Thyroid eye disease: Not limited to visual impairment

This article was reviewed by Yao Wang, MD

Thyroid eye disease (TED) goes far beyond simply affecting patients’ vision. It has a profound effect on their quality of life (QOL) and mental health, as well, according to the authors of a recent survey, which reflected physicians’ perceptions of the disease’s impact on their patients.

The FDA recently approved teprotumumab-trbw (Tepezza; Horizon Therapeutics) to treat TED.

Related: Study: Therapy reduces proptosis, diplopia in TED

The administration’s drug trial snapshot released on January 21, 2020, noted that after 6 months of treatment, a higher proportion of patients treated with teprotumumab-trbw (71%-83%) demonstrated a reduction in proptosis compared with patients treated with placebo (10%-20%)^.1

The inflammation associated with TED plays a big role in the disease pathology. Retro-orbital and orbital inflammation cause eyelid retraction, proptosis, and periocular swelling. In patients with severe inflammation, vision is compromised because of exposure of the cornea and compression of the optic nerve.

Although the inflammation can subside in about 3 years, it leaves behind disfiguring sequelae, visual changes, and dry eye, reported the study authors, who conducted the survey to determine physicians’ perspectives on TED and how they clinically managed their patients’ condition.

In the online survey, endocrinologists and ophthalmologists responded to questions about the degree to which the disease affected their patients’ school and work attendance, social function, enjoyment of everyday activities, driving, and psychological wellness.

Related: Questionnaire asseses vision in pediatric eye cases

The physicians were asked to provide information on up to 4 patients who had moderate to severe TED. The authors then studied the disease’s comorbidities, visual symptoms, and structural changes to gain an understanding of its impact on QOL.

Results
According to a press release detailing the investigators’ findings, 181 physicians (108 ophthalmologists, 73 endocrinologists) responded to the survey with information on 432 and 282 patients, respectively.

Most patients were women (65.3%), the average patient age was 49.4 years, and 102 patients had severe TED.²

The authors reported that QOL and psychological well-being were the most severely affected factors, both with a score of 4.1 on a scale of 1 to 7 used to rate impact (1 representing not at all impaired and 7 representing extremely impaired).

The data showed that 36.4% of patients experienced anxiety and/or depression; significantly more patients with moderate TED experienced anxiety (28.4%) compared with those with other degrees of TED (13.7%).

Patients with moderate and severe TED experienced depression more often compared with those with mild disease (21.6% vs 17.8%, respectively).

Related: Strategies for coping with physician depression during COVID-19

After subdividing patients based on higher and lower QOL impairment, the investigators found that 66.2% of patients experienced a greater impact on their QOL.

“These patients had shorter disease duration, higher clinical activity scores, and a higher proportion of severe disease than patients with lower quality of life impact,” the investigators reported.

The QOL impact scores for patients with severe TED were significantly higher than those for patients with moderate disease (5.2 vs 4.0, respectively).

Patients with higher QOL impact had more pain; however, both groups experienced intense ocular dryness and grittiness that was equally prevalent in both groups (84.2% and 84.8%, respectively).

Others reported pain and discomfort symptoms including photophobia, pain with ocular movement, and pain in primary gaze.

Patients with a higher QOL impact experienced the vison-related signs and symptoms of TED significantly more often (P < .001). These included decreased vision, diplopia, and color vision changes.

The investigators also observed more orbital and ocular changes in the group with higher QOL impact, most notably proptosis, soft tissue swelling, and conjunctival redness.

Related: Ocular surface inflammation: Vicious cycle of ocular surface disruption

The authors ultimately concluded that moderate and severe TED highly affects patients’ QOL.

In addition, more than a third of patients had a mental health issue, which is almost double the proportion of US adults in the general population.

“Our findings agree with previous studies that patients with more severe TED and more active disease had a greater quality of life impact.

Diplopia resulting from uneven motility restrictions and proptosis independently have negative effects on patients’ quality of life.

Diplopia is a principle driver of occupational disability, and the quality of life decreases associated with strabismus are largely driven by diplopia,” the authors commented.

Treating TED
Yao Wang, MD, one of the study’s authors, is a neuroophthalmologist and oculoplastics specialist who sees patients with TED in her practice.

“Because of the heterogeneity of the clinical presentation of TED, the treatment will vary depending on the patients’ complaints and symptoms,” she said. “Patients with mild, nondebilitating symptoms can be managed conservatively with eye drops and lubrication, whereas those with progressive, active disease may benefit from [infusions of] teprotumumab-trbw, which was just approved by the FDA for treatment of TED.”

Wang also noted that patients can undergo surgeries such as orbital decompression, strabismus surgery, and periocular aesthetic reconstructive procedures as needed.

Related: Dropless regimen after cataract surgery relieves patient treatment burden

Wang concluded that when physicians examine patients with TED, they must assess not only the physical symptoms—such as eye bulging, blurry vision, and pain—but also the impact of the disease on overall QOL.

“This gives the physician a more complete picture of how TED is affecting their patients on a daily basis and provides important considerations when making treatment decisions,” she said.

Read more by Lynda Charters

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Yao Wang, MD
Dr Wang has no proprietary interest in this subject matter. She is affiliated with Cedars-Sinai Medical Center in Los Angeles, California.

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References
1. Drug trial snapshot: Tepezza. FDA. Updated January 29, 2020. Accessed TK. https://www.fda.gov/drugs/drug-approvals-and-databases/drug-trial-snapshot-tepezza

2. U.S. physician survey illustrates the devastating impact of thyroid eye disease on patient quality of life. News release. Horizon Therapeutics. May 11, 2020. Accessed TK. https://ir.horizontherapeutics.com/news-releases/news-release-details/us-physician-survey-illustrates-devastating-impact-thyroid-eye