Treatment of Thyroid Eye Disease in Childhood

Corticosteroids

As the expectation remains that the expression of GO in children is, in most instances, both mild and transient most of the physicians who are dealing with such cases prefer the 'wait-and-see' policy. Indeed, in our recent study [35] 70% of the respondents recommended such a policy for the eye changes. Active intervention (predominantly with steroids) is considered appropriate in case of worsening of eye changes or no improvement of eye changes when the patient has become euthyroid [35]. Doses between 5 and 20 mg prednisone daily are used depending on the severity of the case. Our policy in moderately severe cases is to start with 20 mg daily for 4-6 weeks when usually a beneficial effect is expected and then we tapering the dose accordingly. We are reluctant to use higher doses of glucocorticoids (GC) as well as intravenous glucocorticosteroids. It has to be kept in mind that prolonged prednisone administration, which should be used in some severe cases of TED, is associated with weight gain, immune suppression and growth failure in children [38]. Retrobulbar irradiation, which has been proved beneficial in adult cases with TED [2], has no place in the treatment of juvenile GO in view of the theoretical risk of tumor induction [3].

One important issue is the use of steroids in patients with TED who received radioiodine treatment (RAI) for hyperthyroidism. Two randomized, prospective, controlled clinical trials by Tallstedt et al. [33] and Bartalena et al. [39] clearly demonstrated in adults that radioiodine administration may be associated with a progression of ophthalmopathy in a small proportion of patients (~15%). GC can prevent, at relatively low doses and for short periods of time, exacerbation of eye disease and can effectively cure pre-existing ocular manifestations.

Table 6. Relative abundance of somatostatin receptor mRNA expression in retrobulbar fibroblasts and lymphocytes obtained from Graves' ophthalmopathy and control patients (reproduced from Pasquali et al. [42, 43])
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