Objective Diplopia Outcomes for Patients Treated With Teprotumumab for Thyroid Eye Disease.

BACKGROUND: Thyroid eye disease (TED) is a condition caused by inflammatory damage to the periocular tissue that often leads to double vision. Teprotumumab is an insulin-like growth factor 1 receptor antibody that was FDA approved for the management of TED in 2020, although much is yet to be elucidated regarding its effects on diplopia outcomes among patients with TED. Diplopia is a significant and life-altering effect of TED. Previous studies have reported the effect of teprotumumab on double vision subjectively using the Gorman diplopia score. However, there is a gap in the literature addressing the effect of teprotumumab treatment on objective ocular alignment measures. The purpose of our study was to address this gap. METHODS: We performed a retrospective review of patients who were diagnosed with TED, presented with diplopia, and treated with teprotumumab in a single-center academic ophthalmology practice. The primary outcome was change in ocular alignment in primary gaze position at 6 months (completion of teprotumumab treatment). Secondary outcomes included change in ocular alignment in other gaze positions, proptosis, eyelid position, and clinical activity score (CAS) at 6 months compared with baseline. To determine what factors may predict ocular alignment response to teprotumumab, we analyzed baseline characteristics among 3 groups, divided based on whether ocular alignment was worsened, stable, or improved at 6 months. RESULTS: Seventeen patients met inclusion criteria, 3 (18%) worsened, 10 (59%) were stable, and 4 (24%) improved. CAS ( P = 0.02) was significantly different among the groups and was higher in those who worsened and those who improved compared with those who remained stable. Right gaze horizontal prism deviation ( P = 0.01) and left gaze horizontal prism deviation ( P = 0.03) were significantly different among the groups, with a greater degree of left gaze horizontal prism deviation in the worse group than the stable group ( P = 0.04). CONCLUSIONS: Our study demonstrated that most patients remained stable after teprotumumab treatment regarding ocular alignment in primary gaze and the number of patients who improved was slightly higher than the number of patients who worsened after teprotumumab treatment. There are some baseline measures, such as CAS and right and left gaze horizontal prism deviation that can help better predict how a patient will respond to teprotumumab treatment. Our results can better inform physicians of how to counsel patients with TED when considering teprotumumab therapy.

Stability of Ocular Alignment After Teprotumumab Therapy in a Cohort of Patients With Thyroid Eye Disease and Baseline Diplopia.

BACKGROUND: Teprotumumab is a monoclonal antibody that is effective in treating patients with thyroid eye disease (TED) and has been shown to produce subjective improvements in diplopia in this group. The aims of this study were to evaluate the rate and timing of recurrence/worsening of diplopia after teprotumumab treatment in a cohort of patients with TED presenting with diplopia at baseline. METHODS: A retrospective chart review of 15 patients with diplopia secondary to TED, treated with teprotumumab, was conducted in a single-center academic institution. The primary outcome was the rate of recurrence/worsening of diplopia after completing teprotumumab. Secondary outcomes include the time to recurrence/worsening of diplopia and clinical activity scores (CAS) to correlate with changes in ocular alignment. RESULTS: Fifteen patients met the inclusion criteria for this study, and 7 of these had recurrence of diplopia (46.7%). Two patients had worsening of CAS to ≥4, 6 had worsening of CAS to 3, and the other 7 had CAS ≤2 during the follow-up period. The mean follow-up period was 20.4 months (SD 7.2) after completing teprotumumab. The mean time to diplopia recurrence/worsening was 8.8 months (range 6.7-12.2, SD 1.8). CONCLUSIONS: Patients with TED and baseline diplopia have a substantial rate of recurrence/worsening of diplopia after teprotumumab therapy, suggesting that they may not have stable ocular alignment immediately after treatment. Strabismus surgeons may need to weigh the significant risk of disease relapse when planning optimum timing for surgical correction.

Perspectives on Application and Interview Capping in Residency Selection of Surgical Subspecialties.

OBJECTIVE: With the advent of virtual interviews, the potential for interview hoarding by applicants became of greater concern due to lack of financial constraints associated with in-person interviewing. Simultaneously, the average number of applications submitted each year is rising. Currently there is no cap to the number of applications or interviews an applicant may complete when applying to residency, with the exception of ophthalmology with a cap of 15 interviews. No studies have assessed the applicants' perspectives on an application or interview cap. We assessed the attitudes of surgical subspecialty applicants towards capping, which may be useful when considering innovations in residency selection. DESIGN/SETTING/PARTICIPANTS: About 1841 applicants to the Johns Hopkins' ophthalmology, urology, plastic surgery, and orthopedic surgery residency programs from the 2022-2023 cycle were invited to respond to a 22-item questionnaire. Statistical analyses of aggregate data were conducted using R. RESULTS: Of the 776/1841 (42%) responses, 288 (40%) were in support of an application cap, while 455 (63%) were in support of an interview cap. Specialty (p < 0.001), gender (p < 0.001), taking a gap year (p = 0.02), medical school region (p = 0.04), and number of interviews accepted off of a waitlist (p = 0.01) were all significantly associated with a difference in opinion regarding an application cap. Specialty (p < 0.001), USMLE Step 1 score (p = 0.004), number of interviews (p < 0.001), and number of programs ranked (p < 0.001) were all significantly associated with a difference in opinion regarding an interview cap. Of those applicants who were in support of the respective caps they believed that on average a cap should consist of 48.1 (16.1) applications and 16.0 (8.0) interviews. CONCLUSIONS: Our findings highlight the desire for interview caps among the majority of applicants to surgical subspecialties and thus this innovation may be considered by other specialties in the era of virtual interviews.