patients have not had previous treatment elsewhere, they tend to use intravenous high-dose glucocorticoids, consisting of 1 g methyl prednisolone for 3 days repeated if necessary over the following weeks. If no response is noted, the patient is offered an orbital decompression, whereas if there is evidence of amelioration, we continue with the high-dose glucocorticosteroids along with orbital radiotherapy. Once stability has been achieved, decompression or rehabilitative surgery may be suggested if needed.

Jack Rootman

Dr. Rootman felt that the approach described by Dr. Marcocci mirrored to a large degree that of his practice.

With moderate disease, they attempt a disease modifying approach, if possible, and sometimes do a trial of steroids. Pulsed steroids are preferred and they will wait longer than 2 weeks before repeating the course. In some instances, the wait period has lasted 6 weeks, and they have found that quite a high proportion of the patients last longer than 2 weeks.

One caveat that Dr. Rootman noted was that diabetic patients with thyroid orbitopathy are a special population. Radiotherapy is certainly contraindicated in them. In this group of patients, he has had better results with pulsed steroids in combination with some sort of immunosuppressive drug to modify the disease. Alternatively, they may proceed earlier to surgery. If a small, tight orbital apex is encountered, the orbit specialist is usually forced to do surgery as a primary event for this population, high-dose steroids would also be administered.

He agreed whole heartedly with what the panels members had said, that the patients require a lot of patience and hand-holding and that they should have a very good prospective idea of what is going to happen to them, as it is disruptive to their lives. In his experience, many of the patients are very grateful for restoring them to as close to normal as possible, which should be the goal.

Dr. Rootman made one final remark with regard to nutrition and the issue of smoking. He agreed that these patients

are better motivated to quit smoking, and many of them are interested in nutritional approaches. Indeed, the use of antioxidant therapy may not be inappropriate.

Wilmar Wiersinga

In all patients with Graves’ ophthalmopathy, euthyroidism is restored using antithyroid drugs. Patients are held on a combination of antithyroid drugs plus thyroxine until treatment for their Graves’ ophthalmopathy is complete, which may be in 2–3 years. Also, patients are asked to refrain from smoking and offered help to achieve this.

With regard to the specific treatment of Graves’ ophthalmopathy within the three categories of very severe, moderately severe, and mild disease, the very severe cases are defined as those with optic neuropathy. In this group of patients, intravenous pulses of methyl prednisolone are given, 1 g daily for three successive days in the first week and repeated in the second week. After 2 weeks, visual functions are assessed and if no improvement noted, an urgent decompression is undertaken; otherwise, they continue with oral prednisone.

Management of patients with moderately severe Graves’ ophthalmopathy is determined by the activity of the eye disease. If the eye disease is inactive in nature, a rehabilitative surgical program is initiated. If active eye disease is still present, the patients qualify for immunosuppressive treatment, and it is Dr. Wiersinga’s opinion that the most effective treatment currently is a combination of intravenous pulses of methyl prednisolone plus radiotherapy.

Probably the most difficult cases, in a way, are the patients with mild Graves’ ophthalmopathy. In a recent randomized clinical trial comparing retrobulbar irradiation with sham-irradiation in patients with mild Grave’s ophthalmopathy, they found that radiotherapy was also an effective treatment, especially for diplopia and eye muscle motility, but the effect is limited. Radiotherapy did not prevent the worsening of the ophthalmopathy, which occurred in 30% of the irradiated patients and 30% of the sham-irradiated subjects. As

a result of this study, his center continues to adopt the ‘‘wait-and-see’’ policy with the mild Graves’ ophthalmopathy patients, despite the fact that the patients themselves do not perceive their eye disease as being mild. In another study, they developed a disease-specific quality of life questionnaire and applied it to this category of patients. One of the results of their study showed that these patients felt their quality of life was low, at the same level as patients with chronic inflammatory bowel disease or diabetic patients with their complications.

It is the practice in their center to see these patients with the orbital surgeon and also with a representative of the thyroid eye disease patient association. They have found that patients derive considerable help and support when they are able to talk to a fellow patient about the process they are about to enter.

Lastly, because many investigations are often needed, frequent visits to the hospital are not uncommon, which can be a problem for the patient. At their center, they have endeavored to change this by organizing the visits all into one day. Patients arrive early in the morning and blood tests are done. All the results of the thyroid function tests and thyroid antibodies are therefore complete and available by the end of the day. During the morning, the patient will first be seen by one of the endocrinology staffs and then by orbital surgeons. In the afternoon, imaging and all other required investigations are completed. By 4:30 in the afternoon, the patient is once again seen by the endocrinologist and orbital surgeon together and a diagnosis and management plan is then offered.

QUESTION AND ANSWER SESSION

Question 1 (from R. Goldberg)

‘‘If all the experts agree that steroids are the mainstay treatment of medical Graves’ orbitopathy, I, in my practice, find periorbital steroid injections absolutely indispensable. One cc of 40 mg per cc Kenalog—I find to be clinically about as effective as a 3-week course of oral prednisone and particularly in patients that are going to require a more extended

course of steroids. It spares a lot of the systemic side effects of oral steroids. I was surprised that none of the speakers mentioned that. Is that not a popular treatment in other centers?’’

Answer

John Kennerdell responded. He did not use steroid injections. He had tried them many years ago and got more complications than justification for the treatment. He also noted that in orbital disease, he preferred not to ‘‘put things in’’ and was very much against injections.

Question 1 (continued)

‘‘I perhaps have given 500 or 800 injections and I really have not seen local complications related to the injection, but I am open-minded about it. At least my anecdotal experience is that they are safe and I think compared to the risk of continued oral steroids, the risks may favor injection, in my opinion. The injection can be periorbital with a small needle, just behind the septum or even right next to the septum. One cc of 40 mg per cc Kenalog—it does not have to be in the deep intraconal space to have a good effect.’’

Answer

Claudio Marcocci stated that his group performed a randomized trial a couple of years ago that compared the effectiveness of oral glucocorticoids and locally administered steroids. They found that the local treatment was much less effective than the general treatment. He then stated that currently they use the local injection in very, very selective cases with contraindication to systemic glucocorticoids as a treatment for ophthalmopathy.

Question 2 (from M. Potts)

‘‘I have been interested in and committed to treating thyroid eye disease as an autoimmune disease for about 10 years and in the first few years, I tried radiotherapy and steroids. They worked but they are not enough by themselves and you need