Monteiro MLR, Gonçalves ACP, Silva CTM, Moura JP, Ribeiro CS, Gebrim EMMS. Diagnostic ability of Barrett's index to detect dysthyroid optic neuropathy using multidetector computed tomography. Clinics. 2008;63:301-6. OBJECTIVES:The objective of this study was to evaluate the ability of a muscular index (Barrett's Index), calculated with multidetector computed tomography, to detect dysthyroid optic neuropathy in patients with Graves' orbitopathy. METHODS: Thirty-six patients with Graves' orbitopathy were prospectively studied and submitted to neuro-ophthalmic evaluation and multidetector computed tomography scans of the orbits. Orbits were divided into two groups: those with and without dysthyroid optic neuropathy. Barrett's index was calculated as the percentage of the orbit occupied by muscles. Sensitivity and specificity were determined for several index values. RESULTS: Sixty-four orbits (19 with and 45 without dysthyroid optic neuropathy) met the inclusion criteria for the study. The mean Barrett's index values (± SD) were 64.47% ± 6.06% and 49.44% ± 10.94% in the groups with and without dysthyroid optic neuropathy, respectively (p<0.001). Barrett's index sensitivity ranged from 32% to 100%, and Barrett's index specificity ranged from 24% to 100%. The best combination of sensitivity and specificity was 79%/72% for BI=60% (odds ratio: 9.2). CONCLUSIONS: Barrett's Index is a useful indicator of dysthyroid optic neuropathy and may contribute to early diagnosis and treatment. Patients with a Barrett's index ≥60% should be carefully examined and followed for the development of dysthyroid optic neuropathy.

Objective: To report the use of sodium diclofenac, an antagonist of PPAR-gamma and cyclooxigenase-2 (COX-2) inhibitor in the treatment of mild to moderate Graves' ophthalmopathy. Subjects and methods: Thirteen patients with clinical activity score (CAS) 2 to 7 were treated during a period ranging from 3 to 12 months (mean 7.8 ± 3.4) with oral sodium diclofenac, 50 mg every 12 hours. Results: Extra-ocular muscle restriction and CAS improved significantly, p = 0.003 and = 0.004, respectively. Ocular pain and diplopia disappeared, except for one patient who reported improvement of these symptoms. No recurrence was found after interruption of treatment. Conclusions: Treatment of moderate Graves' ophthalmopathy with oral sodium diclofenac is a good, safe and less expensive therapeutic option. Like others new treatment trials, findings must be confirmed in a greater number of patients in a controlled study. Arq Bras Endocrinol Metab. 2011;55(9):692-5

There was no significant difference between the results of the isolated antral-ethmoidal orbital decompression and that associated with orbital fat removal. The removal of 1 ml of seems not to improve the retroplacement of the globe as an association with a 2-wall orbital decompression. However, many conditions must be considered to conclude any comparison between the two orbital decompression techniques, such as orbital soft tissue compliance, amount of fat removal and size of bone opening.

Background Graves’ disease (GD) is an autoimmune thyroid disease usually associated with hyperthyroidism. There have been cases of patients switching from hyperthyroidism to hypothyroidism, and even rarer patients flipping from hypothyroidism to hyperthyroidism. However, a case of spontaneously alternating hyperthyroidism and hypothyroidism in GD is comparably an even rarer phenomenon. It is thought that the switching of stimulating TSH receptor antibodies (TSAb) and blocking TSH receptor antibodies (TBAb) has a role in alternating thyroid function. We present a case of spontaneously oscillating thyroid function, pretibial myxedema and achropachy in three months. CASE REPORT 50 y,m,active smoker(90 yr old), weight loss (12 kg),tremors, irritability,proptosis,bad sensation eyes and acropachy(FigE) hyperthyroidism and ophthalmopathy secondary GD,underwent irregular treatment with methimazole 1st y. After1y, Graves' ophthalmopathy was worsened CAS 9(FigAB),with stereotactic radiotherapy, 10sec, 20Gy,pulse methylprednisolone followed by oral prednisone and decompressive surgery, initially used methimazole 30mg/d with reduction to 10mg/d.After 3 months of corticotherapy the patient returns with complaints of intestinal constipation, asthenia, brittle nails, the appearance of pre-tibial myxedema (FigC), being confirmed hypothyroidism frankly associated with the increase of thyroid autoantibodies (tb1), thyroid USG showing parenchyma with diffuse and grossly heterogeneous ecotexture and reduced echogenicity, diffusely increased vascularization, total thyroid volume of 33.4 ml (FigD). Patient maintained ambulatory follow-up, maintaining hypothyroidism on remission with levothyroxine 6 months ago. DISCUSSION This's the first case presenting hyperthyroidism shift to abrupt hypothyroidism with myxedema and acropachy in patient with GO. GD spontaneous change from hyperthyroidism to hypothyroidism (without ablative radioactive iodine intervention or treatment with antithyroid drugs) can occur in two ways: by the unexpected development of TBI (TSH receptor blocking immunoglobulin); or by chronic lymphocytic thyroiditis surpassing the stimulatory effects of TSI (Immune Globulin stimulating TSH receptors). The shift from TSI to TBI, with changes in immunoglobulin concentration, affinity and potency, leading to TBI dominance, is usually associated with the use of DAT (antithyroid drugs) and immunosuppressive states. We describe a case of hyperthyroidism due to GD evolving with frank hypothyroidism probably related to the alternation of TSI to TBI, with a predominance of the TBI effect, with onset after immunosuppressive therapy with corticosteroids. CONCLUSION The occurrence of a shift of predominance of the stimulatory effect to the inhibitor on TSH receptors emphasizes the need for careful monitoring of patients with Graves' disease.