Antithyroid drugs in Graves' hyperthyroidism: differences between "block and replace" and "titration" regimes in frequency of euthyroidism and Graves' orbitopathy during treatment.

PURPOSE: Whereas antithyroid drugs (ATD) are the preferred treatment modality for Graves' hyperthyroidism (GH), there is still controversy about the optimal regimen for delivering ATD. To evaluate whether 'Block and Replace' (B + R) and 'Titration' (T) regimes are equivalent in terms of frequency of euthyroidism and Graves' Orbitopathy (GO) during ATD therapy. METHODS: A prospective multicentre observational cohort study of 344 patients with GH but no GO at baseline. Patients were treated with ATD for 18 months according to B + R or T regimen in line with their institution's policy. RESULTS: Baseline characteristics were similar in both groups. In the treatment period between 6 and 18 months thyrotropin (TSH) slightly increased in both groups, but TSH was on average 0.59 mU/L (95% CI 0.27-0.85) lower in the B + R group at all time points (p = 0.026). Serum free thyroxine (FT4) remained stable during the same interval, with a tendency to higher values in the B + R group. The point-prevalence of euthyroidism (TSH and FT4 within their reference ranges) increased with longer duration of ATD in both groups; it was always higher in the T group than in the B + R group: 48 and 24%, respectively, at 6 months, 81 and 58% at 12 months, and 87 and 63% at 18 months (p < 0.002). There were no significant differences between the B + R and T regimens with respect to the fall in thyrotropin binding inhibiting immunoglobulins (TBII) or thyroid peroxidase antibodies (TPO-Ab). GO developed in 15.9% of all patients: 9.1 and 17.8% in B + R group and T group, respectively, (p = 0.096). GO was mild in 13% and moderate-to-severe in 2%. CONCLUSION: The prevalence of biochemical euthyroidism during treatment with antithyroid drugs is higher during T compared to B + R regimen. De novo development of GO did not differ significantly between the two regimens, although it tended to be higher in the T group. Whether one regimen is clinically more advantageous than the other remains unclear.

Asymmetry indicates more severe and active disease in Graves' orbitopathy: results from a prospective cross-sectional multicentre study.

PURPOSE: Patients with Graves' orbitopathy can present with asymmetric disease. The aim of this study was to identify clinical characteristics that distinguish asymmetric from unilateral and symmetric Graves' orbitopathy. METHODS: This was a multi-centre study of new referrals to 13 European Group on Graves' Orbitopathy (EUGOGO) tertiary centres. New patients presenting over a 4 month period with a diagnosis of Graves' orbitopathy were included. Patient demographics were collected and a clinical examination was performed based on a previously published protocol. Patients were categorized as having asymmetric, symmetric, and unilateral Graves' orbitopathy. The distribution of clinical characteristics among the three groups was documented. RESULTS: The asymmetric group (n = 83), was older than the symmetric (n = 157) group [mean age 50.9 years (SD 13.9) vs 45.8 (SD 13.5), p = 0.019], had a lower female to male ratio than the symmetric and unilateral (n = 29) groups (1.6 vs 5.0 vs 8.7, p < 0.001), had more active disease than the symmetric and unilateral groups [mean linical Activity Score 3.0 (SD 1.6) vs 1.7 (SD 1.7), p < 0.001 vs 1.3 (SD 1.4), p < 0.001] and significantly more severe disease than the symmetric and unilateral groups, as measured by the Total Eye Score [mean 8.8 (SD 6.6) vs 5.3 (SD 4.4), p < 0.001, vs 2.7 (SD 2.1), p < 0.001]. CONCLUSION: Older age, lower female to male ratio, more severe, and more active disease cluster around asymmetric Graves' orbitopathy. Asymmetry appears to be a marker of more severe and more active disease than other presentations. This simple clinical parameter present at first presentation to tertiary centres may be valuable to clinicians who manage such patients.

Graves' orbitopathy as a rare disease in Europe: a European Group on Graves' Orbitopathy (EUGOGO) position statement.

BACKGROUND: Graves' orbitopathy (GO) is an autoimmune condition, which is associated with poor clinical outcomes including impaired quality of life and socio-economic status. Current evidence suggests that the incidence of GO in Europe may be declining, however data on the prevalence of this disease are sparse. Several clinical variants of GO exist, including euthyroid GO, recently listed as a rare disease in Europe (ORPHA466682). The objective was to estimate the prevalence of GO and its clinical variants in Europe, based on available literature, and to consider whether they may potentially qualify as rare. Recent published data on the incidence of GO and Graves' hyperthyroidism in Europe were used to estimate the prevalence of GO. The position statement was developed by a series of reviews of drafts and electronic discussions by members of the European Group on Graves' Orbitopathy. The prevalence of GO in Europe is about 10/10,000 persons. The prevalence of other clinical variants is also low: hypothyroid GO 0.02-1.10/10,000; GO associated with dermopathy 0.15/10,000; GO associated with acropachy 0.03/10,000; asymmetrical GO 1.00-5.00/10,000; unilateral GO 0.50-1.50/10,000. CONCLUSION: GO has a prevalence that is clearly above the threshold for rarity in Europe. However, each of its clinical variants have a low prevalence and could potentially qualify for being considered as a rare condition, providing that future research establishes that they have a distinct pathophysiology. EUGOGO considers this area of academic activity a priority.

MR dacryocystography in the evaluation of patients with obstructive epiphora treated by means of interventional radiologic procedures.

BACKGROUND AND PURPOSE: Most imaging techniques used for the evaluation of obstructive epiphora, such as DS DCG, rely on undesired ionizing radiation. We evaluated the efficacy of topical contrast-enhanced MR DCG in comparison with DS DCG in patients with obstructive epiphora who underwent balloon DCG or stent placement. MATERIALS AND METHODS: Thirty-six LDSs of 21 patients treated with balloon DCG (n = 11) or stent placement (n = 11) were examined with MR DCG and DS DCG. Contralateral LDSs (n = 14) were also evaluated in patients with unilateral disease. A sterile 0.9% NaCl solution containing 1:100 diluted gadolinium chelate was instilled into conjunctival sacs. The 3D FSPGR sequence was used with a 1.5T scanner. MR and DS DCG findings were scored and compared according to morphology of the lacrimal sac, junction, and NLD and the presence of contrast media in the nasal cavity. RESULTS: Comparison of MR DCG and DS DCG findings showed no significant statistical differences in reference to anatomic locations according to the McNemar test (P > .05). Good or very good agreement (κ value > 0.61) was observed according to the κ statistics. CONCLUSIONS: Topical contrast-enhanced MR DCG is an effective and reliable noninvasive method for evaluation of the LDS in patients treated with IR procedures. This method avoids both cannulation and ionizing radiation and can, therefore, be repeated as often as is necessary in these complex patients.

Hyperthyroidism and severity of orbital disease do not change the central corneal thickness in Graves' ophthalmopathy.

PURPOSE: To investigate whether the central corneal thickness (CCT) shows alterations in Graves disease and Graves ophthalmopathy (GO) cases according to the disease severity and hormonal status of the patients. METHODS: A total of 150 patients (62 male, 88 female) with Graves disease and 32 control subjects (11 male, 21 female) were included in the study. The patients were divided into six groups according to the severity of orbital involvement and thyroid hormone status. Best-corrected visual acuity, pupillary responses, color vision, biomicroscopy, CCT, intraocular pressure, and funduscopy were performed, and proptosis was measured with Hertel exophthalmometry in all patients. RESULTS: CCT values of patients with Graves disease and patients with GO with hyperthyroid or euthyroid hormonal status showed no statistical difference among themselves and versus control subjects (p>0.05). CONCLUSIONS: Hyperthyroidism or severity of orbital disease does not affect the CCT.

Hyperthyroidism and severity of orbital disease do not change the central corneal thickness in Graves'' ophthalmopathy.

PURPOSE: To investigate whether the central corneal thickness (CCT) shows alterations in Graves disease and Graves ophthalmopathy (GO) cases according to the disease severity and hormonal status of the patients. METHODS: A total of 150 patients (62 male, 88 female) with Graves disease and 32 control subjects (11 male, 21 female) were included in the study. The patients were divided into six groups according to the severity of orbital involvement and thyroid hormone status. Best-corrected visual acuity, pupillary responses, color vision, biomicroscopy, CCT, intraocular pressure, and funduscopy were performed, and proptosis was measured with Hertel exophthalmometry in all patients. RESULTS: CCT values of patients with Graves disease and patients with GO with hyperthyroid or euthyroid hormonal status showed no statistical difference among themselves and versus control subjects (p>0.05). CONCLUSIONS: Hyperthyroidism or severity of orbital disease does not affect the CCT.

Long-term results of balloon dacryocystoplasty: success rates according to the site and severity of the obstruction.

PURPOSE: To evaluate the long-term patency of lacrimal drainage system (LDS) after balloon dacryocystoplasty (BD) and to give the long-term success rates according to the severity and localization of the obstruction. METHODS: Between May 1993 and December 2003, BD was attempted in 117 eyes of 108 patients with idiopathic-acquired LDS obstruction. Patients with active dacryocystitis, dacryolithiasis, traumatic obstruction or lacrimal mass, obstructions at the superior or inferior canaliculi lateral to the common canaliculus, and follow-up period less than 36 months were excluded from the study. RESULTS: The results of BD were evaluated in 99 eyes of 94 cases. The obstruction was seen at the common canaliculus in seven eyes, proximal nasolacrimal duct in 70 eyes, and distal nasolacrimal duct in 22 eyes. The mean follow-up period was 100.0+/-38.4 months (range: 36-142 months). The long-term overall success rate was 40.8% (20/49 eyes) in complete obstruction and 68% (34/50 eyes) in partial obstruction. The clinical success rate was 57.1% in common canalicular (complete: 33.3%, partial: 75%), 50% in proximal nasolacrimal duct (complete: 38.5%, partial: 64.5%), and 68.2% in distal nasolacrimal duct (complete: 57.1%, partial: 73.3%) obstructions. The overall success was 54.5% (54/99 eyes) for the entire series at the last clinical follow-up visit. CONCLUSION: The long-tem success rate of BD for the treatment of epiphora is low and is not comparable to conventional dacryocystorhinostomy. More predictable results can only be achieved in carefully selected patients and this procedure can be recommended in cases demonstrating partial obstruction of the distal nasolacrimal duct.

Ascorbic acid levels in human tears after photorefractive keratectomy, transepithelial photorefractive keratectomy, and laser in situ keratomileusis.

PURPOSE: To investigate the level of ascorbic acid in human tear fluid after photorefractive keratectomy (PRK), transepithelial PRK, and laser in situ keratomileusis (LASIK). SETTING: Departments of Ophthalmology and Biochemistry, School of Medicine, Gazi University, Ankara, Turkey. METHODS: Twenty patients (7 women and 13 men) were included in this study. Traditional PRK with epithelial scraping by a blunt spatula followed by surface ablation (7 eyes), transepithelial PRK (7 eyes), or LASIK (6 eyes) was performed. Tears were collected preoperatively and 1 and 5 days postoperatively. Ascorbic acid levels were measured using 2-4 dinitrophenylhydrazine. RESULTS: Ascorbic acid levels in the tear fluid were decreased significantly 1 day after PRK, transepithelial PRK, and LASIK (P <.05). On the fifth day, the ascorbic acid levels were significantly lower than preoperatively in all groups. CONCLUSION: After PRK, transepithelial PRK, and LASIK, the ascorbic acid levels of the tear fluid decreased significantly. Because ascorbic acid is the major scavenger of superoxide radicals in tears, topical ascorbic acid therapy may help eliminate the harmful effect of free radicals from excimer laser surgery.

Laser in situ keratomileusis in an eye with congenital nystagmus.

A 38-year-old man with congenital nystagmus had laser in situ keratomileusis (LASIK) to correct a spherical equivalent of -11.0 diopters (D) in the right eye and -10.0 D in the left eye. Baseline uncorrected visual acuity (UCVA) was 20/400 in both eyes, and best spectacle-corrected visual acuity was 20/60 in the right eye and 8/20 in the left. The procedure was performed using the Aesculap Meditec MEL 60 excimer laser system and a semicircular suction ring device. Six months after LASIK, the patient had a UCVA of 20/60 in the right eye and 8/20 in the left eye, with no improvement with spectacle correction. Laser in situ keratomileusis can be performed with a semicircular suction ring device to correct refractive errors in patients with congenital nystagmus, but more cases have to be performed to confirm that the device is safe and suitable for these patients.

Results of photorefractive keratectomy in keratoconus suspects at 4 years.

PURPOSE: We studied the long-term results of photorefractive keratectomy (PRK) in keratoconus suspects detected by videokeratography (TMS). METHODS: Bilateral inferior corneal steepening was detected in 6 candidates for PRK presenting with moderate myopia or astigmatism. Mean follow-up was 44.5 +/- 4.4 months (range, 38 to 54 mo). Mean spherical equivalent refraction was -5.18 +/- 1.60 D (mean sphere, -4.73 D; mean cyclinder, -0.92 D) which was stable for at least the preceding year. The quantitative measurement of inferior corneal steepening (I-S value) was greater than +1.60 (mean, 1.83 +/- 0.11) in all eyes. An Aesculap Meditec Mel 60 excimer laser was used for the PRK procedures and mean follow-up was 44.5 months. Postoperative pachymetric measurements were also performed in 6 eyes. RESULTS: Postoperative uncorrected visual acuity was 20/20 in 8 eyes (66.6%) and 20/32 or better in all eyes with a mean postoperative spherical equivalent refraction of -0.70 +/- 0.74 D (mean sphere, -0.63 D; mean cyclinder, -0.39 D). Five eyes (41.6%) were within +/- 0.50 D spherical equivalent refraction. Inferior steepening was associated with thinning of the inferior cornea which was statistically significantly thinner than the superior thickness (Student's t-test, P < .05). There were no wound healing problems or any sign that the excimer laser adversely affected the cornea during follow-up. CONCLUSIONS: Photorefractive keratectomy seems to be a safe procedure for reducing or eliminating myopia or astigmatism in keratoconus suspect eyes-most probably forme fruste keratoconus-with a stable refraction, but this may be different in eyes with early keratoconus, known to be a progressive disease.