Can you predict which patients with Thyroid Eye Disease will respond to immunosuppressive treatment? In this 1997 study, patients with Graves’ Ophthalmopathy were assessed using the Clinical Activity Score (CAS) and treated with oral prednisone (n = 22) or retrobulbar irradiation (n = 21) and graded on their response to treatment based on the CAS.
Overall, the CAS Graves’ Ophthalmopathy study is a landmark study because it offered an easy, inexpensive, and entirely clinical score that providers can use to predict which patients are more likely to respond to immunosuppressive therapy. These data can be used to assist clinical decision-making and patient satisfaction in the treatment of Thyroid Eye Disease.
Do doctors need to suppress the use of immunosuppressants? Corticosteroids had been the mainstay of treatment for patients with severe ocular inflammatory disease despite the known side effects. Many ophthalmologists were resistant to using other types of systemic due to concern for increased risk of malignancy. The retrospective cohort SITE study sought to determine if the use of immunosuppressants for the treatment of severe ocular inflammatory disease had a higher risk of development of malignancy than conventional therapy with corticosteroids.
This study concluded that the rate of developing malignancy in patients with severe ocular inflammatory disease treated with immunosuppressants was no different than those patients treated with corticosteroids alone. Their results support substituting immunosuppressants for corticosteroids in the treatment of these patients since the latter have become increasingly ineffective and chronic use causes highly unfavorable side-effects.
Now that you see it, what do you do with it? The COMS was a prospective multicenter trial organized by the National Eye Institute in 1985 to examine mortality outcomes of different treatment options for uveal melanoma. They also examined cancer free survival, metastasis free survival, and years of functional vision. There were three main arms of the study, which differentiated melanomas based upon tumor size. It is important to note that this study is not applicable to melanomas of the ciliary body or peripapillary choroid.
Small tumor trial (1mm < height <3mm and 5mm < diameter < 16mm)
Medium tumor trial (2.5mm < height < 10mm and diameter <16mm)
Large tumor trial (height > 8mm and/or diameter > 16mm)
The COMS is a landmark study because it helped guide physicians on when and how to treat ocular melanomas, which are the most common primary eye tumors in adults. Although nonmalignant choroidal nevi are more common than choroidal melanomas, all nevi should be evaluated for features concerning for melanoma as choroidal melanomas have high mortality rates.
What must you do to effectively treat noninfectious uveitis? In the 2011 MUST trial, patients with noninfectious intermediate, posterior, or panuveitis from 23 centers were randomized to fluocinolone acetonide implant therapy (n = 129) or systemic therapy (n = 126) with two-year follow-up.
The MUST trial highlights the effectiveness of both forms of anti-inflammatory corticosteroid-based therapies for noninfectious uveitis. This is a landmark study as neither approach was determined to be superior to the other, allowing for choice of treatment to be based on pros and cons specific to a patient’s individual clinical circumstances.
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