; 9: 788228.
- Salvi M, Vannucchi G, Campi I et al. Treatment of Graves’ disease and associated ophthalmopathy with the anti-CD20 monoclonal antibody rituximab: an open study. Eur J Endocrinol 2007; 156: 33–40.
- Khanna D, Chong KK, Afifiyan NF et al. Rituximab treatment of patients with severe, corticosteroid-resistant thyroid-associated ophthalmopathy. Ophthalmology 2010; 117: 133–139.
- Stan MN, Salvi M. Rituximab therapy for Graves’ orbitopathy – lessons from randomized control trials. Eur J Endocrinol 2017; 176: R101–R109.
- Shen WC, Lee CH, Loh EW et al. Efficacy and safety of rituximab for the treatment of Graves’ orbitopathy: A meta-analysis of randomized controlled trials. Pharmacotherapy 2018; 38: 503–510.
- Wang C, Ning Q, Jin K et al. Does rituximab improve clinical outcomes of patients with thyroid-associated ophthalmopathy? A systematic review and meta-analysis. BMC Ophthalmol 2018; 18: 46.
- Salvi M, Vannucchi G, Currò N et al. Small dose of rituximab for graves orbitopathy: new insights into the mechanism of action. Arch Ophthalmol 2012; 130: 122–114.
- Karásek D, Cibíčková L, Karhanová M et al. Clinical and immunological changes in patients with active moderate-to-severe Graves' orbitopathy treated with very low-dose rituximab. Endokrynol Pol 2017; 68: 498–504.
- Insull EA, Sipkova Z, David J et al. Early low-dose rituximab for active thyroid eye disease: An effective and well-tolerated treatment. Clin Endocrinol (Oxf) 2019; 91: 179–186.
- Smith TJ, Kahaly GJ, Ezra DG et al. Teprotumumab for thyroid-associated ophthalmopathy. N Engl J Med 2017; 376: 1748–1761.
- Douglas RS, Kahaly GJ, Patel A et al. Teprotumumab for the treatment of active thyroid eye disease. N Engl J Med 2020; 382: 341–352.
- Mourits MP, van Kempen-Harteveld ML, Garcia MB et al. Radiotherapy for Graves’ orbitopathy: randomised placebo-controlled study. Lancet 2000; 355: 1505–1509.
- Prummel MF, Terwee CB, Gerding MN et al. A randomized controlled trial of orbital radiotherapy versus sham irradiation in patients with mild Graves’ ophthalmopathy. J Clin Endocrinol Metab 2004; 89: 15–20.
- Kim JW, Han SH, Son BJ et al. Efficacy of combined orbital radiation and systemic steroids in the management of Graves' orbitopathy. Graefes Arch Clin Exp Ophthalmol 2016; 254: 991–998.
- Oeverhaus M, Witteler T, Lax H et al. Combination therapy of intravenous steroids and orbital irradiation is more effective than intravenous steroids alone in patients with Graves' orbitopathy. Horm Metab Res 2017; 49: 739–747.
- Kahaly GJ, Rosler HP, Pitz S, Hommel G. Low- versus high-dose radiotherapy for Graves’ ophthalmopathy: a randomized, single blind trial. J Clin Endocrinol Metab 2000; 85: 102–108.
- Antico JC, Crovetto L, Tenca E, Artes C. Initial experience with gamma knife surgery for endocrine ophthalmopathy. J Neurosurg 2005; 102 (Suppl.): 272–275.
- Finamor FE, Martins JR, Nakanami D et al. Pentoxifylline (PTX) – an alternative treatment in Graves’ ophthalmopathy (inactive phase): assessment by a disease specific quality of life questionnaire and by exophthalmometry in a prospective randomized trial. Eur J Ophthalmol 2004; 14: 277–283.
- Antonelli A, Saracino A, Alberti B et al. Highose intravenous immunoglobulin treatment in Graves’ ophthalmopathy. Acta Endocrinol (Copenh) 1992; 126: 13–23.
Labels
Addictology Allergology and clinical immunology Angiology Audiology Clinical biochemistry Dermatology & STDs Paediatric gastroenterology Paediatric surgery Paediatric cardiology Paediatric neurology Paediatric ENT Paediatric psychiatry Paediatric rheumatology Diabetology Pharmacy Vascular surgery Pain management Dental HygienistArticle was published in
Journal of Czech Physicians
Most read in this issue
- Hippocratic Oath and current medical oaths
- Management of Graves’ ophthalmopathy – 2022 update
- 125 let od narození profesora Josefa Charváta
- The importance of molecular autopsy in forensic medicine