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Update on Thyroid-Associated Ophthalmopathy with a Special Emphasis on the Ocular Surface Priscila Novaes1†, Ana Beatriz Diniz Grisolia1† and Terry J

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Update on Thyroid-Associated Ophthalmopathy with a Special Emphasis on the Ocular Surface Priscila Novaes1†, Ana Beatriz Diniz Grisolia1† and Terry J Novaes et al. Clinical Diabetes and Endocrinology (2016) 2:19 DOI 10.1186/s40842-016-0037-5 REVIEWARTICLE Open Access Update on thyroid-associated Ophthalmopathy with a special emphasis on the ocular surface Priscila Novaes1†, Ana Beatriz Diniz Grisolia1† and Terry J. Smith1,2,3* Abstract Thyroid-associated ophthalmopathy (TAO) is a condition associated with a wide spectrum of ocular changes, usually in the context of the autoimmune syndrome, Graves’ disease. In this topical review, we attempted to provide a roadmap of the recent advances in current understanding the pathogenesis of TAO, important aspects of its clinical presentation, its impact on the ocular surface, describe the tissue abnormalities frequently encountered, and describe how TAO is managed today. We also briefly review how increased understanding of the disease should culminate in improved therapies for patients with this vexing condition. Keywords: Graves’ disease, Ophthalmopathy, Thyroid, Orbit, Ocular surface Background factors, and several partially characterized environmental Thyroid-associated ophthalmopathy (TAOa, aka thyroid triggers [8]. Several recent reviews have addressed TAO; eye disease or Graves’ ophthalmopathy) refers to several however none has detailed insights of the association ocular manifestations related to the systemic auto- and interactions between TAO, the ocular surface (OS) immune process, Graves’ disease (GD) [1]. This syn- and dry eye syndrome (DES). We have thus included an drome has been attributed to the loss of immune emphasis on the OS and DES in this review. tolerance to the thyrotropin receptor (TSHR) and per- haps other auto-antigenic proteins [2, 3]. TAO results Pathogenesis from the linked conspiracy of auto-reactivity and tissue The central participant in the pathogenesis of TAO is remodeling. The factors that over-arch the ocular com- the orbital fibroblast [9, 10]. Orbital fibroblasts from ponents of GD with the pathology occurring in the thy- healthy individuals appear to differ from those with TAO roid have yet to be identified unambiguously. TAO is the [11–13]. They represent a heterogeneous population of most common and serious extra-thyroidal manifestation cells with divergent capacities for terminal differentiation of GD, with 25–50% in those with the thyroid disease and gene expression. We now know that a subpopula- [4–6]. While the majority of individuals with GD be- tion of orbital fibroblasts in TAO derive from bone mar- come hyperthyroid sometime in the course of their dis- row derived fibrocytes [14]. These cells express several ease, TAO can also occur in primary hypothyroidism thyroid antigens that have been implicated in TAO. and in patients who remain euthyroid [7]. Substantial Among them is the TSHR. TSHR has been detected in evidence suggests that GD and TAO result from com- orbital connective tissue and on orbital fibroblasts, albeit plex interplay between genetic susceptibility, epigenetic at extremely low levels [15, 16] but the basis for its ex- pression has remained uncertain. Fibrocytes were found * Correspondence: [email protected] to infiltrate the TAO orbit and express higher levels of †Equal contributors 1Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, TSHR than those found on orbital fibroblasts [14, 17, 18]. University of Michigan Medical School, Ann Arbor, MI 48105, USA Furthermore, the receptor displayed on fibrocytes is func- 2 Division of Metabolism, Endocrinology, and Diabetes, Department of tional in that TSH and thyroid-stimulating immunoglobu- Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48105, USA lins (TSI) provoke the generation of extremely high levels Full list of author information is available at the end of the article of inflammatory cytokines. These include IL-6, TNF-α,IL- © The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Novaes et al. Clinical Diabetes and Endocrinology (2016) 2:19 Page 2 of 10 8, and IL-1β [19]. How the receptor participates in TAO is eyelid) or Müller’s muscle (upper eyelid). This is less certain. In addition to TSHR, other thyroid autoanti- thought to be a consequence of direct thyroid hor- gens have also been detected in orbital tissues and mone actions. The concept of anterior globe dis- expressed by orbital fibroblasts [8]. Persistence of detect- placement as a mechanism for eyelid retraction able thyroid autoantibodies in patients with therapy- resulting from proptosis is demonstrated by improve- resistant TAO may support a role for these autoantigens ment of eyelid retraction following surgical correc- in disease pathogenesis [20]. tion of proptosis [24, 30, 31]. Overall, these theories It is unclear how the abnormal behavior of orbital fi- appear compatible with the variations of clinical dis- broblasts in TAO interplays with the recruited lympho- ease presentation. cytes, mast cells and macrophages. Their accumulation in the orbit is characteristic of the disease. Development Clinical presentation of their therapeutic targeting is of considerable import- The onset of ocular symptoms/signs and hyperthyroid- ance [12, 18]. Subpopulations of orbital fibroblasts may ism can occur simultaneously or diverge temporally by explain, at least in part, the diversity of clinical TAO months to years [32]. Patients undergo an initial period presentation. The disease can manifest as predominantly where inflammation, progressive orbital congestion, and fat expansion or with isolated extraocular muscle (EOM) variably worsening proptosis evolve. This stage is termed involvement or most commonly a mixture of both [13, 21]. the active phase. The activity of the disease can be Fibroblasts can be identified on the basis of cell surface assessed by calculating the clinical activity score (CAS), markers such as Thy-1 and CD34. Subsets differ in based on seven signs (Table 1). In addition, clinical their ability to differentiate into adipocytes or myofi- severity can be classified using the NOSPECS score broblasts [13, 22]. Cells from orbital fat differ pheno- (Table 2). According to Rundle’s curve, this phase can typically from those of perimysial derivation [23]. last from months to several years [33]. Activity gives way TAO is associated with accelerated glycosaminoglycan to a period of stabilization and ultimately leads to the in- production, resulting in mechanical embarrassment of active phase where the disease no longer progresses. the orbital contents [14, 24, 25]. Orbital fibroblast prolif- This stable phase is seldom associated with a complete eration and differentiation into adipocytes leads to fat normalization of ocular changes [4]. tissue expansion. In muscle, increased glycosaminogly- Proptosis or exophthalmos occurs as a consequence of can accumulation can interfere with normal contraction expanding orbital contents being confined within the and movement [9, 14, 25]. In advanced stages of the dis- boney orbit and the naturally occurring decompression ease, fibrotic changes can affect muscle functions, result- resulting from anterior displacement of the globe. TAO ing in restricted eye movement. is the most common cause of both unilateral and bilat- Many clinical signs and symptoms of TAO arise from eral proptosis in adults. Pseudo-ptosis and true ptosis expansion of soft-tissues within the orbit, leading to may be seen in patients with TAO. The former results exophthalmos [9, 25, 26]. Disturbance of the ocular sur- from contralateral lid retraction but true ptosis occurs face is caused by inadequate lid coverage; the increased when the levator muscle suffers dehiscence or when palpebral fissure width results in accelerated tear evapor- concurrent myasthenia gravis is manifested. Strabismus ation and elevated tear osmolarity [27, 28], perpetuating is common in TAO, resulting from restrictive extraocu- an inflammatory cycle [29] and contributing to a major lar muscle impairment. It can induce head tilt and diplo- source of disease morbidity. pia. The inferior and medial rectus muscles are most Eyelid structures are also altered in TAO, resulting commonly involved in TAO, resulting in horizontal and in retraction of both upper and lower eyelids. Three vertical deviations. The basis for this predilection has different mechanisms have been proposed [24]. The not been identified [23]. Diplopia develops from inflam- cicatricial and restrictive theory is explained by the mation and swelling of the extraocular muscles and is effects of TAO on EOM and on the elastic compo- generally restrictive. It is classified as intermittent nents of eyelid retractor muscles. Enlarged inferior (present upon awakening or during fatigue, present at rectus muscle dimension and the generalized orbit extremes of gaze) or constant when present in primary connective tissue congestion may retract the lower gaze and/or reading position [4, 9]. One other important eyelid margin. This is due to increased tension on sign of EOM involvement is the elevation of IOP in the lower eyelid
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