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Thyroid orbitopathy part 2: Different phases of disease need different treatments
Diagnosis and treatment of thyroid orbitopathy can be subjective, so large trials are needed to help standardize treatment.
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In part 1 of this column, I discussed the pathophysiology and clinical presentation of thyroid orbitopathy. (See part 1 of this article online at http://www.healio.com/ophthalmology/cornea-external-disease/news/print/ocular-surgery-news/%7B50e32061-7fdc-41d2-a51d-bec5f7feab30%7D/thyroid-orbitopathy-part-1-further-study-of-correlation-needed.) In part 2, I will cover current treatment options and future directions of the disease.
Treatment options
Active and cicatricial phases of thyroid orbitopathy require different treatments. The euthyroid state should be achieved in active disease. Working with an endocrinologist is crucial in stabilizing active eye disease and achieving euthyroid state.
Mild active disease can be monitored with local supportive measures, such as lubricants for dry eye symptoms. The use of supplemental selenium improves quality of life in this subset of patients. This has been shown in large randomized controlled trials out of Europe.
Traditionally, treatment for moderate-to-severe disease has been limited to oral steroids, periorbital steroid injections or orbital radiation, dependent on practitioner preference. Orbital radiation was the treatment of choice in the 1970s and has varied results of efficacy, according to literature. It is not considered the preferred choice of treatment. While oral steroids and periorbital steroid injections have been widely accepted and used as the preferred treatment option, recent research has shown limitations.
Jenny Y. Yu
The use of intravenous steroids in higher doses over a shorter treatment time tend to have less side effect profiles and better efficacy vs. oral steroids. The European Group on Graves’ Orbitopathy (EUGOGO) has established guidelines based on large trials. Sight-threatening disease may require urgent orbital decompression in addition to intravenous steroids.
In a small subset of patients, disease activity simmers despite intervention. Clinically, these patients have a history of radioactive iodine treatment for hyperthyroidism and/or smoking and tend to fare the worst. In such a population, medical therapy (ie, intravenous glucocorticoid) combined with surgical therapy (ie, orbital decompression) may not be enough to prevent loss of vision. Biologic immunosuppressants, such as Rituxan (rituximab, Genentech), are used in these refractory cases. Rituximab is a monoclonal antibody thought to disrupt the autoantibody generation in thyroid orbitopathy along with disrupting the cascade of inflammation mediated by fibroblasts. It has proven to be more effective than other biologic immunosuppressants in controlling refractory active thyroid orbitopathy. Rheumatologists are often consulted when considering biologic immunosuppressants.
Rehabilitative surgery in the cicatricial phase is approached stepwise. Surgical decisions are made to restore function and appearance. Orbital decompression is done before any strabismus and/or lid surgery. Eyelid surgeries in thyroid orbitopathy patients are done to help with exposure issues, as well as to improve cosmesis. Surgeries may include repair of lid retraction, as well as brow fat removal and blepharoplasties.
Future directions
Determining disease activity remains challenging in the management of thyroid orbitopathy patients. Frequent monitoring is needed, and much of the diagnosis and treatment is subjective. Large trials, such as the ones conducted by EUGOGO, are standardizing treatment, but there is still much to be understood regarding the pathogenesis.
Varying data exist in the literature with regard to the genetic susceptibility of thyroid orbitopathy. The variation in disease severity is not quite understood and can be due to multiple genetic and environmental susceptibilities. Treatment options could be broadened once we can clarify the multiple fronts of the immune response in thyroid orbitopathy.
Visit UPMCPhysicianResources.com/Ocular to learn more about treatment options for facial rejuvenation. You can also submit clinical questions or read the most recent questions asked of the UPMC Eye Center’s ophthalmology experts.