more. So in the last 6 years, and we are about to publish this, we have been using for our compressive optic neuropathy (our severe group) quadruple therapy. The quadruple therapy is you give them intravenous methyl prednisolone to recover their color vision and get their vision back. All you do is buy some time. Then you start them on azathioprine and low-dose oral steroids and orbital radiotherapy. If you give them quadruple therapy, you will find (when we produce our paper) that I have done no decompressions in the last 6 years. Also, because you return those muscles back to a normal size by immunosuppressing the disease that is going on in the muscles, we did only one squint operation in those 26 patients with dysthyroid optic neuropathy. So, if you hit them hard enough, early enough, you can reverse the process almost completely. We do end up doing a bit of lid lowering. We do a little bit of blepharoplasties, but if you use quadruple therapy, then you could switch the disease process off.’’

Answer

Jack Rootman commented that he would be interested in seeing these results as they differ from his experience. In his practice, the patients are usually not seen at an early stage of their disease but have had their ‘‘primary’’ immunologic event prior to presentation. He also expressed interest in seeing evidence of mechanical changes. In a recent study, they looked at over 200 patients treated with either corticosteroids, radiotherapy or observation and followed them for 5 years with CT imaging. Structurally, the muscles did not change in size; they may physically behave differently but they did not change in size.

Question 2 (continued)

‘‘If you use MRI scanning, particularly STIR sequence scanning, you look at the amount of water in them and the water loading goes down; but you have to get these patients very early in their disease when there is mainly lymphocytes, before the fibroblasts proliferate. I think once the fibroblasts have proliferated, laid down the collagen, you have missed

the boat. In the West Country, all the endocrinologists are very educated and send the patients very early to me. If you hit them very hard in that early sensitive phase, you can switch the whole disease process off.’’

Question 3

‘‘I have got a three-part question. Dr. Wiersinga, am I to understand that when you are going to use steroids in patients with thyroid eye disease, your initial dose is IV pulsed? Is there a role for oral steroids at all in your treatment with thyroid eye disease, or I am getting an impression from the panel that everybody is going to IV pulsed steroids first. If you are going to use steroids, you might as well use them in big doses. Is that correct?’’

Answer

In his opinion, Dr. Wiersinga felt that the efficacy of IV pulsed steroids is higher than that of oral steroids, and that the side effects of IV pulsed steroids are less than those of oral steroids. However, there have been two deaths reported from IV pulses, one from Vienna and the other from Pisa, with both patients dying from liver failure. Although it is a fairly rare event, severe liver function disorders can result from IV pulses. This has not been encountered in other diseases in which these IV pulses have been applied, such as rheumatoid arthritis, so some caution may be needed. The cumulative dose of glucocorticoids given by IV pulses is usually much higher than the cumulative dose of oral prednisone, so the question arises as to whether the difference in total glucocorticosteroid dose is factor. It is probably but there is also a suggestion from the Italians that if the total dose of IV glucocorticoids does not exceed 8 g, the severe side effects from the liver may be avoided.

Question 3 (continued)

‘‘As a neuro-ophthalmologist, I use IV pulsed steroids constantly for patients with demyelinating disease and with

reckless abandon. In fact, we have done quite well with it and now do it as home therapy, but the question really was what is the role for oral prednisone because many patients come to me from endocrinologists saying, ‘I will start them on 40 mg or 60 mg and you can see them.’ My answer is ‘‘to let me see them first and then possibly just do 1000 mg IV pulses. It makes better sense and I am not afraid to use that dose at all.’’

Answer

Jack Rootman commented that the biological difference between oral and IV steroids had not been brought forward. He has been very disillusioned with oral steroids because of the many side effects. As an ocular oncologist, he has had many discussions with pediatric oncologists about the use of oral steroids vs. IV pulsed steroids. In the treatment of lymphoma, a difference is noted. There is a lymphocytolysis that occurs with high-dose pulsed steroids that does not happen with oral corticosteroids, so there is something of a biologic rationale for that idea. There are a lot less of the other side effects with IV pulsed steroids so he is much more comfortable using it. In his practice, it is done as an outpatient procedure.

Question 3 (continued)

‘‘I have also been impressed that we have not induced diabetes in patients who are diabetic, as sugar is not going up with IV pulses as opposed to oral. My second question is to Dr. Rootman. You alluded to the fact that you liked the transcaruncular approach to the medial orbital decompression. Is this to replace the endoscopic endonasal ENT approach, or which one do you like better?’’

Answer

In response, Dr. Rootman felt that he could see the orbit better using the more direct orbital approaches, in fact, a lot

better than looking up through the nose. He prefers it because it is a clear approach for him.

Question 3 (continued)

‘‘The last question is for Dr. Kennerdell. I agree with you that in our institution also, I have had a great experience with radiotherapy, but had a recent very interesting experience with a call from an insurance company quoting the Mayo Clinic article saying, ‘‘But radiation does not work and you are asking me to approve a $12,000 therapy for your patient.’’ I got around it by saying that it was not for severe ophthalmopathy and our patient had severe orbitopathy. They kind of believed me and approved it, but what is your indication to use radiation therapy and if you have had this problem with the insurance companies quoting the Mayo Clinic literature that says it does not work?’’

Answer

John Kennerdell emphasized once again that they as a group believe that radiotherapy works in carefully selected patients. The carefully selected individualization of these patients is what is required. He believes that radiotherapy does not work in chronic patients and is not effective in patients that are subacute. However, radiotherapy does work in patients that are acute, with or without optic neuropathy.

Dr. Kennerdell made an additional comment with regard to the first question posed, regarding peribulbar steroid injections. The results of using of injected peribulbar steroids, in his experience, were variable and the complications high.

With regard to oral steroids, he generally uses steroids as a test for whether radiation therapy will work, but he tends to use oral steroids less and less. If steroids are used, usually in acute congestive patients whether they have optic neuropathy or corneal exposure, he tends to administer it in a high-dose fashion, as has been described, and will switch to oral steroids if they work and continue to work. Generally, if after a week the patient continues to have a good response, he will proceed with radiation therapy combined with oral steroids while the