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Open-Angle Glaucoma and Cardiovascular Mortality
Letters to the Editor Open-Angle Glaucoma and Cardiovascular Mortality Dear Editor: In their article on open-angle glaucoma and cardiovascular mortality in the Blue Mountains Eye Study,1 Mitchell et al suggest a higher cardiovascular mortality in glaucoma patients using topical timolol. I suggest that economic factors might play a role in that finding. Patients with fewer resources of money, insurance, or drug coverage tend to resist the conversion to higher-cost glaucoma medications. These same patients might seek less care for routine systemic examinations, more advanced testing, or specialty care for cardiovascular disease. I look forward to further research of this topic. NORMAN I. MEYER, MD Sebastian, Florida Reference 1. Lee AJ, Wang JJ, Kifley A, Mitchell P. Open-angle glaucoma and cardiovascular mortality. The Blue Mountains Eye Study. Ophthalmology 2006;113:1069 –76.
Graves’ Orbitopathy Dear Editor: Infiltrative orbitopathy occurring in the absence of objective evidence of thyroid dysfunction has been referred to as euthyroid Graves’ disease.1 This group of patients with clinical Graves’ orbitopathy (GO), but no symptoms or laboratory findings of autonomous thyroid function, can be a diagnostic challenge. We report that patients with euthyroid GO have less severe clinical orbital disease than their dysthyroid counterparts (Bhatnagar A. Euthyroid and Graves’ related orbitopathy—a retrospective study. Poster presented at: World Ophthalmology Congress, February 19 –24, 2006, Sao Paulo, Brazil). A total of 669 patients with Graves’ disease observed over a 6-year period were identified. A diagnosis of euthyroid GO was made if patients presented with symptoms and signs of thyroid-related orbitopathy but without confirmatory systemic thyroid abnormalities, including normal thyroid function at the time of diagnosis and 2 years later.2 Sixty-three patients achieved euthyroid criteria, whereas 63 dysthyroid patients were chosen as a control group. The groups were controlled for age, smoking history, and presence of hyperthyroidism. Hypothyroid patients who became hyperthyroid after treatment were excluded. Patients with orbitopathy but with the presence of other orbital diseases such as neoplasia or specific orbital inflammation also were excluded from the study. Demographics, including referring diagnosis, clinical features, and treatment, are detailed in Table 1 (available at http://aaojournal.org). Mean ages at presentation were 53.3 and 54.6 years, and female/male ratios were 1.62 and 3.2 in the euthyroid group and dysthyroid group, respectively. We found that euthyroid males presented with orbital disease
392
more often than males from the dysthyroid group, as stated in previous studies.3,4 Nearly 75% of the patients in both groups presented with eyelid retraction, and more than half (54% euthyroid, 56% dysthyroid) demonstrated asymmetrical proptosis. However, a smaller fraction of euthyroid patients demonstrated proptosis (68% vs. 87%) and motility restriction (24% vs. 68%). Fourteen percent of euthyroid patients presented with diplopia, as opposed to 35% in the dysthyroid group (P ⫽ 0.006). Inflammation was found in 4 (6%) euthyroid patients and 17 (27%) dysthyroid patients (P ⫽ 0.002). Eight (13%) euthyroid patients had lid lag, compared with 18 (29%) dysthyroid patients (P ⫽ 0.028). Optic neuropathy was found in 9 (14%) dysthyroid patients but none of the euthyroid patients. Surgical treatment (orbital decompression, eyelid retraction correction, or strabismus surgery) was done in 15 (24%) euthyroid patients, compared with 29 (46%) dysthyroid patients. Interestingly, none of the euthyroid patients underwent strabismus surgery (Fig 1 [available at http://aaojournal.org]). Four euthyroid and 6 dysthyroid patients had coexistent myasthenia gravis. Additionally, 3% of patients in each group were diabetic. Patients in the euthyroid group remained euthyroid during the 2-year follow-up, although 1 patient did develop hyperthyroidism 2.5 years after the first visit. Our findings suggest that euthyroid GO is less severe than dysthyroid GO. We noted that euthyroid patients had less severe restrictive myopathy and proptosis and were less likely to require surgical management. When such patients present with mild, unilateral, or markedly asymmetric orbitopathy, diagnosis often can be difficult, and therefore, appropriate management might be delayed. However, it should be kept in mind that our data were obtained retrospectively, and data recording relied heavily on patient recall of timing of onset of GO and qualitative self-report of thyroid function tests. In fact, as thyroid testing becomes more sophisticated, we may be able to eliminate the concept of euthyroid GO, because most likely there is subclinical involvement of the thyroid gland in almost all patients with orbitopathy. One important caveat to the current study is the lack of autoantibody testing in many patients. Typically, thyroid dysfunction correlates with autoantibody formation. To validate our current findings, a prospective trial would be necessary to assess the observed differences in clinical severity. A prospective trial with meticulously defined clinical criteria, including autoantibody detection, stringent measures of thyroid dysfunction, and radiographic assessment of disease, should accomplish this goal. APARNA BHATNAGAR, MD ANGELO TSIRBAS, MD RAYMOND S. DOUGLAS, MD, PHD ROBERT A. GOLDBERG, MD, FACS Los Angeles, California ERIKA HOYAMA, MD Londrina, Brazil
Graves’ Orbitopathy Dear Editor: Infiltrative orbitopathy occurring in the absence of objective evidence of thyroid dysfunction has been referred to as euthyroid Graves’ disease.1 This group of patients with clinical Graves’ orbitopathy (GO), but no symptoms or laboratory findings of autonomous thyroid function, can be a diagnostic challenge. We report that patients with euthyroid GO have less severe clinical orbital disease than their dysthyroid counterparts (Bhatnagar A. Euthyroid and Graves’ related orbitopathy—a retrospective study. Poster presented at: World Ophthalmology Congress, February 19 –24, 2006, Sao Paulo, Brazil). A total of 669 patients with Graves’ disease observed over a 6-year period were identified. A diagnosis of euthyroid GO was made if patients presented with symptoms and signs of thyroid-related orbitopathy but without confirmatory systemic thyroid abnormalities, including normal thyroid function at the time of diagnosis and 2 years later.2 Sixty-three patients achieved euthyroid criteria, whereas 63 dysthyroid patients were chosen as a control group. The groups were controlled for age, smoking history, and presence of hyperthyroidism. Hypothyroid patients who became hyperthyroid after treatment were excluded. Patients with orbitopathy but with the presence of other orbital diseases such as neoplasia or specific orbital inflammation also were excluded from the study. Demographics, including referring diagnosis, clinical features, and treatment, are detailed in Table 1 (available at http://aaojournal.org). Mean ages at presentation were 53.3 and 54.6 years, and female/male ratios were 1.62 and 3.2 in the euthyroid group and dysthyroid group, respectively. We found that euthyroid males presented with orbital disease
392
more often than males from the dysthyroid group, as stated in previous studies.3,4 Nearly 75% of the patients in both groups presented with eyelid retraction, and more than half (54% euthyroid, 56% dysthyroid) demonstrated asymmetrical proptosis. However, a smaller fraction of euthyroid patients demonstrated proptosis (68% vs. 87%) and motility restriction (24% vs. 68%). Fourteen percent of euthyroid patients presented with diplopia, as opposed to 35% in the dysthyroid group (P ⫽ 0.006). Inflammation was found in 4 (6%) euthyroid patients and 17 (27%) dysthyroid patients (P ⫽ 0.002). Eight (13%) euthyroid patients had lid lag, compared with 18 (29%) dysthyroid patients (P ⫽ 0.028). Optic neuropathy was found in 9 (14%) dysthyroid patients but none of the euthyroid patients. Surgical treatment (orbital decompression, eyelid retraction correction, or strabismus surgery) was done in 15 (24%) euthyroid patients, compared with 29 (46%) dysthyroid patients. Interestingly, none of the euthyroid patients underwent strabismus surgery (Fig 1 [available at http://aaojournal.org]). Four euthyroid and 6 dysthyroid patients had coexistent myasthenia gravis. Additionally, 3% of patients in each group were diabetic. Patients in the euthyroid group remained euthyroid during the 2-year follow-up, although 1 patient did develop hyperthyroidism 2.5 years after the first visit. Our findings suggest that euthyroid GO is less severe than dysthyroid GO. We noted that euthyroid patients had less severe restrictive myopathy and proptosis and were less likely to require surgical management. When such patients present with mild, unilateral, or markedly asymmetric orbitopathy, diagnosis often can be difficult, and therefore, appropriate management might be delayed. However, it should be kept in mind that our data were obtained retrospectively, and data recording relied heavily on patient recall of timing of onset of GO and qualitative self-report of thyroid function tests. In fact, as thyroid testing becomes more sophisticated, we may be able to eliminate the concept of euthyroid GO, because most likely there is subclinical involvement of the thyroid gland in almost all patients with orbitopathy. One important caveat to the current study is the lack of autoantibody testing in many patients. Typically, thyroid dysfunction correlates with autoantibody formation. To validate our current findings, a prospective trial would be necessary to assess the observed differences in clinical severity. A prospective trial with meticulously defined clinical criteria, including autoantibody detection, stringent measures of thyroid dysfunction, and radiographic assessment of disease, should accomplish this goal. APARNA BHATNAGAR, MD ANGELO TSIRBAS, MD RAYMOND S. DOUGLAS, MD, PHD ROBERT A. GOLDBERG, MD, FACS Los Angeles, California ERIKA HOYAMA, MD Londrina, Brazil