thyroid eye disease graves’ orbitopathy graves’ disease · confirmed diagnosis of graves'...
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Thyroid Eye DiseaseGraves’ OrbitopathyGraves’ Disease James C. Fleming, MD, FACSPhilip M. Lewis Professor Director, Department of OphthalmologyHamilton Eye Institute University of Tennessee Health Science Center
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Financial Disclosure
Lecturer for AO North America Lecturer for StrykerAll monies received are donated to charity
Premier Research – Phase II drug study for active thyroid eye disease
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Epidemiology
Incidence 0.4% In US( 1,000,000 diagnosed in one year) Female to Male Ratio About 5-6 to 1 Age Usually 40s and 50s Most Common Orbital Disorder
( 10 to 20 % sight threatening disease) Most Common Cause of Exophthalmos
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Historical Background
Three people have been credited with describing the syndrome
Caleb Parry – EnglandRobert James Graves – IrelandKarl von Basedow - Germany
The association between thyroid disease and exophthalmos has been known for two centuries
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Graves’ Disease(Autoimmune Disorder)
Fundamental cause Autoantibodies that bind to and stimulate the TSH receptor on the thyrocyte This Ig G molecule is in the class of auto
antibodies that activate the cell surface receptors Genetic predisposition Environmental factors (smoking)
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The anti-TSH receptor T-cell interacts with the thyroid cell receptor, activating thyroid hormone production independent of the normal regulatory pathway
Classic Theory of Autoimmunity
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Autoimmune Mechanisms“Unclear”
Little direct evidence linking extra-thyroidal TSH-Receptor expression with Graves’disease
Autoantibodies from patients with Graves’disease bind the Insulin-like growth factor 1 receptor (IGF 1 receptor) on the surface of fibroblast
TJ Smith. Autoimmunity. 2003;36:409
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Thyroid eye diseaseThe orbit is a secondary target organ
Orbital fibroblasts appear to be the prime targets of the autoimmune attack in the orbit
Retro-orbital preadipocyte fibroblasts
These cells undergo adipocite differentiation (increased orbital fat)
T-cell mediated inflammatory response (swelling and inflammation)
T-cell mediators induce effector cell proliferation and elaboration of glycosaminoglycans (GAG) (increased thickness of extraocular muscles and increased edema)
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Thyroid eye diseaseThe orbit is a secondary target organ
DuttonandHaik2002
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Thyroid Eye DiseaseClinical Features
Eyelid retraction 91% Exophthalmos 63% Restrictive myopathy 42% Optic nerve dysfunction 6%
Extraocular muscle enlargement 55%** of those imagedEuthyroid 7% Bartley
1994
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The Clinical Course “Rundle’s Curve”
Inflammatory phase Acute Subacute
Active changes 6-24 months(This is quite variable)
Chronic phase (fibrotic changes) Proptosis change over 5+ years
(Two long term studies)unchanged in 72%increased in 23%decreased in only 5%
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The Clinical Course “Rundle’s Curve”
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The Literature : Risk Modifiers
Correlation does not equal Causality
Cigarette smoking*** confirmed multiple studies
Selenium ?Thyroidectomy ?Statins ?
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Risk Factors: Selenium
Mean serum selenium levels were significantly lower in GO (1·10 ± 0·18 μm) than in GD (1·19 ± 0·20 μm) (P = 0·001). Mean selenium levels appeared to decrease in parallel with increasing severity of GO; selenium level was 1·19 ± 0·20 μm in GD, 1·10 ± 0·19 μm in moderate-to-severe GO and 1·09 ± 0·17 μm in sight-threatening GO (P = 0·003). Serum selenium levels remained significantly lower in GO after adjusting for age, smoking status, thyroidectomy, radioactive iodine treatment and residential location.
Serum selenium status in Graves' disease with and without orbitopathy: a case-control study.2014 ( 198 subjects)Khong JJ1, Goldstein RF, Sanders KM, Schneider H, Pope J, Burdon KP, Craig JE, Ebeling PR.
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Risk factors: Statins
Data from 8404 beneficiaries in a large US managed care network who received a confirmed diagnosis of Graves' disease between 2001 and 2009
Patients who used statins for 60 days or more had a 40% reduced hazard for developing TAO (adjusted hazard ratio, 0.60; 95% confidence interval, 0.37 - 0.93). Stein JD, Childers D, Gupta S, Talwar N, Nan B, Lee BJ, Smith TJ, Douglas
R. Risk factors for developing thyroid-associated ophthalmopathy among individuals with Graves’ disease. JAMA Ophthalmol. 2014
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Risk Factors- Thyroidectomy Data from 8404 beneficiaries in a large US
managed care network who received a confirmed diagnosis of Graves' disease between 2001 and 2009. They found that 740 of these patients (8.8%) developed TAO.
Patients with Graves' disease who underwent surgical thyroidectomy had 74% reduction in their hazard of developing TAO compared with patients who did not undergo the surgery (adjusted hazard ratio, 0.26; 95% confidence interval, 0.12 - 0.51).
Stein JD, Childers D, Gupta S, Talwar N, Nan B, Lee BJ, Smith TJ, Douglas R. Risk factors for developing thyroid-associated ophthalmopathy among individuals with Graves’ disease. JAMA Ophthalmol. 2014
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Active Phase Disease Management Medical Therapy Localized ophthalmic protective measures Anti-inflammatory treatment
Corticosteroids Oral Orbital injection
Pulse IV steroid therapy **Therapy with statins represents a newly recognized risk factor for liver damage in patients undergoing treatment with high-dose intravenous methylprednisolone for active moderate to severe Graves' orbitopathy, independently of the dose administered,"
Immunosuppression ** (rituximab) Targeted immunosuppression
Orbital Radiotherapy Controversy over benefit
Surgical intervention
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European Group On Graves' Orbitopathy (EUGOGO)
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ITEDS: International Thyroid Eye Disease Society
Douglas RS, Tsirbas A, Gordon M, Lee D, Khadavi N, Garneau HC, Goldberg RA, Cahill K, Dolman PJ, Elner V, Feldon S, Lucarelli M, Uddin J, Kazim M, Smith TJ, Khanna D; International Thyroid Eye Disease Society. Development of criteria for evaluating clinical response in thyroid eye disease using a modified Delphi technique. Arch Ophthalmol 2009; 127(9): 1155-60.
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Acute orbitopathy Severe Exposure Compressive optic
neuropathy Globe prolapse
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Acute Optic Neuropathy Patients improve with oral corticosteroids Prednisone 1.0-1.5 mg/kg/day Methylprednisolone pulse therapy 500mgMP
over 3 days in 4 weekly cycles (6g total)**risk! Surgical decompression
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Optic Neuropathy
Etiology – orbital congestion with compression of the optic nerve
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Acute/Active Phase Disease Management
Steroid therapy Oral Periocular
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Radiation Technique
Megavoltage radiation therapy (4-6 MeV) High-energy linear
accelerator Well collimated beam
20 GY delivered to entire content of bony orbit Fractionated over 10 days
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Radiothearpy
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Orbital Radiotherapy “Controversial”
Prospective trials: Gorman CA et al. Ophthalmology. 2001 Sep;108(9):1523-34 Prummel MF et al. J Clin Endocrinol Metab.2004
Jan;89(1):13-4.
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Active Phase ManagementMedical Recomendations
Stop smoking !!! Documentation of location on Rundle’s curve
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Chronic Congestive PhaseCosmetic vs “Rehabilitation”Treatment Decision Path Orbital surgery Strabismus surgery Eyelid surgery
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Types of Decompression
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Evaluation of the Ophthalmopathy – CT scan
Size and depth of orbit
Size of muscles Size and position of
sinuses Bone thickness
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Rehabilitation surgery Two subgroups
Group I Proptosis with restrictive myopathy(clinically significant diplopia)
Group II Proptosis minimal restrictive myopathy
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Gradation ofFloor and medial wall
Lateral walldecompression
Strabismus surgery
Eyelid surgery
Treatment -Group I (type1)Proptosis with restrictive myopathy
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Area of Floor / Medial Decompression
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Floor Removal
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Medial approach
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3 Wall Decompression
Strabismus surgery Malar augmentation Eyelid surgery
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Group II Minimal Myopathy (type 2)
LateralDecompression
Possible Malar augmentation
Eyelid surgery
PossibleFat removal
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Area of Lateral Decompression
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Lateral Decompression
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Lateral Decompression
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Lateral decompression
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Lateral Rim Modification
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Lateral wall decompression Orbital fat removal
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Supplemental Procedures
Preseptal fat may be removed to relieve orbital pressure and add to decompression effect
Malar or orbital rim augmentation
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Rim Augmemtation
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This is an Autoimmune Disease
The FutureMy Prediction These patients will not require major
surgical management of this disease
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Immunotherapy : Block Specific Receptors (address the fundamental cause)
Phase II studies ofTeprotumumab o a monoclonal antibody.
Blocking autoantibodies that bind to and stimulate the TSH receptor on the orbital fibroblast This Ig G molecule is in the class of auto antibodies that activate
the cell surface receptors
This is directed at the fibroblast activity
Teprotumumab for Thyroid-Associated Ophthalmopathy. Smith TJ, Kahaly GJ, Ezra DG, Fleming JC, Dailey RA, Tang RA, Harris GJ, Antonelli A, Salvi M, Goldberg RA,
Gigantelli JW, Couch SM, Shriver EM, Hayek BR, Hink EM, Woodward RM, Gabriel K, Magni G, Douglas RS. N Engl J Med. 2017 May 4;376(18):1748-1761. doi: 10.1056/NEJMoa1614949.
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Polling Questions
1. 1.What is the usual age of onset of TED?
a) 20-30b) 30-40c) 40-50d) 50-60
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Polling Questions
2. TED is the most common orbital disorder?
a) Trueb) False
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Polling Questions3. Thyroid eye disease affects the orbit by
a) Increasing Orbital Fatb) Causing swellingc) Increasing the thickness of extraocular
musclesd) All of the above
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Polling Questions4. Thyroid eye disease affect optic nerve dysfunction in
a) 20%b) 6%c) 50%d) 63%
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Polling Questions5. Clinical course of TED is equal to “Rundal’s curve” lasting
a) 2 monthsb) 6 monthsc) 6-24 monthsd) 36 months
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Polling Questions6. What are the reported risk modifiers in TED?
a) Low Selenium levelsb) Thyroidectomyc) Statinsd) All of the above
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Thank You
Questions?