Patients with thyroid eye disease, Graves’ orbitopathy (GO), often appear distressed and it is likely that features of the condition such as disturbances in visual function, orbital discomfort and alterations in facial appearance can impart significant psychological morbidity upon the patient, which in turn can be detrimental to their quality of life. When considering the psychological impact of GO, two elements of the disease are important. The disfiguring changes to the eyes and face can have a direct effect upon psychological health, while physical aspects of the disease such as altered visual acuity, diplopia, orbital pain and lacrimation may influence psychological function as a secondary phenomenon, due to interference with daily living. Evidence appears to confirm the anecdotal impression of many clinicians dealing with GO patients that the prevalence of psychological morbidity in this patient group is high. A ‘biopsychosocial’ approach to care that addresses biological and psychosocial functioning as major determinants of health is an appropriate strategy when treating patients with GO.
I Coulter, S Frewin, G E Krassas and P Perros
P Perros, L Baldeschi, K Boboridis, A J Dickinson, A Hullo, G J Kahaly, P Kendall-Taylor, G E Krassas, C M Lane, J H Lazarus, C Marcocci, M Marino, M P Mourits, M Nardi, J Orgiazzi, A Pinchera, S Pitz, M F Prummel and W M Wiersinga
Group-author : The European Group of Graves’ Orbitopathy
Objective: To determine management patterns among clinicians who treat patients with Graves’ orbitopathy (GO) in Europe.
Design and methods: Questionnaire survey including a case scenario of members of professional organisations representing endocrinologists, ophthalmologists and nuclear medicine physicians.
Results: A multidisciplinary approach to manage GO was valued by 96.3% of responders, although 31.5% did not participate or refer to a multidisciplinary team and 21.5% of patients with GO treated by responders were not managed in a multidisciplinary setting. Access to surgery for sight-threatening GO was available only within weeks or months according to 59.5% of responders. Reluctance to refer urgently to an ophthalmologist was noted by 32.7% of responders despite the presence of suspected optic neuropathy. The use of steroids was not influenced by the age of the patient, but fewer responders chose to use steroids in a diabetic patient (72.1 vs 90.5%, P < 0.001). Development of cushingoid features resulted in a reduction in steroid use (90.5 vs 36.5%, P < 0.001) and increase in the use of orbital irradiation (from 23.8% to 40.4%, P < 0.05) and surgical decompression (from 20.9 to 52.9%, P < 0.001). More ophthalmologists chose surgical decompression for patients with threatened vision due to optic neuropathy, who were intolerant to steroids than other specialists (70.3 vs 41.8%, P < 0.01).
Conclusion: Deficiencies in the management of patients with GO in Europe were identified by this survey. Further training of clinicians, easier access of patients to specialist multidisciplinary centres and the publication of practice guidelines may help improve the management of this condition in Europe.
W M Wiersinga, P Perros, G J Kahaly, M P Mourits, L Baldeschi, K Boboridis, A Boschi, A J Dickinson, P Kendall-Taylor, G E Krassas, C M Lane, J H Lazarus, C Marcocci, M Marino, M Nardi, C Neoh, J Orgiazzi, A Pinchera, S Pitz, M F Prummel, M S Sartini, M Stahl and G von Arx
Group-author : The European Group on Graves’ Orbitopathy (EUGOGO)
MF Prummel, A Bakker, WM Wiersinga, L Baldeschi, MP Mourits, P Kendall-Taylor, P Perros, C Neoh, AJ Dickinson, JH Lazarus, CM Lane, AE Heufelder, GJ Kahaly, S Pitz, J Orgiazzi, A Hullo, A Pinchera, C Marcocci, MS Sartini, R Rocchi, M Nardi, GE Krassas and A Halkias
To improve management of patients with Graves' orbitopathy, a multi-center collaborative approach is necessary in order to have large enough sample sizes for meaningful randomized clinical trials. This is hampered by a lack of consensus on how to investigate the eye condition. The European Group on Graves' Orbitopathy aims to overcome this and has designed a preliminary case record form (CRF) to assess Graves' orbitopathy patients. This form was used in this first multi-center study. AIM: To investigate patient characteristics and treatment strategies in 152 new consecutively referred patients with thyroid eye disease seen in nine large European referral centers. METHODS: Newly referred patients with Graves' orbitopathy were included who were seen between September and December 2000. Demographic data and a complete ophthalmological assessment were recorded. RESULTS: One-hundred and fifty-two patients (77% females) were included. Diabetes was present in 9%, and glaucoma or cataract in 14% of patients. Forty percent were current smokers, 9% also had dermopathy, and only 33% reported a positive family history of thyroid disease. Mild eye disease was seen in 40%, moderately severe eye disease was seen in 33% and severe eye disease was seen in 28% of patients. Soft tissue involvement was the most frequent abnormality (seen in 75%), proptosis > or =21 mm was found in 63%, eye motility dysfunction in 49%, keratopathy in 16% and optic nerve involvement was found in 21% of patients. According to the clinical impression, 60% had active eye disease. Immunosuppressive treatment was planned more frequently in active patients (57/86; 66%) than in inactive patients (5/57, 9%; Chi-square 46.16; P<0.02). There were no important differences among the eight centers regarding the severity and the activity of their patients. CONCLUSIONS: In view of the large number of patients recruited in only 4 months, multi-center studies in the eight EUGOGO centers appear to be feasible.