EZH2 as a major histone methyltransferase in PDGF-BB-activated orbital fibroblast in the pathogenesis of Graves' ophthalmopathy.

Graves' ophthalmopathy (GO) is an extra-thyroidal complication of Graves' disease which can lead to vision loss in severe cases. Currently, treatments of GO are not sufficiently effective, so novel therapeutic strategies are needed. As platelet-derived growth factor (PDGF)-BB induces several effector mechanisms in GO orbital fibroblasts including cytokine production and myofibroblast activation, this study aims to investigate the roles of histone lysine methyltransferases (HKMTs) in PDGF-BB-activated GO orbital fibroblasts by screening with HKMTs inhibitors library. From the total of twelve selective HKMT inhibitors in the library, EZH2, G9a and DOT1L inhibitors, DZNeP, BIX01294 and Pinometostat, respectively, prevented PDGF-BB-induced proliferation and hyaluronan production by GO orbital fibroblasts. However, only EZH2 inhibitor, DZNeP, significantly blocked pro-inflammatory cytokine production. For the HKMTs expression in GO orbital fibroblasts, PDGF-BB significantly and time-dependently induced EZH2, G9a and DOT1L mRNA expression. To confirm the role of EZH2 in PDGF-BB-induced orbital fibroblast activation, EZH2 silencing experiments revealed suppression of PDGF-BB-induced collagen type I and α-SMA expression along with decreasing histone H3 lysine 27 trimethylation (H3K27me3) level. In a more clinically relevant model than orbital fibroblast culture experiments, DZNeP treated GO orbital tissues significantly reduced pro-inflammatory cytokine production while slightly reduced ACTA2 mRNA expression. Our data is the first to demonstrate that among all HKMTs EZH2 dominantly involved in the expression of myofibroblast markers in PDGF-BB-activated orbital fibroblast from GO presumably via H3K27me3. Thus, EZH2 may represent a novel therapeutics target for GO.

Selenium supplementation in inactive moderate to severe Graves' orbitopathy patients: a randomized controlled trial.

PURPOSE: This study was designed to evaluate the effect of selenium supplementation in inactive moderate-severe Graves' orbitopathy (GO) patients. METHODS: This study was a single-center, placebo-controlled, double-masked, randomized trial. Inactive moderate-severe GO participants were randomized to receive six months of 200 micrograms/day of selenium supplementation or placebo. Thorough eye exams, clinical activity score (CAS), Graves' Ophthalmopathy quality of life questionnaire (GO-QOL), and serum selenium level were evaluated at baseline and 6 months after the interventions. The chi-squared or Fisher's exact test was used to compare categorical variables. The t-test and the paired t-test were used to compare continuous variables between two independent samples and two dependent samples, respectively. RESULTS: A total of 25 participants were enrolled, 13 in the selenium group and 12 in the placebo group. Both groups had adequate baseline serum selenium levels at 98.96 ± 15.63 mcg/L and 102.55 ± 17.71 mcg/L, respectively. After 6 months of intervention, the selenium group showed a greater improvement in palpebral aperture (mean difference: -1.4 ± 1.7 mm, p = .04) compared to the placebo group (-0.3 ± 2.7 mm). Notably, 5(41.67%) people in the placebo group developed larger palpebral apertures. Proptosis, ocular motility, and soft tissue signs did not change significantly. GO-QOL and CAS score improvement showed no statistically significant difference between both groups. Minor adverse effects were observed. CONCLUSIONS: Selenium supplementation has a positive effect on eyelid aperture even in inactive moderate-to-severe GO patients with a sufficient baseline selenium level.

Epiphora before and after upper eyelid functional blepharoplasty: A retrospective cohort study.

Epiphora and dermatochalasis are common presentations in the ophthalmology clinic. To evaluate the change of epiphora before and after functional blepharoplasty, this retrospective cohort study reviewed 39 medical records of epiphora patients who underwent upper blepharoplasty. Severity of epiphora using MUNK score was collected and compared between before and at 6 months after blepharoplasty. The analysis model was performed to measure tear breakup time (TBUT) and frequency of artificial tears use. Subgroups of subjects before blepharoplasty to short baseline TBUT (≤ 10 seconds) and long TBUT (≥ 10 seconds) were also evaluated for the MUNK score change. From the analysis of 39 patients, the results showed a statistically significant decrease in post blepharoplasty MUNK score compared to the baseline (all P < 0.001). There was no significant difference between baseline and post-operative TBUT (P > 0.05). Twenty patients were in the short TBUT group and 19 in the long TBUT group. The reduction of MUNK score after blepharoplasty in the short TBUT group was not different to the long TBUT group (P = 0.50, 95% CI -0.84 to 0.41). However, in short TBUT group, frequency of artificial tears use after surgery was less than pre-operation. From the study, upper eyelid blepharoplasty might be one technique reducing the bothersome epiphora in dermatochalasis patients.

Histone Deacetylase 4 Controls Extracellular Matrix Production in Orbital Fibroblasts from Graves' Ophthalmopathy Patients.

Background: Graves' ophthalmopathy (GO) is an autoimmune eye disease with the characteristic symptoms of eyelid retraction and proptosis. Orbital fibroblast activation induced by platelet-derived growth factor-BB (PDGF-BB) stimulation plays a crucial role in GO pathogenesis, leading to excessive proliferation and extracellular matrix production by orbital fibroblasts. Currently, GO treatment options remain limited and novel therapies including targeted drugs are needed. Histone deacetylases (HDACs) are associated with the development and progression of several cancers and autoimmune diseases by epigenetically controlling gene transcription, and HDAC inhibitors (HDACis) may have therapeutic potential. Nevertheless, the role of HDACs in orbital fibroblasts from GO is unknown. Therefore, we studied the expression of HDACs as well as their contribution to extracellular matrix production in orbital fibroblasts. Methods: Orbital tissues were obtained from GO patients (n = 18) who underwent decompression surgery with approval from the Institutional Review Board of the Faculty of Medicine (Protocol number 401/61), Chulalongkorn University (Bangkok, Thailand). Furthermore, orbital tissue was obtained from control patients (n = 3) without inflammatory or thyroid disease who underwent surgery for cosmetic reasons. Orbital fibroblast cultures were established from the orbital tissues. HDAC mRNA and protein expression in orbital fibroblasts was analyzed by reverse transcription-quantitative real-time PCR and Western blot. PDGF-BB-activated orbital fibroblast and orbital tissues were treated with HDACis or HDAC4 small-interfering RNA. Results: PDGF-BB-stimulated orbital fibroblasts had upregulated HDAC4 mRNA and protein expression. HDAC4 mRNA expression was significantly higher in GO compared with healthy control orbital fibroblasts. Histone H3 lysine 9 acetylation (H3K9ac) decreased upon PDGF-BB stimulation. Treatment with HDAC4i (tasquinimod) and HDAC4/5i (LMK-235) significantly decreased both proliferation and hyaluronan production in PDGF-BB-stimulated orbital fibroblasts. HDAC4 silencing reduced mRNA expression of hyaluronan synthase 2 (HAS2), collagen type I alpha 1 chain (COL1A1), Ki67, and α-smooth muscle actin (α-SMA), as well as hyaluronan production in PDGF-BB-stimulated orbital fibroblasts. Tasquinimod significantly reduced HAS2 and α-SMA mRNA expression in whole orbital tissue. Conclusion: Our data indicated, for the first time, that altered HDAC4 regulation along with H3K9 hypoacetylation might represent a mechanism that contributes to excessive proliferation and extracellular matrix production by orbital fibroblasts in GO. HDAC4 might represent a novel target for GO therapy.

Meibomian glands dropout in patients with inactive thyroid related orbitopathy.

PURPOSE: To evaluate the structure and function of meibomian glands in patients with thyroid related orbitopathy (TRO) compared with age- and sex-matched controls without TRO. METHODS: This cross-sectional study included 106 eyes of 53 patients with TRO and 106 eyes of 53 age- and sex-matched controls without TRO. Patients with TRO were assessed for thyroid hormone status, activity and severity of TRO. All participants completed OSDI questionnaires. Their meibomian glands' structure and function were assessed, including the area of meibomian gland dropout, lipid layer thickness (LLT), meibum expressibility and quality scores, tear break-up time (TBUT), corneal and conjunctival staining scores. A generalized estimating equation (GEE) was used to compare between the two groups. The correlations between the area of meibomian gland dropout with symptoms and signs of TRO were evaluated using GEE and Spearman correlation. RESULTS: All patients with TRO had inactive status. The mean area of meibomian gland dropout was higher in the TRO group (34.5±11.2%) compared with that of controls (30.1±10.7%, P = 0.03). Both mean meibum quality (TRO, 1.6±0.7; Controls, 2.0 ±0.5) and expressibility (TRO, 1.5 ±0.7; Controls, 1.7 ±0.6) scores were slightly better in the TRO group compared with those of controls (P = 0.01). There was no significant difference in OSDI, corneal and conjunctival staining, TBUT and LLT. The area of meibomian gland dropout in patients with TRO was correlated with euthyroid status (P<0.05) and lagophthalmos (P = 0.03). CONCLUSIONS: Patients with inactive TRO showed significantly higher meibomian gland dropout compared with that of age- and sex-matched controls without TRO.

Clinical presentation and treatment outcomes of primary ocular adnexal MALT lymphoma in Thailand.

BACKGROUND: Primary ocular adnexal extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (POML) is the most common subtype of lymphoma involving the eyes in Thailand. We sought to assess the characteristics and treatment outcomes of patients with POML in Thailand. METHODS: We retrospectively reviewed patient data and included patients diagnosed with POML between January 2004 and December 2016 at Chiang Mai University Hospital and King Chulalongkorn Memorial Hospital, Thailand. We collected and analyzed patients' clinical characteristics and treatment outcomes. RESULTS: Among 146 patients with lymphoma involving the eyes, 121 (82%) were diagnosed with POML. Sixty-four (52.9%) were women with median age 58 (range, 22-86) years. The most common presenting symptom was orbital mass (71.1%). Common sites of origin were the orbit (46.3%) and lacrimal gland (34.7%). At presentation, 22.3% of patients had bilateral eye involvement. About half of patients had stage I disease (N=59, 56.2%) and 20% had stage IV. Most patients (73.3%) had a low-risk International Prognostic Index. Radiotherapy was the main treatment for patients with limited-stage disease (66.7% in stage I and 56.5% in stage II). The overall response rate was 100% with complete response rates 80%, 77.3%, and 64.7% for stages I, II, and IV, respectively. Five-year progression-free survival (PFS) and overall survival were 66.1% and 94.0%, respectively. For patients with limited-stage disease, radiotherapy significantly improved PFS compared with treatment not involving radiotherapy (5-year PFS 89.9% vs. 37.3%, P=0.01). CONCLUSION: We revealed that POML has good response to treatment, especially radiotherapy, with excellent long-term outcome.

Orbital myeloid sarcoma in adult mimicking nasolacrimal duct obstruction: A case report.

PURPOSE: To describe an orbital myeloid sarcoma in adult presenting with a swollen mass at inferomedial canthal area and epiphora which was misdiagnosed as nasolacrimal duct obstruction. OBSERVATIONS: A 45-year-old male presented with a swollen right lower eyelid around medial canthal area for 2 months with tearing for 6 month-period earlier. Eye examination demonstrated a high tear meniscus, slightly erythematous eyelid with palpable mass closed to the lacrimal sac along the inferior orbital rim. Computed tomography scan depicted infiltrative mass at the inferomedial aspect of right orbit with bony erosion, extended to adjacent paranasal sinuses. An incisional biopsy was performed. Histopathological study revealed soft tissue which was diffusely infiltrated by monotonous medium-sized round cells resembling blasts with lymphoglandular bodies, focally positive myeloperoxidase and negative lymphoid markers. The findings were consistent with myeloid sarcoma. No systemic involvement was found. The patient underwent chemotherapy and radiation without systemic leukemic disease progression. CONCLUSIONS AND IMPORTANCE: Although orbital myeloid sarcoma is rare and difficult to diagnose, it can mimic nasolacrimal duct obstruction. We should consider this condition in our differential diagnosis.