- Email: [email protected]
Bromocriptine Therapy for Thyroid Ophthalmopathy
680
AMERICAN JOURNAL OF OPHTHALMOLOGY
References 1. Bialasiewicz, A. A., Ruprecht, K. W., Naumann, G. O. H., and Blenk, H.: Bilateral diffuse choroiditis and exudative retinal detachments with evidence of Lyme disease. Am. J. Ophthalmol. 105:419,1988. 2. Wu, G., Lincoff, H., Ellsworth, R. M., and Haik, B. G.: Optic disc edema and Lyme disease. Ann. Ophthalmol. 18:252, 1986. 3. Jacobson, D. M., and Frens, D. B.: Pseudotumor cerebri syndrome associated with Lyme disease. Am. J. Ophthalmol. 107:81, 1989. 4. Baum, J., Barza, M., Weinstein, P., Groden, J., and Aswad, M.: Bilateral keratitis as a manifestation of Lyme disease. Am. J. Ophthalmol. 105:75, 1988. 5. Bertuch, A. W., Rocco, E., and Schwartz, E. G.: Lyme disease. Ocular manifestations. Ann. Ophthalmol. 20:376, 1988.
Bromocriptine Ophthalmopathy
Therapy
for Thyroid
Marta O. Lopatynsky, M.D., and Gregory B. Krohel, M.D. Department of Ophthalmology, Albany Medical College. This study was supported in part by Training Grant EY0703702 from the National Institutes of Health, National Eye Institute; Research Grant EY05816 from the National Institutes of Health, National Eye Institute to the Albany Medical College Department of Ophthalmology; and an unrestricted grant from Research to Prevent Blindness, Inc.
Inquiries to Gregory B. Krohel, M.D., Department of OpMhalmology, Albany Medical College, Albany, NY 12208.
The present management of thyroid ophthalmopathy with optic neuropathy includes three primary modalities: corticosteroids, orbital decompressive surgery, and radiotherapy. Response to therapy is not always predictable and relapses can occur. We recently successfully treated two patients with thyroid ophthalmopathy with bromocriptine, a dopamine agonist. Case 1 In January 1988, a 50-year-old woman with a history of multiple sclerosis developed thyroid ophthalmopathy with marked chemosis and corneal exposure. In February 1988, a regimen of 80 mg of prednisone was started by her internist. Improvement in chemosis and corneal exposure was noted. The condition relapsed when the dosage was tapered to 20 mg. Orbital decompression and radiation therapy were recommended because of optic neuropathy, with a
June, 1989
decrease in visual acuity to 20/40 and increased intraocular pressure to 26 mm Hgin both eyes. Surgery was delayed because of poor thyroid control and radiation therapy was refused by the patient. In August 1988, the patient began a regimen of 1.25 mg of bromocriptine twice a day for seven days, increased to 2.5 mg twice a day for seven days, and finally to 2.5 mg three times a day. The prednisone was successfully tapered and discontinued, without recurrence of the chemosis. The optic neuropathy improved, with stabilization of visual acuity at 20/25 in both eyes on a regimen of 2.5 mg of bromocriptine three times a day. Treatment has been continued for three months. Case 2 Euthyroid thyroid ophthalmopathy was diagnosed in this 51-year-old woman in September 1987. She had chemosis and optic neuropathy with a decrease in visual acuity to 20/25 and bilateral arcuate scotomas on visual field testing. The patient was treated with 80 mg of prednisone every other day for one month without improvement in clinical signs. Prednisone, 80 mg, was then given daily, with improvement in visual fields and chemosis. However, as the corticosteroids were tapered, the optic neuropathy then worsened and visual acuity decreased to 20/40 in both eyes. Disk edema developed bilaterally. Transcutaneous two-wall orbital decompressive surgery was performed in February 1988. Postoperatively, visual acuity improved to 20/20 in both eyes. The corticosteroids were again tapered, but visual acuity decreased to 20/40 bilaterally, chemosis worsened, and marked limitation of motility developed when prednisone was reduced to 10 mg daily. The patient then received 2,000 rad to both orbits over a three-week period while taking 60 mg of prednisone daily. Two months after radiation therapy the patient developed diplopia secondary to extraocular muscle restriction; her vision had not improved. Bromocriptine, 2.5 mg, three times a day was started. Ten days after initiation of bromocriptine, the chemosis had markedly improved and visual acuity had improved to 20/25. Over the next six weeks the prednisone was tapered and discontinued. Bromocriptine was continued, without relapse of the ophthalmopathy. The bromocriptine was discontinued after four months. On examination in November 1988, visual acuity was 20/20 in each eye and no chemosis was present. The mechanism by which bromocriptine improves thyroid ophthalmopathy remains unclear. Pharmacologic studies on animals have
Vol. 107, No.6
Letters to the Journal
demonstrated that bromocriptine, a synthetic alkaloid, binds to dopamine receptors with a resultant decrease in prolactin levels. I Bromocriptine has been used in the treatment of prolactin-secreting pituitary tumors where it not only decreases prolactin levels but also decreases the size of the tumor.! Bromocriptine therapy also produces a blunting of the normal rise in prolactin levels after thyroid releasing hormone stimulation. The baseline thyroid stimulating hormone levels and the thyroid stimulating hormone response to thyroid releasing hormone stimulation are also lowered. This suggests that bromocriptine may inhibit thyroid stimulating hormone secretion by binding to dopamine receptors. Bromocriptine has also been shown to have a direct antiproliferative effect on T lymphocyte replication in vitro. 3 Corticosteroids also inhibit lymphocyte activity. The suppression of immunocompetent cells by bromocriptine may be additive to corticosteroids and this may explain the apparent beneficial effects on thyroid ophthalmopathy. In a previous study, 18 patients with thyroid ophthalmopathy showed clinical improvement after approximately six weeks of bromocriptine therapy.' Three of the five patients with thyroid ophthalmopathy treated with bromocriptine in another study also showed significant clinical Improvement." All of these patients had increased thyroid stimulating hormone and prolactin levels. The two patients who did not improve had normal thyroid stimulating hormone and prolactin levels. Our Patient 1 had an increased thyroid stimulating hormone level, whereas Patient 2 had normal thyroid stimulating hormone levels. Pretreatment prolactin levels were not obtained in our patients. Both patients had improvement of the thyroid ophthalmopathy. B.romocriptine may prove to be useful in the treatment of thyroid ophthalmopathy and deserves further study. References 1. Roehrich, H., Dackis, C. A., and Gold, M. S.: Bromocriptine. Med. Res. Rev. 7:243, 1987. 2. Dernura, R., Demura, H., Odagiri, E., and Shizume, K.: A case of acromegaly associated with Graves' disease. A possible role of endogenous TRH and an effect of bromocriptine on GH and TSH secretion. Endocrinol. Ipn. 31:801, 1984. 3. Kolodziej-Maciejewska, H., and Reterski, Z.: Positive effect of bromocriptine treatment in Graves'
681
disease orbitopathy. Exp. Clin. Endocrinol. 86:241, 1985. 4. Kazeev, K. N., Zinkevich, I. V., Karaseva, G. I., and Kostareva, L. N.: Short-term results of Parlodel therapy of patients with diffuse toxic goiter complicated by endocrine ophthalmopathy. Probl. Endokrinol. 33:3, 1987.
Transscleral Nd:YAG Photocoagulation for Cataract Incision Vascularization Associated With Recurrent Hyphema Theresa R. Kramer, M.D., Reay H. Brown, M.D., Mary G. Lynch, M.D., and Luis Martinez, M.D. Emory University School of Medicine, Department of Ophthalmology. This work was supported by a departmental grant from Research to Prevent Blindness, Inc. and by P30 EY06360, a National Institutes of Health Departmental Core Grant.
Inquiries to Reay H. Brown, M.D., Emory University School of Medicine, Department of Ophthalmology, 1327 Clifton Rd. N.E., Atlanta, GA 30322.
Neodymium:YAG transscleral cyclophotocoagulation in the thermal mode has been used successfully as a cyclodestructive procedure for glaucoma.!" We used transscleral Nd:YAG photocoagulation to treat cataract incision vascularization associated with recurrent hyphema. A 73-year-old woman with primary openangle glaucoma was referred for recurrent hyphema eight months after cataract extraction in the left eye. Argon laser treatments had been performed twice to the anterior chamber angle in the area of the cataract wound but the hyphemas recurred. On examination, visual acuity was 20/30 in the left eye. There was a 10% hyphema. A patent peripheral iridectomy was present and there was no rubeosis. A posterior chamber intraocular lens was present over an intact posterior capsule. The intraocular pressure was 16 mm Hg in the left eye. Gonioscopy of the left eye showed an open angle and a thin stream of hemorrhage was observed coming from a small internal gape in the cataract wound. However, no vessels were seen. Argon laser goniophotocoagulation was applied directly to the bleeding site immediately. The settings were 1.0 to 1.5 W, a duration of 0.2 seconds, and a 200 urn-spot size. A total of 15
AMERICAN JOURNAL OF OPHTHALMOLOGY
References 1. Bialasiewicz, A. A., Ruprecht, K. W., Naumann, G. O. H., and Blenk, H.: Bilateral diffuse choroiditis and exudative retinal detachments with evidence of Lyme disease. Am. J. Ophthalmol. 105:419,1988. 2. Wu, G., Lincoff, H., Ellsworth, R. M., and Haik, B. G.: Optic disc edema and Lyme disease. Ann. Ophthalmol. 18:252, 1986. 3. Jacobson, D. M., and Frens, D. B.: Pseudotumor cerebri syndrome associated with Lyme disease. Am. J. Ophthalmol. 107:81, 1989. 4. Baum, J., Barza, M., Weinstein, P., Groden, J., and Aswad, M.: Bilateral keratitis as a manifestation of Lyme disease. Am. J. Ophthalmol. 105:75, 1988. 5. Bertuch, A. W., Rocco, E., and Schwartz, E. G.: Lyme disease. Ocular manifestations. Ann. Ophthalmol. 20:376, 1988.
Bromocriptine Ophthalmopathy
Therapy
for Thyroid
Marta O. Lopatynsky, M.D., and Gregory B. Krohel, M.D. Department of Ophthalmology, Albany Medical College. This study was supported in part by Training Grant EY0703702 from the National Institutes of Health, National Eye Institute; Research Grant EY05816 from the National Institutes of Health, National Eye Institute to the Albany Medical College Department of Ophthalmology; and an unrestricted grant from Research to Prevent Blindness, Inc.
Inquiries to Gregory B. Krohel, M.D., Department of OpMhalmology, Albany Medical College, Albany, NY 12208.
The present management of thyroid ophthalmopathy with optic neuropathy includes three primary modalities: corticosteroids, orbital decompressive surgery, and radiotherapy. Response to therapy is not always predictable and relapses can occur. We recently successfully treated two patients with thyroid ophthalmopathy with bromocriptine, a dopamine agonist. Case 1 In January 1988, a 50-year-old woman with a history of multiple sclerosis developed thyroid ophthalmopathy with marked chemosis and corneal exposure. In February 1988, a regimen of 80 mg of prednisone was started by her internist. Improvement in chemosis and corneal exposure was noted. The condition relapsed when the dosage was tapered to 20 mg. Orbital decompression and radiation therapy were recommended because of optic neuropathy, with a
June, 1989
decrease in visual acuity to 20/40 and increased intraocular pressure to 26 mm Hgin both eyes. Surgery was delayed because of poor thyroid control and radiation therapy was refused by the patient. In August 1988, the patient began a regimen of 1.25 mg of bromocriptine twice a day for seven days, increased to 2.5 mg twice a day for seven days, and finally to 2.5 mg three times a day. The prednisone was successfully tapered and discontinued, without recurrence of the chemosis. The optic neuropathy improved, with stabilization of visual acuity at 20/25 in both eyes on a regimen of 2.5 mg of bromocriptine three times a day. Treatment has been continued for three months. Case 2 Euthyroid thyroid ophthalmopathy was diagnosed in this 51-year-old woman in September 1987. She had chemosis and optic neuropathy with a decrease in visual acuity to 20/25 and bilateral arcuate scotomas on visual field testing. The patient was treated with 80 mg of prednisone every other day for one month without improvement in clinical signs. Prednisone, 80 mg, was then given daily, with improvement in visual fields and chemosis. However, as the corticosteroids were tapered, the optic neuropathy then worsened and visual acuity decreased to 20/40 in both eyes. Disk edema developed bilaterally. Transcutaneous two-wall orbital decompressive surgery was performed in February 1988. Postoperatively, visual acuity improved to 20/20 in both eyes. The corticosteroids were again tapered, but visual acuity decreased to 20/40 bilaterally, chemosis worsened, and marked limitation of motility developed when prednisone was reduced to 10 mg daily. The patient then received 2,000 rad to both orbits over a three-week period while taking 60 mg of prednisone daily. Two months after radiation therapy the patient developed diplopia secondary to extraocular muscle restriction; her vision had not improved. Bromocriptine, 2.5 mg, three times a day was started. Ten days after initiation of bromocriptine, the chemosis had markedly improved and visual acuity had improved to 20/25. Over the next six weeks the prednisone was tapered and discontinued. Bromocriptine was continued, without relapse of the ophthalmopathy. The bromocriptine was discontinued after four months. On examination in November 1988, visual acuity was 20/20 in each eye and no chemosis was present. The mechanism by which bromocriptine improves thyroid ophthalmopathy remains unclear. Pharmacologic studies on animals have
Vol. 107, No.6
Letters to the Journal
demonstrated that bromocriptine, a synthetic alkaloid, binds to dopamine receptors with a resultant decrease in prolactin levels. I Bromocriptine has been used in the treatment of prolactin-secreting pituitary tumors where it not only decreases prolactin levels but also decreases the size of the tumor.! Bromocriptine therapy also produces a blunting of the normal rise in prolactin levels after thyroid releasing hormone stimulation. The baseline thyroid stimulating hormone levels and the thyroid stimulating hormone response to thyroid releasing hormone stimulation are also lowered. This suggests that bromocriptine may inhibit thyroid stimulating hormone secretion by binding to dopamine receptors. Bromocriptine has also been shown to have a direct antiproliferative effect on T lymphocyte replication in vitro. 3 Corticosteroids also inhibit lymphocyte activity. The suppression of immunocompetent cells by bromocriptine may be additive to corticosteroids and this may explain the apparent beneficial effects on thyroid ophthalmopathy. In a previous study, 18 patients with thyroid ophthalmopathy showed clinical improvement after approximately six weeks of bromocriptine therapy.' Three of the five patients with thyroid ophthalmopathy treated with bromocriptine in another study also showed significant clinical Improvement." All of these patients had increased thyroid stimulating hormone and prolactin levels. The two patients who did not improve had normal thyroid stimulating hormone and prolactin levels. Our Patient 1 had an increased thyroid stimulating hormone level, whereas Patient 2 had normal thyroid stimulating hormone levels. Pretreatment prolactin levels were not obtained in our patients. Both patients had improvement of the thyroid ophthalmopathy. B.romocriptine may prove to be useful in the treatment of thyroid ophthalmopathy and deserves further study. References 1. Roehrich, H., Dackis, C. A., and Gold, M. S.: Bromocriptine. Med. Res. Rev. 7:243, 1987. 2. Dernura, R., Demura, H., Odagiri, E., and Shizume, K.: A case of acromegaly associated with Graves' disease. A possible role of endogenous TRH and an effect of bromocriptine on GH and TSH secretion. Endocrinol. Ipn. 31:801, 1984. 3. Kolodziej-Maciejewska, H., and Reterski, Z.: Positive effect of bromocriptine treatment in Graves'
681
disease orbitopathy. Exp. Clin. Endocrinol. 86:241, 1985. 4. Kazeev, K. N., Zinkevich, I. V., Karaseva, G. I., and Kostareva, L. N.: Short-term results of Parlodel therapy of patients with diffuse toxic goiter complicated by endocrine ophthalmopathy. Probl. Endokrinol. 33:3, 1987.
Transscleral Nd:YAG Photocoagulation for Cataract Incision Vascularization Associated With Recurrent Hyphema Theresa R. Kramer, M.D., Reay H. Brown, M.D., Mary G. Lynch, M.D., and Luis Martinez, M.D. Emory University School of Medicine, Department of Ophthalmology. This work was supported by a departmental grant from Research to Prevent Blindness, Inc. and by P30 EY06360, a National Institutes of Health Departmental Core Grant.
Inquiries to Reay H. Brown, M.D., Emory University School of Medicine, Department of Ophthalmology, 1327 Clifton Rd. N.E., Atlanta, GA 30322.
Neodymium:YAG transscleral cyclophotocoagulation in the thermal mode has been used successfully as a cyclodestructive procedure for glaucoma.!" We used transscleral Nd:YAG photocoagulation to treat cataract incision vascularization associated with recurrent hyphema. A 73-year-old woman with primary openangle glaucoma was referred for recurrent hyphema eight months after cataract extraction in the left eye. Argon laser treatments had been performed twice to the anterior chamber angle in the area of the cataract wound but the hyphemas recurred. On examination, visual acuity was 20/30 in the left eye. There was a 10% hyphema. A patent peripheral iridectomy was present and there was no rubeosis. A posterior chamber intraocular lens was present over an intact posterior capsule. The intraocular pressure was 16 mm Hg in the left eye. Gonioscopy of the left eye showed an open angle and a thin stream of hemorrhage was observed coming from a small internal gape in the cataract wound. However, no vessels were seen. Argon laser goniophotocoagulation was applied directly to the bleeding site immediately. The settings were 1.0 to 1.5 W, a duration of 0.2 seconds, and a 200 urn-spot size. A total of 15