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Frontiers in Endocrinology 2023The effects of various treatments on Graves' ophthalmopathy (GO) have been studied. As monoclonal antibodies (mAbs) have been proposed for the treatment of moderate to... (Meta-Analysis)
Meta-Analysis
BACKGROUNDS
The effects of various treatments on Graves' ophthalmopathy (GO) have been studied. As monoclonal antibodies (mAbs) have been proposed for the treatment of moderate to severe GO, direct comparisons between different mAbs are lacking.We therefore conducted this meta-analysis to objectively compare the efficacy and safety of intravenous mAbs.
METHODS
To identify eligible trials, references published before September 2022 were electronically searched in PubMed, Web of Science, Pubmed, Embase,Cochrane Library, CBM, CNKI,Wan-Fang and ICTRP databases.The Newcastle-Ottawa scale (NOS) and the Cochrane Risk of Bias Assessment Tool were used to assess the risk of bias of the original studies.The primary and secondary outcomes were the response and inactivation rates, with the secondary outcomes being the clinical activity score (CAS),the improvement of proptosis and diplopia improvement,and the adverse event rate. Publication bias was evaluated, along with subgroup and sensitivity analyses.
RESULTS
A total of 12 trials with 448 patients were included. The meta-analysis showed that TCZ (tocilizumab) was most likely to be the best treatment in terms of response according to indirect contrast, followed by TMB (teprotumumab) and RTX (rituximab).TCZ, followed by TMB and RTX, was also most likely to be the best treatment in terms of reducing proptosis. In terms of improving diplopia, TMB was most likely to be the best treatment, followed by TCZ and RTX.TCZ was the highest probability of safety, followed by RTX and TMB.
CONCLUSIONS
Based on the best available evidence,TCZ should be the preferred treatment for moderate to severe GO.In the absence of head-to-head trials,indirect comparisons of treatments are routinely used to estimate the effectiveness of the treatments of interest. In addition,the optimal dose and potential mechanism of action of monoclonal antibodies remain to be established,and it is encouraging that the treatment paradigm for GO may change in the future.This study was designed in accordance with the Preferred Reporting Items for conducting Systematic Reviews and Meta-Analyses (PRISMA)(27).
SYSTEMATIC REVIEW REGISTRATION
http://www.crd.york.ac.uk/prospero, identifier CRD42023398170.
Topics: Humans; Antibodies, Monoclonal; Immunoglobulins, Intravenous; Diplopia; Rituximab; Graves Ophthalmopathy; Exophthalmos
PubMed: 37288301
DOI: 10.3389/fendo.2023.1160936 -
Romanian Journal of Ophthalmology 2022Orbital myositis is a rare clinical condition that involves idiopathic inflammation mostly of extraocular muscles. The purpose of this study was to present a diagnostic...
Orbital myositis is a rare clinical condition that involves idiopathic inflammation mostly of extraocular muscles. The purpose of this study was to present a diagnostic and treatment plan of orbital myositis. A 60-year-old female presented with decreased visual acuity on her left eye, ocular hypertension, restricted and painful left abduction, diplopia, swollen eyelids, and orbital discomfort. MRI, as well as ultrasound, showed enlargement in width of medial rectus muscle. After other diagnoses were excluded, the diagnosis of left orbital myositis was established. She was started on systemic corticosteroid treatment, but each time the steroid dose was tapered she experienced a relapse. Immunosuppressive therapy was introduced and the steroid dose was gradually tapered and excluded. One year after immunosuppressive therapy, the clinical findings improved. The diagnosis of orbital myositis requires detailed examination, laboratory testing and MRI scans of the orbits in order to exclude other diseases with similar clinical findings. The first line treatment option is systemic corticosteroid therapy with additional immunosuppressive therapy if needed. MRI = magnetic resonance imaging, BCVA = best corrected visual acuity, ENT = ear, nose, throat specialist, CBC = complete blood count, WBC = white blood cell, ESR = erythrocyte sedimentation rate, CRP = C reactive protein, HM = hand motion, TED = thyroid eye disease, SLE = systemic lupus erythematosus, ECG = electrocardiogram, CT = computed tomography.
Topics: Adrenal Cortex Hormones; Diplopia; Female; Humans; Magnetic Resonance Imaging; Middle Aged; Oculomotor Muscles; Orbital Myositis; Steroids
PubMed: 35935078
DOI: 10.22336/rjo.2022.34 -
Indian Journal of Ophthalmology Mar 2023To assess the clinical profiles and outcomes of strabismus in pediatric patients with orbital wall fractures.
PURPOSE
To assess the clinical profiles and outcomes of strabismus in pediatric patients with orbital wall fractures.
METHODS
A retrospective interventional study of all consecutive children of age ≤16 years who presented with traumatic orbital wall fractures with and without resultant strabismus was conducted. The details of patient demographics, clinical features, interventions, and outcomes were obtained.
RESULTS
Forty-three children presented with traumatic orbital fractures to a tertiary care center. The mean age at presentation was 11 years and there was a male predominance (72.09%). Isolated floor fracture involvement was the most common (n = 24, 55.81%), and almost half of the children had a white-eyed or trapdoor fracture (n = 21, 48.83%). Twenty-six (60.46%) children had surgical repair of fracture(s). Manifest strabismus following orbital fracture was documented in 12 children (27.90%). Of these, an exotropia was noted in seven (58.33%), hypotropia in two (16.67%), hypertropia in one (8.33%), and esotropia in one patient (8.33%), while an exotropia with hypotropia was noted in one patient (8.33%). Restrictive nature of strabismus due to either muscle entrapment or local trauma was more commonly observed in 11/12 patients (91.66%). Primary position diplopia before orbital wall fracture repair was observed in four children and after repair was observed in two children with manifest strabismus. Four children underwent strabismus surgery post-fracture repair.
CONCLUSION
An improvement in strabismus and ocular motility was noted in majority of the patients after fracture repair. The few that underwent strabismus surgery had a restrictive nature of strabismus. Trapdoor fractures and the nature of trauma in children vary compared to adults. Persistence of strabismus may be due to an excessive time interval between trauma and fracture repair or the extensive nature of trauma.
Topics: Adult; Humans; Child; Male; Adolescent; Female; Orbital Fractures; Retrospective Studies; Strabismus; Esotropia; Exotropia
PubMed: 36872720
DOI: 10.4103/ijo.IJO_1929_22 -
JAMA Ophthalmology Apr 2022Thyroid eye disease can be a debilitating autoimmune disorder characterized by progressive proptosis or diplopia. Teprotumumab has been compared with placebo in... (Meta-Analysis)
Meta-Analysis
Proptosis and Diplopia Response With Teprotumumab and Placebo vs the Recommended Treatment Regimen With Intravenous Methylprednisolone in Moderate to Severe Thyroid Eye Disease: A Meta-analysis and Matching-Adjusted Indirect Comparison.
IMPORTANCE
Thyroid eye disease can be a debilitating autoimmune disorder characterized by progressive proptosis or diplopia. Teprotumumab has been compared with placebo in randomized clinical trials, but not with intravenous methylprednisolone (IVMP), which sometimes is used in clinical practice for this condition.
OBJECTIVE
To conduct a matching-adjusted indirect comparison of teprotumumab vs IVMP vs placebo.
DATA SOURCES
Deidentified patient-level data from teprotumumab trials and aggregate-level data from literature on the most recommended regimen of IVMP.
STUDY SELECTION
PubMed and Embase were searched for randomized/observational studies using key terms and controlled vocabulary. Full texts of eligible articles were reviewed and cataloged.
DATA EXTRACTION AND SYNTHESIS
Conducted by 1 reviewer (R.A.Q.) and 1 verifier (R.B.), including study characteristics, eligibility criteria, baseline characteristics, and outcomes.
MAIN OUTCOMES AND MEASURES
Changes in proptosis by millimeter and diplopia response (percentage with ≥1 grade reduction) from baseline to week 12 in patients receiving IVMP and placebo, and to week 24 in patients receiving teprotumumab.
RESULTS
The search identified 1019 records, and 6 through manual searches, alerts, and secondary references. After excluding duplicates and screening full-text records, 12 IVMP studies were included in the matching-adjusted indirect comparison (11 for proptosis change [n = 419], 4 for diplopia response [n = 125], and 2 teprotumumab [n = 79] and placebo [n = 83] comparator studies). Treatment with IVMP resulted in a proptosis difference of -0.16 mm (95% CI, -1.55 to 1.22 mm) from baseline to week 12 vs placebo. The proptosis treatment difference between IVMP and teprotumumab of -2.31 mm (95% CI, -3.45 to -1.17 mm) favored teprotumumab. Treatment with IVMP (odds ratio, 2.69; 95% CI, 0.94-7.70) was not favored over placebo in odds of diplopia response; however, teprotumumab was favored over IVMP (odds ratio, 2.32; 95% CI, 1.07-5.03).
CONCLUSIONS AND RELEVANCE
This meta-analysis suggests that use of IVMP is associated with a small, typically not clinically relevant, change from baseline in proptosis vs placebo, with modest changes in diplopia. While this nonrandomized comparison suggests that use of teprotumumab, compared with IVMP, is associated with greater improvements in proptosis and may be twice as likely to have a 1 grade or higher reduction in diplopia, randomized trials comparing these 2 treatments would be warranted to determine if 1 treatment is superior to the other to a clinically relevant degree.
Topics: Antibodies, Monoclonal, Humanized; Diplopia; Exophthalmos; Graves Ophthalmopathy; Humans; Methylprednisolone
PubMed: 35175308
DOI: 10.1001/jamaophthalmol.2021.6284 -
JAMA Ophthalmology Nov 2020Patients with epiretinal membrane (ERM) sometimes close 1 eye for improved vision, but associations have not been rigorously studied. (Comparative Study)
Comparative Study
IMPORTANCE
Patients with epiretinal membrane (ERM) sometimes close 1 eye for improved vision, but associations have not been rigorously studied.
OBJECTIVE
To evaluate associations with monocular eye closure in patients with ERM, and to report binocular interference (closing 1 eye to improve visual quality).
DESIGN, SETTING, AND PARTICIPANTS
Retrospective medical record review of an adult strabismus clinic at a tertiary referral center. Patients with ERM referred from retina clinicians between June 2010 and October 2019 who completed the Adult Strabismus (AS)-20 questionnaire, including the question: "I cover or close one eye to see things better." Two groups were identified: (1) patients reporting eye closure sometimes or more, and (2) patients reporting no eye closure (as control patients).
MAIN OUTCOMES AND MEASURES
Frequencies of (1) central-peripheral rivalry (CPR)-type diplopia (dragged fovea diplopia); (2) binocular interference (monocular eye closure but no diplopia or strabismus); and (3) other, associated with monocular eye closure. Visual acuity, metamorphopsia, aniseikonia, and AS-20 quality of life domain scores (self-perception, interactions, reading function, and general function) compared between binocular interference, CPR-type diplopia, and control patients.
RESULTS
A total of 124 patients with ERM (58 of 124 were women [47%]; mean [SD] age, 70 [9] years) reported monocular eye closure. Associations were binocular interference in 36 (29%; 95% CI, 21%-38%), CPR-type diplopia in 34 (27%; 95% CI, 20%-36%), and other (primarily strabismus) in 54 (44%). Compared with control patients with ERM (n = 11), patients with ERM and binocular interference had worse quality of life on AS-20 reading function (95 vs 62; mean difference, 22 points; 95% CI, 7-27 points; P = .007) and general function (89 vs 68; mean difference, 23 points; 95% CI, 13-34 points; P = .01) domains. Compared with CPR-type diplopia, patients with binocular interference had poorer worst-eye visual acuity (median 0.50 vs 0.30 logMAR [20/63 vs 20/40]; mean difference, 0.13 logMAR; 95% CI, 0.00-0.25 logMAR [20/20 to 20/35]; P = .03), and a larger interocular difference (0.46 vs 0.19 logMAR [20/58 vs 20/30]; mean difference, 0.15 logMAR; 95% CI, 0.03-0.28 logMAR [20/21 to 20/38]; P = .004).
CONCLUSIONS AND RELEVANCE
Study findings suggest that binocular interference, manifesting as monocular eye closure (without diplopia or strabismus), is a distinct entity affecting quality of life in patients with epiretinal membrane.
Topics: Diplopia; Epiretinal Membrane; Female; Follow-Up Studies; Humans; Male; Quality of Life; Retrospective Studies; Vision, Binocular; Visual Acuity
PubMed: 32910144
DOI: 10.1001/jamaophthalmol.2020.3328 -
Acta Medica Portuguesa Oct 2020Percutaneous coronary intervention is a coronary revascularization procedure that may rarely result in thromboembolic events. Although infrequent, ophthalmological...
Percutaneous coronary intervention is a coronary revascularization procedure that may rarely result in thromboembolic events. Although infrequent, ophthalmological complications of percutaneous interventions include a wide range of clinical presentations, with differing severity and outcomes. In this case report, an 83-year-old woman, with multiple cardiovascular risk factors, presents with horizontal diplopia after a percutaneous transluminal coronary angioplasty. After ophthalmological evaluation and a head computed tomography scan, the diagnosis of isolated ischemic internuclear ophthalmoplegia was established. After six months of follow-up, the patient showed complete recovery of her symptoms and ocular movements. We discuss the post-percutaneous intervention ophthalmic complications that, although uncommon, must be recognized by health care providers.
Topics: Aged, 80 and over; Angioplasty, Balloon, Coronary; Diplopia; Female; Head; Humans; Myocardial Revascularization; Ophthalmoplegia; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 33135624
DOI: 10.20344/amp.11751 -
Ceska a Slovenska Oftalmologie :... 2023Intraocular pressure (IOP) measurement in patients with thyroid-associated orbitopathy (TAO) can be difficult and misleading, particularly in patients with diplopia and...
INTRODUCTION
Intraocular pressure (IOP) measurement in patients with thyroid-associated orbitopathy (TAO) can be difficult and misleading, particularly in patients with diplopia and eye deviation (esotropia or hypotropia). However, when measuring IOP, it is also necessary to pay sufficient attention to TAO patients without diplopia in primary gaze direction and without motility disorder that might not be readily apparent.
PURPOSE
The aim of this study was to evaluate the accuracy of measurement of intraocular pressure (IOP) using three different types of tonometers: the rebound tonometer (iCARE), the Goldmann applanation tonometer (GAT) and the non-contact airpuff tonometer (NCT) in patients with inactive TAO. Materials and Methods: A total of 98 eyes of 49 adult patients with TAO were examined. The study group included 36 females and 13 males, with an age range of 19-70 years and a median age of 55.0. All the patients had evidence of thyroid disease, a history of mild to moderate TAO, no clinical signs or symptoms of active disease, and no diplopia in direct gaze direction. In addition to a comprehensive eye examination, all the patients underwent measurement of intraocular pressure with three tonometers: NCT, iCARE, and GAT. The measurements with these three devices were compared.
RESULTS
The mean IOP was 18.1 ± 2.4 mmHg (range 13-25 mmHg) with GAT, 22.3 ±5.0 mmHg (range 13-35 mmHg) with NCT, and 18.0 ±2.4 mmHg (range 13.3-26 mmHg) with iCARE. The mean difference between the GAT and iCARE measurements (using the Bland-Altman analysis) was -0.1 ±1.16 mmHg (limits of agreement -2.4 to 2.1). The mean difference between the GAT and NCT measurements was 4.2 ±3.6 mmHg (limits of agreement -2.8 to 11.2). The mean difference between the iCARE and NCT measurements was -4.3 ±3.7 mmHg (limits of agreement -11.6 to 2.9). No significant difference was found between GAT and iCARE (p = 1.000). However, there was a significant difference between GAT and NCT (p < 0.0001), as well as between iCARE and NCT (p < 0.0001). Conclusions: In patients with TAO, NCT significantly overestimates IOP values compared to the GAT and ICare. By contrast, the iCARE rebound tonometer provides IOP measurements comparable to the gold standard GAT in these patients.
Topics: Adult; Male; Female; Humans; Young Adult; Middle Aged; Aged; Graves Ophthalmopathy; Diplopia; Reproducibility of Results; Tonometry, Ocular; Intraocular Pressure; Strabismus
PubMed: 38086704
DOI: 10.31348/2023/38 -
Ophthalmic Plastic and Reconstructive...Complex bony orbital defects are reconstructively challenging due to loss of intraoperative anatomical landmarks and adjacent support. Presized and precontoured porous...
PURPOSE
Complex bony orbital defects are reconstructively challenging due to loss of intraoperative anatomical landmarks and adjacent support. Presized and precontoured porous polyethylene-titanium implants (Medpor Titan 3D Orbital Floor Implant) are designed to reestablish normal orbital floor and medial wall anatomy and are modeled after anatomically averaged orbits. This is the first study to report clinical outcomes with this implant.
METHODS
This retrospective case series reviewed clinical data and outcomes for patients undergoing orbital reconstruction with a presized and precontoured porous polyethylene-titanium orbital implant from January 2016 to June 2018.
RESULTS
A total of 34 orbits of 33 patients were identified (mean age: 43 ± 16 years, 70% men). Most bony defects were a result of trauma and included large orbital floor deformities (100%), medial wall defects (74%), disrupted inferomedial struts (68%), and broken posterior ledges (82%). Symptomatic diplopia (73%) and enophthalmos (89%, mean: 3.7 ± 2.1 mm) were common preoperatively. Many cases were revisions (44%). Mean follow up was 7.8 ± 6.7 months. All patients had improved globe positioning, enophthalmos, and hypoglobus. Seven patients had persistent postoperative diplopia: 6 responded to prism therapy and 1 required strabismus surgery. One patient required retrobulbar hematoma drainage and 1 patient required implant explantation due to chronic infection.
CONCLUSIONS
Commercially available presized and precon toured porous polyethylene-titanium implants are useful for complex orbital bony defects and can achieve functional improve ments in diplopia, enophthalmos, and extraocular motility with a low incidence of postoperative complications or revisional surgery.
Topics: Adult; Enophthalmos; Female; Humans; Male; Middle Aged; Orbit; Orbital Fractures; Orbital Implants; Polyethylene; Porosity; Plastic Surgery Procedures; Retrospective Studies; Titanium; Treatment Outcome
PubMed: 32976336
DOI: 10.1097/IOP.0000000000001829 -
The British Journal of Ophthalmology Jun 2022Teprotumumab, a specific blocking antibody to the insulin like growth factor 1 receptor, significantly reduced proptosis in patients with thyroid eye disease (TED) in... (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
Teprotumumab, a specific blocking antibody to the insulin like growth factor 1 receptor, significantly reduced proptosis in patients with thyroid eye disease (TED) in recent clinical trials. Given its specificity, we expect it to demonstrate greater efficacy on the worse affected orbit, in patients with asymmetric TED. Herein, we investigate the differential impact of teprotumumab on the orbits of such patients.
METHODS
In this pooled analysis of patients who were enrolled in the recent phase 2 (NCT01868997) and phase 3 (NCT03298867) trials, all patients with asymmetric TED (difference in exophthalmometry of ≥3 mm) were screened for eligibility. The primary outcomes of the trials, proptosis, diplopia and Clinical Activity Score (CAS) response, were evaluated in both orbits of patients who had received treatment or placebo, to examine the differential response from baseline to week 24.
RESULTS
From a pooled group of 84 patients randomised to receive teprotumumab and 87 randomised to placebo, 10 (12%) and 12 (14%), respectively, met the inclusion criteria. The teprotumumab-treated patients demonstrated significant reductions in proptosis, CAS and diplopia in both orbits of each patient and this was not seen with placebo. The reduction in proptosis and CAS was significantly greater in the worse affected orbit, improving symmetry. In the placebo arm, while the mean CAS in the study eye reduced over time, proptosis and diplopia did not change in either orbit.
CONCLUSION
The findings in this study suggest the differential impact of teprotumumab on orbits that are clinically more affected by TED, suggesting that teprotumumab reduces asymmetry.
Topics: Antibodies, Monoclonal, Humanized; Diplopia; Exophthalmos; Graves Ophthalmopathy; Humans
PubMed: 33579690
DOI: 10.1136/bjophthalmol-2020-318314 -
Surgical Neurology International 2021Epidural hematomas are common intracranial pathologies secondary to traumatic brain injuries and are associated with overlying skull fractures up to 85% of the time....
BACKGROUND
Epidural hematomas are common intracranial pathologies secondary to traumatic brain injuries and are associated with overlying skull fractures up to 85% of the time. Although many require immediate surgical evacuation, some are observed for stability and followed up conservatively with serial imaging or enlarge slowly overtime, similar to chronic subdural hematomas. Those in the latter category may present with vague symptoms such as diplopia or headache and are often found on routine outpatient evaluation. When concerning findings such as significant mass effect are present, surgical evacuation is necessary.
CASE DESCRIPTION
Here, we present the case of a 32-year-old man who presented with diplopia 6 weeks after experiencing head trauma and was found to have a chronic epidural hematoma. On resection, thick, inflammatory tissue was observed and carefully resected, revealing normal dura underneath. Six weeks after evacuation of the hematoma, the patient had near-complete resolution of his diplopia and complete resolution of his epidural hematoma.
CONCLUSION
Given the consistency and nature of the fibrous material observed intraoperatively in this case, near-complete resection of the tissue was likely necessary to help facilitate adequate reexpansion of brain parenchyma and improve clinical outcomes.
PubMed: 34513184
DOI: 10.25259/SNI_480_2021