Diago (Diagnosis of Graves' orbitopathy): An Office Tool for Practising Endocrinologists

Program: Abstracts - Orals, Poster Preview Presentations, and Posters
Session: SAT 0528-0545-Thyroid Autoimmunity
Saturday, June 21, 2014: 1:00 PM-3:00 PM
Hall F (McCormick Place West Building)

Poster Board SAT-0543
Anna L Mitchell, MBBS, MRCP, PhD1, Lemonia Mathiopoulou1, Margaret Morris1, Bijay Vaidya2, A Jane Dickinson1, Anthony Quinn2, Colin M Dayan3, Julie McLaren4, Janis L Hickey5, John H Lazarus3, Geoffrey E Rose6, Peter Foley5, Caroline J MacEwen7 and Petros Perros8
1Newcastle upon Tyne NHS Hospitals Trust, Newcastle upon Tyne, United Kingdom, 2Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom, 3Cardiff University School of Medicine, Cardiff, United Kingdom, 4Thyroid Eye Disease Charitable Trust, Bristol, United Kingdom, 5British Thyroid Foundation, Harrogate, United Kingdom, 6Moorfields Eye Hospital, London, United Kingdom, 7Ninewells Hospital, Dundee, United Kingdom, 8Newcastle upon Tyne NHS Hospitals Trust, Newcastle Upon Tyne, United Kingdom
Background: In the early phase of Graves’ orbitopathy (GO), when there is increased disease activity, treatment can dramatically improve the final cosmetic and visual functional outcome. Diagnostic delay can result in significant morbidity and increases patient dissatisfaction. It can be a challenge for endocrinologists to recognise GO and decide who should be referred to an ophthalmologist.

Aim: To develop and test a clinical assessment tool for use in all patients diagnosed with Graves’ disease (GD). The purpose of the tool is to guide clinicians towards a possible diagnosis of GO in those patients with GD who have orbital signs or symptoms, and thereby prompt earlier ophthalmic referral.

Methods: A 20 point assessment tool was devised, comprising polar (“yes/no”) questions in 2 sections aimed at eliciting GO symptoms and signs. The tool was tested on 104 GD patients in two centres over 17 months: 77 attending endocrine clinic and 27 positive controls with GO attending multidisciplinary thyroid eye clinics. Those referred from endocrine clinics according to protocol were assessed and followed up in the multidisciplinary thyroid eye clinic to determine the appropriateness of referral and whether treatment was initiated.

Results: 88 of the 104 patients (85%) were female: the mean age at assessment was 48.5 years (range 18-76 years). All 27 controls scored above the threshold for referral but none met the criteria for urgent referral. Excluding the controls, 77 people with GD were evaluated using the tool. 27 (35%) scored above the threshold for referral: 2/27 (7%) scored for signs, 6/27 (22%) scored for symptoms and 19/27 (70%) scored for both signs and symptoms. GO was confirmed in 24 (89%) and 14 (58%) were offered 1 or more specific treatments: 2 radiotherapy, 2 orbital decompression, 1 IV steroids and 1 Botulinum toxin treatment. In addition, 7 were prescribed selenium and 5 artificial tears.

Discussion: The timely, accurate diagnosis of GO is important as early intervention in the active phase of disease can improve prognosis. This clinical assessment tool uses polar answers to 20 questions to assist the clinician in making a diagnosis of possible GO and to suggest the need for referral to specialist ophthalmic care. The tool, which is sensitive to the diagnosis of GO, does not require specialist skills in ophthalmic assessment but can quickly and easily be used for assessment of all GD patients in any setting. Overall, over half of those referred following use of this tool were offered specific treatment, suggesting its use might actively alter management of patients who might not otherwise have been referred to specialist ophthalmic care.

Nothing to Disclose: ALM, LM, MM, BV, AJD, AQ, CMD, JM, JLH, JHL, GER, PF, CJM, PP

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