| Heufelder et al., Marburg, Germany, treated 16 patients with OGD, who were resistant to treatment with prednisone + orbital irradiation, with methotrexate 15 mg/week. Response to therapy was assessed by clinical activity scores (CAS) and NOSPECS. A successful outcome was observed in 12 patients at 6 weeks of therapy, largely due to changes in soft tissue involvement, eye muscle motility and proptosis. TRAK measurements that were elevated in 15/16 patients prior to therapy declined markedly in 13/15 patients. Serious side effects were not observed and the authors conclude that methotrexate therapy may be effective and well tolerated in active OGD patients who are resistant to prednisone + orbital irradiation. (Comment: This is a new development in treatment of OGD that is most welcome.) Stamato et al., Sao Paulo, Brazil, compared the effectiveness of 1.5 mg/day colchicine for 3 months versus 0.75 mg/kg/day prednisone for 1 month and subsequently decreasing to zero in 2 months, in two groups each of 10 patients with active OGD who were euthyroid for at least 3 months. Success rate was assessed by clinical activity score (CAS) and MRI. All patients showed symptomatic relief and improvement in appearance. Inflammatory symptoms decreased in 100% of orbits in colchicine treated patients and in 85% in prednisone treated patients. CAS decreased in 10 orbits (50%) and 11 orbits (55%) of these groups respectively. MRI abnormalities decreased similarly in both groups. No side effects of colchicine were seen. (Comment: The following step is to evaluate if colchicine has an effect on CAS in prednisone resistant patients with OGD and vice versa.) Rendl et al., Würzburg, Germany, performed iodine-123-interleukin-2 orbital scintigraphy in 2 patients with active OGD, 2 patients with inactive OGD, and 4 controls. Uptake in active OGD orbits was two times higher than in controls, while uptake in inactive OGD was not different from controls. (Comment: This study shows results that are interesting but very preliminary. If confirmed, interleukin-2 may be of use both in diagnosis. What about basiliximab [IL-2 receptor antagonist] for treatment in scintigraphy - pos. patients?) Inaba et al., Osaka, Japan, measured retinal blood flow by pulsed Doppler mode at the branch of the central retinal artery from which a resistant index (RI) was calculated in 47 patients with treated OGD versus 70 age- and sex-matched normal controls. RI and proptosis were positively correlated in OGD subjects but not in controls. Antithyroid drug treatment in 20 Graves' disease patients with OGD significantly reduced RI during the course of medication. The reduction in RI during drug treatment significantly correlated with pulse pressure and ultrasound distensibility of the carotid artery. Patients with OGD only to fat accumulation had normal RI in contrast to patients with extraocular muscle enlargement. The authors suggest that RI changes may result from cardiovascular effects and/or activity of retro-obital inflammation in extraocular muscles. Terwee et al., Amsterdam and Utrecht, The Netherlands, discussed interpretability of changes in quality of life assessment in OGD patients in different categories depending on aim of treatment i.e. improvement of visual functioning or of appearance. The patients were divided in different treatment groups such as radiotherapy, decompression, eyelid lengthening, and blepharoplasty. On the basis of their analysis and depending on the setting of the study they suggest that a change in 6 points of this score indicates a significant change in daily functioning of patients for less than major therapies. For major therapies, however, at least a change of 10 points indicates significant improvement. Prummel et al., Amsterdam and Utrecht, The Netherlands, performed a randomized placebo-controlled study on the beneficial effects of radiotherapy in patients with mild OGD. Eighty-eight consecutive patients with mild OGD, defined as mild eye muscle motility impairment and absence of severe soft tissue swelling, proptosis, or impaired visual acuity, were either irradiated (10 daily fractions of 2 Gy each) or sham irradiated. All patients were euthyroid for >2 months and untreated for OGD. Radiotherapy resulted in a success rate of 52% versus 27% in sham irradiated subjects. The quality of life score improved similarly in both groups. The authors conclude that, although radiotherapy is effective, in this group of patients the improvements are too modest to justify its routine use in such patients. Wakelkamp et al., Amsterdam, The Netherlands, measured soluble factors of adhesion molecules in 62 patients with untreated OGD and 62 controls matched for sex, age and smoking habits. The following factors were measured: sICAM-1, sVCAM-1, and sELAM-1. They found that these three factors were elevated in OGD as compared to controls, and that smoking is associated with increased sICAM-1 and lower sVCAM-1 levels independently of the presence or absence of OGD. Furthermore, sICAM-1 levels correlated with severity of OGD. (Comment: These results are interesting as adhesion molecules play a key role in autoimmune inflammatory processes and part of these adhesion molecules can circulate in blood as soluble factors.) Marino et al., Pisa, Italy, investigated if thyroglobulin was present in retroorbital tissues of 3 patients with OGD who were operated for decompression and compared the results with extraocular tissue obtained from 2 autopsies of subjects without OGD or thyroid disease. They found intact Tg both in soluble and membrane-associated fractions of orbital tissue extracts in patients but not in controls. An anti-T4 antibody captured Tg in orbital tissues of patients indicating that this Tg was of thyroidal origin. The investigation was done by the authors as it has been suggested in the past that Tg may migrate from the thyroid to the retroorbital tissues and may act as an antigen in the development of OGD in patients with Graves' disease. (Comment: The theory that thyroglobulin could migrate to the orbita and act as an antigen in the development of OGD was advanced by J.P. Kriss in the early 70's and is still not excluded as a realistic possibility. The number of subjects in the here reported study are very limited but the results are of interest.) |
