Subclinical Visual Field Alterations are Commonly Present in Patients with Graves' Orbitopathy and are Mainly Related to the Clinical Activity of the Disease

Abstract

The present study was aimed to investigate optic nerve involvement by computerized perimetry in 40 (29 women, 11 men) consecutive GO patients not showing definite dysthyroid optic neuropathy (DON). All patients presenting visual acuity defects, pallor or swelling of the optic nerve, concomitant eye disease, evidence of apical crowding or optic nerve stretching at either MRI or CT imaging were excluded. Normal perimetry occurred in 7 patients (17.5%), 5 patients (12.5%) had “indeterminate” results and 28 patients (70%) presented abnormal perimetry. Particularly, 7 isolated paracentral, 5 pericentral and 16 combined peri and paracentral scotomas were found. On the contrary, 15/20 patients in the group without GO had normal perimetry, isolated scotomas were found in 5 cases (1 pericentral and 4 paracentral) and no case of combined scotoma occurred. The difference between the 2 groups was statistically significant (χ²=9.17; p=0.025). Overall, the sensitivity resulted 70%, the specificity 75% and the positive predictive value 84.8%. In patients with GO, the proportion of visual field alterations was significantly increased for Clinical Activity Score ≥3 (p=0.0005), while no relationship occurred with proptosis degree (p=0.115). In conclusion, a great proportion of GO patients without clinically evident DON presents visual field defects, mainly related to GO activity.

Key words

Graves' disease - Graves' Orbitopathy - visual field - computerized perimetry - optic nerve

References

• 1 Bartalena L, Pinchera A, Marcocci C. Management of Graves’ ophthalmopathy: reality and perspectives.  Endocr Rev. 2000;  21 168-199.3
• 2 Bartalena L, Wiersinga WM, Pinchera A. Graves’ ophthalmopathy: state of the art and perspectives.  J Endocrinol Invest. 2004;  27 295-301
• 3 Burch HB, Wartofsky L. Graves' ophthalmopathy: current concepts regarding pathogenesis and management.  Endocr Rev. 1993;  14 747-793
• 4 Day RM, Carroll FD. Optic nerve involvement associated with thyroid dysfunction.  Arch Ophthalmol. 1962;  67 289-297
• 5 Santo LW De. The total rehabilitation of Graves’ ophthalmopathy.  Laryngoscope. 1980;  90 1652-1678
• 6 Dickinson AJ, Perros P. Controversies in the clinical evaluation of active thyroid-associated orbitopathy: use of a detailed protocol with comparative photographs for objective assessment.  Clinical Endocrinology. 2001;  55 283-303
• 7 Eckstein AK, Plicht M, Lax H, Neuhäuser M, Mann K, Lederbogen S, Heckmann C, Esser J, Morgenthaler NG. Thyrotropin receptor autoantibodies are independent risk factors for Graves' ophthalmopathy and help to predict severity and outcome of the disease.  J Clin Endocrinol Metab. 2006;  91 3464-3470
• 8 Gasser P, Flammer J. Optic neuropathy of Graves’ disease.  Ophthalmologica. 1986;  192 22-27
• 9 Hedges Jr TR, Scheie Hg. Visual field defects in exophthalmos associated with thyroid disease.  AMA Arch Ophthalmol. 1955;  54 885-892
• 10 Henderson JW. Optic neuropathy of exophthalmic goiter (Graves’ disease).  AMA Arch Ophthalmol. 1958;  59 471-480
• 11 Henson DB, Chaudry S, Artes PH, Faragher EB, Ansons A. Response variability in the visual field: comparison of optic neuritis, glaucoma, ocular hypertension, and normal eyes.  Investigative Ophthalmology and Visual Science. 2000;  41 417-421
• 12 Khurana AK, Sunder S, Ahluwalia BK, Malhotra KC. Tear film profile in Graves' ophthalmopathy.  Acta Ophthalmol (Copenh). 1992;  70 346-349
• 13 MacKeag D, Lane C, Lazarus JH, Baldeschi L, Boboridis K, Dickinson JA, Hullo A, Kahaly G, Krassas G, Marcocci C, Marino M, Mourits M, Nardi M, Neoh C, Orgiazzi J, Perros P, Pinchera A, Pitz S, Prummel Deceased MF, Sartini MS, Wiersinga WM. Clinical features of dysthyroid optic neuropathy: A European Group on Graves' Orbitopathy (EUGOGO) Survey.  Br J Ophthalmol. 2006;  , doi:10.1136/bjo.2006.094607
• 14 Neigel JM, Rootman J, Belkin RI. et al . Dysthyroid optic neuropathy.  Ophthalmology. 1988;  95 1515-1521
• 15 Prabhakar BS, Bahn RS, Smith TJ. Current perspective on the pathogenesis of Graves' disease and ophthalmopathy.  Endocr Rev. 2003;  24 802-835
• 16 Trobe JD, Glaser JS, Laflamme P. Dysthyroid optic neuropathy.  Arch Ophthalmol. 1978;  96 1199-1209
• 17 Wiersinga WM, Prummel MF. Pathogenesis of Graves' ophthalmopathy- current understanding.  J Clin Endocrinol Metab. 2001;  86 501-503

Correspondence