The Clinical Characteristics of Thyroid Orbitopathy in Thyroid Dysfunction Pediatric Patients

Jeong Bum Bae; Hye Mi Cheong; Jae Ho Yoo; Yoon Hyung Kwon; Hee Bae Ahn

doi:10.3341/jkos.2013.54.8.1149

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Bae, Cheong, Yoo, Kwon, and Ahn: The Clinical Characteristics of Thyroid Orbitopathy in Thyroid Dysfunction Pediatric Patients

Original Article

J Korean Ophthalmol Soc 2013;54(8):1149-1156.

Published online: 7 September 2013

DOI: https://doi.org/10.3341/jkos.2013.54.8.1149

The Clinical Characteristics of Thyroid Orbitopathy in Thyroid Dysfunction Pediatric Patients

Jeong Bum Bae, MD¹, Hye Mi Cheong, MD¹, Jae Ho Yoo, MD, PhD², Yoon Hyung Kwon, MD¹, Hee Bae Ahn, MD, PhD^1,

¹Department of Ophthalmology, Dong-A University College of Medicine, Busan, Korea

²Department of Pediatrics, Dong-A University College of Medicine, Busan, Korea

Address reprint requests to Hee Bae Ahn, MD, PhD Department of Ophthalmology, Dong-A University Medical Center #26 Daesingongwon-ro, Seo-gu, Busan 602-715, Korea Tel: 82-51-240-5227, Fax: 82-51-254-1987, E-mail: hbahn@dau.ac.kr

This study was presented as a narration at the 108th Annual Meeting of the Korean Ophthalmology Society 2012.

This article has been supported by the Intramural Research Fund of the Dong-A University of medicine.

Received 21 December 201210 March 2013 Accepted 18 May 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To investigate the clinical characteristics and treatment methods for pediatric thyroid-associated orbitopathy in pediatric patients with thyroid disorders.

Methods

To determine the prevalence and clinical characteristics of pediatric thyroid-associated orbitopathy, we retro-spectively analyzed the medical records of 34 patients admitted to the Pediatrics Department of our institution between September 2010 and September 2012. The patients had been diagnosed with autoimmune thyroid disorder and were ad-mitted for treatment of thyroid-associated orbitopathy.

Results

In the 24.1 months of follow-up observation, 14 patients were diagnosed with Graves’ disease (41.2%) and 20 patients with Hashimoto’s thyroiditis (58.8%). Of the 34 patients, 15 (44.1%) developed eye symptoms. Among the eye symptoms, lid swelling was the most prevalent in 41.2% of patients, followed by eyelid retraction in 23.5%, lid lag in 17.6%, conjunctival injection in 14.7%, proptosis in 8.8%, and extraocular muscle hypertrophy in 17.6%. Severe impairment of vis-ual acuity, visual field, and ocular motility were not observed in our study. Although eyelid surgery was performed in 3 cas-es, most patients were treated conservatively.

Conclusions

Pediatric thyroid-associated orbitopathy was frequently observed in patients with Graves’ disease and Hashimoto’s thyroiditis. Compared to adults, children showed milder disease manifestation and progression, and the dis-ease could be managed with conservative treatment.

Keywords: Graves’ disease, Hashimoto’s thyroiditis, Pediatric, Thyroid-associated orbitopathy

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Figure 1.

Scatter plots depicting relationships between Free T4 and Proptosis measured by Hertel exophtalmometer. Continuous lines represent regression lines of relationships. (A) Free T4 vs separate value of right eyes (in mm) measured by Hertel exophtalmometer. (B) Free T4 vs separate value of left eyes (in mm) measured by Hertel exophtalmometer.

Table 1.

Modified NOSPECS classification¹¹

Class	Definition
0	No Physical signs or symptoms
1	Only signs, no symptoms (signs limited to upper eyelid retraction, stare, and eyelid lag)
2	Soft tissue involvement, with symptoms and signs
3	Proptosis
4	Extraocular muscle involvement
5	Corneal involvement
6	Sight loss (Optic nerve involvement)

Table 2.

Demographics of the patients

Patient characteristics	Graves disease	Hashimoto’s thyroiditis	p-value^*
Sex (M/F)	1/13 (7.1/92.9)	3/17 (15.0/85.0)
Age diagnosed with thyroid dysfunction (years)	11.3 ± 3.2	11.0 ± 2.9	0.748
Age diagnosed with thyroid orbitopathy (years)	13.1 ± 2.8	12.8 ± 2.9	0.824
Duration after diagnosis thyroid dysfunction to thyroid	17.6 ± 2.0	18.9 ± 2.2	0.870
orbitopathy (months)
Follow-up period (months)	24.9 ± 7.7	23.7 ± 7.5	0.652
Familiy history of thyroid disease	2 (14.3)	6 (30.0)	0.302
Passive smoking history	5 (35.7)	8 (40.0)	0.807
Hormone status at diagnosis
Hyperthyroidism	13 (92.9)	4 (20.0)
Euthyroidism	1 (7.1)	7 (35.0)	p<0.01^†
Hypothyroidism	0 (0)	9 (45.0)

Values are presented as mean ± SD or (n).

^* Mann-Whitney U test

^† Pearson’s chi-square test.

Table 3.

Clinical manifestations of pediatric thyroid-associated orbitopathy

Clinical feature	Total patients (%)	Graves disease (%)	Hashimoto’s thyroiditis (%)
Eyelid swelling	14 (41.2)	8 (57.1)	6 (30.0)
Eyelid retraction	8 (23.5)	5 (35.7)	3 (15.0)
Lig lag	6 (17.6)	3 (21.4)	3 (15.0)
Conjunctival injection	5 (14.7)	4 (28.6)	1 (5.0)
Chemosis	3 (8.8)	2 (14.3)	1 (5.0)
Swollen caruncle	2 (5.9)	1 (71.4)	1 (5.0)
Corneal staining	3 (8.8)	2 (14.3)	1 (5.0)
Proptosis	3 (8.8)	2 (14.3)	1 (5.0)
Muscle hypertrophy	6 (17.6)	4 (28.6)	2 (10.0)

Table 4.

Clinical activity score of pediatric thyroid-associated orbitopathy

CAS	Total patients (%)	Graves disease (%)	Hashimoto’s thyroiditis (%)
0	19 (55.9)	5 (35.7)	14 (70.0)
1	8 (23.6)	4 (28.6)	4 (20.0)
2	3 (8.8)	2 (14.3)	1 (10.0)
3	3 (8.8)	3 (21.4)	0
4	1 (2.9)	0	1 (10.0)
5	0	0	0
6-10	0	0	0
Total	34 (100)	14 (100)	20 (100)

For each item present, one point is given. The sum of these points is the CAS (range 0-10), 0 = No inflammation; 1-3 = Mild inflammation; 4-10 = Active inflammation of the orbital tissues.

CAS = clinical activity score.

Table 5.

NOSPECS classification of pediatric thyroid-associated orbitopathy

NOSPECS	Total patients (%)	Graves disease (%)	Hashimoto’s thyroiditis (%)
Class 0	19 (55.9)	6 (42.9)	13 (65.0)
Class 1	11 (32.3)	5 (35.7)	6 (30.0)
Class 2	4 (11.8)	3 (21.4)	1 (5.0)
Class 3	0	0	0
Class 4	0	0	0
Class 5	0	0	0
Class 6	0	0	0
Total	34 (100)	14 (100)	20 (100)

NOSPECS = no physical sign, only signs, soft tissue involvement, proptosis, extraocular muscle involvement, corneal involvement, sight loss.

Table 6.

Treatments of pediatric thyroid-associated orbitopathy

Treatments	No. of patients (%)
Conservative treatment (artificial tears, therapeutic lens)	31 (91.2)
Medical treatment (steroid therapy)	0 (0)
Radiotherapy	0 (0)
Surgical treatment (lid surgery)	3 (8.8)

Table 7.

Key ophthalmic findings of studies of pediatric thyroid-associated orbitopathy

	Uretsky²⁴	Young²⁵	Gruters²⁶	Chan⁷	Present study
Number of cases	34	33	43	83	34
Ocular signs (%)	67	48	37	63	44
Proptosis (%)	3	3	7	12	9
Lid lag/retraction (%)	63	45	37	50	44
Restrictive strabismus (%)	6	0	0	1	0

Table 8.

Severity of pediatric thyroid-associated orbitopathy in different studies

	Uretsky²⁴	Young²⁵	Gruters²⁶	Chan⁷	Present study
Number of cases	34	33	43	83	34
NOSPECS classification
Class 0	11 (47.8%)	17 (51.5%)	24 (55.8%)	31(37.3%)	18 (52.9%)
Class 1	8 (34.8%)	12 (36.4%)	16 (37.2%)	21 (25.3%)	12 (35.3%)
Class 2	3 (13.0%)	3 (9.1%)	0	12 (14.5%)	4 (11.8%)
Class 3	1 (4.3%)	1 (3.0%)	3 (7.0%)	7 (8.4%)	0
Class 4	0	0	0	1 (1.2%)	0
Class 5	0	0	0	11 (13.3%)	0
Class 6	0	0	0	0	0

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