Combined radiotherapy and medical immunosuppression in the management of thyroid eye disease

Abstract

Although systemic steroids or orbital radiotherapy are effective in limiting the inflammatory response in thyroid eye disease (TED), there are reports of over 70% of treated patients requiring subsequent rehabilitative surgery: either orbital decompression or strabismus correction. This study investigated whether combined immunosuppression with primary orbital radiotherapy together with azathioprine and low-dose prednisolone, applied early in the active disease state, was more effective in treating TED. Forty consecutive patients with active TED were recruited. Orbital MRI (STIR sequence) was used to assess disease activity. Median duration of symptoms was 1.0 year. Subjects were treated with bilateral orbital radiotherapy (20 Gy in 10 fractions) and oral prednisolone and azathioprine. Pre- and post-treatment activity was measured clinically, including uniocular field of fixation, Mourits score and total eye score, until TED became inactive off all treatment. Before treatment, 15 subjects had signs of dysthyroid optic neuropathy, 35 had significant motility restriction and 38 had marked soft tissue signs. On average TED became inactive after 1.2 years (SD 0.7) of immunosuppression, and treatment was well tolerated. One patient required subsequent cosmetic orbital decompression, 6 had successful strabismus surgery and 13 required minor cosmetic lid surgery. Compared with previously reported treatment regimes we think that combined orbital radiotherapy and medical immunosuppression is far more effective than either treatment alone in the management of active TED, and led to fewer side effects of high-dose steroids. In particular there was more than a four-fold reduction in the requirement for orbital decompression and strabismus surgery.

The Role of Intravenous Methylprednisolone Immunosuppression in the Management of Active Thyroid Eye Disease

“…Immunosuppressive agents such as cyclosporine A, azathioprine, cyclophosphamide, and methotrexate have also been advocated for the treatment of active TED. 22,23 The exact role and the drug of choice have not yet been established as they are conceived to carry an unfavorable risk-benefit ratio. 3 Newer antitumor necrosis factor (anti-TNFα) antibodies have been found to be useful especially in refractive cases of TED, but their role is yet uncertain.…”

Results of a neurosurgical two‐wall orbital decompression in the treatment of severe thyroid associated ophthalmopathy

“…Response to immunosuppression on soft tissue involvement is seen in around 2/3 of the patients (Gayno & Strauch 1987), but the effect on proptosis and visual acuity is limited (Burch & Wartofsky 1993). The effect of orbital irradiation is similar (Bartalena et al 1983) although often delayed for more than a year (Claridge et al 1997). These treatment modalities may, however, not always be sufficient so in some patients orbital decompression has been performed.…”

Retrobulbäre Bestrahlung bei endokriner Orbitopathie - Erfahrungen im Langzeitverlauf

“…Frühe Studien berichteten über eine Besserung von Exophthalmus, entzündlicher Weichteilsymptomatik und Augenbeweglichkeit [7]. Eine Reihe von Arbeiten, die sich mit der Kombination verschiedener immunsuppressiver Substanzen mit der Strahlentherapie befassten, konnten einen Rückgang des Exophthalmus nicht belegen [4,16,18]. Sie diskutierten aber, dass eine Kombinationstherapie sowohl bezüglich Weichteilsymptomatik als auch Motilitätseinschränkung wirksamer sei, wenn nicht bereits fibrotische Muskelveränderung bestehen [2,4,16,18].…”