Abstract
Purpose :
As our understanding of the clinical and immune pathology in Thyroid eye disease has matured, so, too, has the logic of its management. In this paper, we explain the rationale behind an immunomodulatory regime which has been pursued in Cambridge for the last 23 years, and present a retrospective analysis of our results. This is the largest case series to determine whether a combined immunomodulatory regime comprising intravenous and oral prednisolone, ciclosporin and removal of disease drives is successful in aborting and maintaining remission of optic nerve compression and ocular motility disturbances.
Methods :
This is a retrospective observation case series of 145 patients treated with the Cambridge Thyroid Eye Regime for sight-threatening disease, defined by either optic nerve compression and/or severe ocular motility disturbance, followed up for 2-10 years. The criteria for optic nerve compression was defined by a reduction in visual acuity of more than two lines on Snellen chart, impairment of colour vision, restriction of mean deviation of visual fields by >5 dB during automated perimetry, or relative afferent pupillary defect. Resolution of the aforementioned criteria, where affected, constituted a recovery. Ocular motility was quantified in patients with diplopia using fields of Binocular Single Vision, and recovery threshold judged as resolution of symptoms with or without prisms, or improvement in BSV to a functional score of at least 50%.
Results :
75 patients with compressive optic neuropathy were treated with this regime, all patients recovering or maintaining pre-morbid visual acuities and all but 6 recovering or maintaining pre-morbid visual fields. In 71 patients with ocular motility disturbances, there was recovery in all but 5 patients who required strabismus surgery. In total, 5 patients required surgical decompression following deterioration. Morbidity from treatment was low, with main adverse effects being impaired renal function in 10 patients and hypertension in 6 patients.
Conclusions :
This immunosuppressive regime aborts, and maintains remission. It brings about a recovery of acuity and motility and helps avoid surgery, and appears to be successful where other regimes have failed. Where possible, medical management should be favoured in reversing, rather than resolving, complications of this autoimmune disease.
This abstract was presented at the 2019 ARVO Annual Meeting, held in Vancouver, Canada, April 28 - May 2, 2019.