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      Graves' Ophthalmopathy: VISA versus EUGOGO Classification, Assessment, and Management

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          Abstract

          Graves' ophthalmopathy (GO) is an autoimmune inflammatory disorder associated with thyroid disease which affects ocular and orbital tissues. GO follows a biphasic course in which an initial active phase of progression is followed by a subsequent partial regression and a static inactive phase. Although the majority of GO patients have a mild, self-limiting, and nonprogressive ocular involvement, about 3–7% of GO patients exhibit a severe sight-threatening form of the disease due to corneal exposure or compressive optic neuropathy. An appropriate assessment of both severity and activity of the disease warrants an adequate treatment. The VISA (vision, inflammation, strabismus, and appearance), and the European Group of Graves' Orbitopathy (EUGOGO) classifications are the two widely used grading systems conceived to assess the activity and severity of GO and guide the therapeutic decision making. A critical analysis of classification, assessment, and management systems is reported. A simplified “GO activity assessment checklist” for routine clinical practice is proposed. Current treatments are reviewed and management guidelines according to the severity and activity of the disease are provided. New treatment modalities such as specific monoclonal antibodies, TSH-R antagonists, and other immunomodulatory agents show a promising outcome for GO patients.

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          Most cited references63

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          Graves' ophthalmopathy.

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            Clinical activity score as a guide in the management of patients with Graves' ophthalmopathy.

            Approximately 35% of patients with Graves' ophthalmopathy do not respond to immunosuppressive treatment. A possible explanation for this finding is that only patients with active ophthalmopathy respond to immunosuppressive treatment, whereas patients with fibrotic end stage disease do not. To distinguish between these two groups and to predict the outcome of immunosuppressive treatment, we developed a clinical activity score (CAS) based on four of the five classical signs of inflammation and tested its efficacy in a double-blind, prospective study. The CAS was determined by an opthalmologist before, on the day of, and after the start of either oral prednisone or retrobulbar irradiation in 43 patients with moderate to severe Graves' ophthalmopathy. The therapeutic outcome was determined by a second ophthalmologist unaware of the CAS stores given. Success of treatment was defined as an improvement in NOSPECS class or grade. Responders (22) and non-responders (21) did not differ in age, sex, duration or severity of their Graves' ophthalmopathy. The pretreatment CAS, however, was significantly higher in responders than in non-responders. Twelve of 22 responders and three of 21 non-responders had a CAS > or = 4 (55% vs 14%; P or = 4 had a similar duration of Graves' ophthalmopathy as patients with a CAS < 4. The clinical activity score has a high predictive value for the outcome of immunosuppressive treatment in Graves' ophthalmopathy. Disease activity, and not disease duration, is the prime determinant of therapeutic outcome.
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              Consensus statement of the European Group on Graves' orbitopathy (EUGOGO) on management of GO.

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                Author and article information

                Journal
                J Ophthalmol
                J Ophthalmol
                JOPH
                Journal of Ophthalmology
                Hindawi Publishing Corporation
                2090-004X
                2090-0058
                2015
                17 August 2015
                : 2015
                : 249125
                Affiliations
                1Department of Ophthalmology, Clínica Universidad de Navarra, Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain
                2Department of Endocrinology and Nutrition, Clínica Universidad de Navarra, Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain
                Author notes
                *Jesús Barrio-Barrio: jbarrio@ 123456unav.es

                Academic Editor: Kyoung Yul Seo

                Article
                10.1155/2015/249125
                4553342
                26351570
                da09c8f5-d9b6-4f82-95a6-31fa65faf0e8
                Copyright © 2015 Jesús Barrio-Barrio et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 19 March 2015
                : 22 July 2015
                Categories
                Review Article

                Ophthalmology & Optometry
                Ophthalmology & Optometry

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