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Commentary

Commentary

Multidisciplinary team approach to tackle thyroid eye disease

Mahesh, Lakshmi

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Indian Journal of Ophthalmology: August 2020 - Volume 68 - Issue 8 - p 1615-1616
doi: 10.4103/ijo.IJO_2202_20
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Nearly every third Indian suffers from one or the other kind of thyroid disorder which most often causes weight gain and hormonal imbalances. There are some geographical variations between the North and the South India. We are seeing an alarming trend of thyroiditis especially amongst youngsters in the Indian subcontinent. Development of multidisciplinary centres for optimal thyroid eye disease (TED) management is the golden need of the hour.[1] We rely mostly on literature from the West for the knowledge on management of this condition. With changing lifestyle and stress especially in the urban young population in India, it is time we have our guidelines for the management of this condition.

This survey is most essential to achieve the goal. The fact that Indians have shallower orbits[23] makes them more prone to Dysthyroid Optic Neuropathy (DON) and the need for early intervention with immune suppressive treatment is an absolute must to preserve vision. Intravenous methylprednisolone (IVMP) in the form of pulse therapy works well in our patients compared to oral steroids which worsen the Orbital inflammation. This is in contrast to the ASOPRS survey[4] where oral steroids was preferred.

MRI is the imaging modality of choice as it picks up the tissue changes be it fat or muscle better along with apical compression of the optic nerve in cases of DON. This is the commonest cause of decreased or loss of vision.

Anti-thyroid Antibodies especially the TSH receptor antibody is a baseline investigation more so in euthyroid eye disease. Euthyroid disease is surprisingly common in our population and this test helps also to convince patients whose thyroid values remain normal despite the orbital disease progression. At present our results with IVMP in reversing the disease progress is very encouraging. It is sometimes difficult to stick on to the recommended cumulative doses of IVMP as our patients with advanced disease tolerate higher doses if need be provided there is meticulous watch and control of the systemic parameters especially the blood glucose levels. Admission and monitoring of these patients by the endocrinologists and internists is essential especially those with severe diabetes and other co morbidities. Otherwise day care admissions for the pulsed IV treatment would suffice.

In this survey, almost 54% of the respondents have chosen immunomodulators as the second line of therapy for recalcitrant disease.[5] Though the results seem promising especially with the recent agent Teprotumumab, one needs to bear in mind the cost of treatment and the future implications. We do see side effects with immunomodulators especially conditions such as immune retinopathy etc.

Years of practice and experience of the respondents is a small drawback in this survey as almost 42% of the respondents had less than five years of experience. Nevertheless, it is heartening that these youngsters do like to approach these patients with a multidisciplinary team. The authors feel that this survey was mainly sent to OPAI members the majority being oculoplasty surgeons in this group and felt that the responses could vary when compared to physicians, endocrinologists, and general ophthalmologists. However, as most respondents here prefer a multidisciplinary team approach it is unlikey that there would be much difference in their approach and management. This need not be considered as a shortcoming at all.

The fact that the authors would like to involve the other disciplines to formulate a Preferred Practice Pattern[56] for TED across the country is a brilliant step and needs early implementation. Just like diabetic retinopathy screening and management it would be good to have TED Clinics in all big eye hospitals where the endocrinologists can come on a visiting basis or have a tie up practice. It is easier to set up and manage such clinics in hospitals with teaching institutions and in multi -speciality hospitals.

Over all the authors have to be congratulated for this survey which highlights an important cause for proptosis be it unilateral or bilateral which can be easily picked up, investigated and managed. TED in India could reach epidemic and alarming proportions and the need for such surveys and studies is of paramount importance. As the number of cases keep mounting up, a multidisciplinary team approach and effort to tackle and control TED will be the main stay and cannot be overemphasised.

1. Bartalena L, Baldeschi L, Dickinson AJ, Eckstein A, Kendall-Taylor P, Marcocci C, et al Consensus statement of the European group on Graves' orbitopathy (EUGOGO) on management of Graves' orbitopathy Thyroid. 2008;18:333–46
2. Gupta V, Prabhakar A, Yadav M, Khandelwal N. Computed tomography imaging-based normative orbital measurement in Indian population Indian J Ophthalmol. 2019;67:659–63
3. Mahesh L. Commentary: Relevance of orbital measurements for the Orbit surgeon Indian J Ophthalmol. 2019;67:664
4. Perumal B, Meyer DR. Treatment of severe thyroid eye disease: A survey of the American society of ophthalmic plastic and reconstructive surgery (ASOPRS) Ophthal Plast Reconstr Surg. 2015;31:127–31
5. Pradhan A, Ganguly A, Naik MN, Nair AG, Desai S, Rath S. Thyroid eye disease survey: An anonymous web-based survey in the Indian subcontinent Indian J Ophthalmol. 2020;68:1609–14
6. Bartalena L, Baldeschi L, Boboridis K, Eckstein A, Kahaly GJ, Marcocci CEuropean Group on Graves' Orbitopathy (EUGOGO). . The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the management of Graves' orbitopathy Eur Thyroid J. 2016;5:9–26
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