Long-term results of irradiation for patients with progressive Graves' ophthalmopathy

Purpose: To determine the long-term outcome of radiotherapy (RT) in patient s with progressively symptomatic thyroid eye disease and to evaluate the po tential long-term sequelae. Methods and Materials: Four hundred fifty-three patients provided written i nformed consent and received retrobulbar RT for Graves' ophthalmopathy at S tanford University Medical Center; 197 with greater than or equal to1 year of follow-up were retrospectively analyzed. Of the 197 patients, 189 receiv ed RT to the bilateral retrobulbar regions, and 4 received unilateral RT. T he technical information was unavailable for 4 patients. Patients were asse ssed by chart review, telephone interview, questionnaire, and multidiscipli nary physician examination. Eye impairment was scored using the SPECS syste m. The end point review included the before and after treatment SPECS score , surgical intervention, and patient satisfaction. Potential complications, including cataract development, retinopathy, and tumor formation, were inv estigated. Multivariate analyses were performed to assess the prognostic va riables. Results: Improvement or resolution was 89% for soft-tissue findings; 70% fo r proptosis; 85% for extraocular muscle dysfunction; 96% for corneal abnorm alities; and 67% for sight loss. The response to RT may take >6 months to s tabilize. Factors predictive of response varied in the individual SPECS cat egories but included the initial SPECS score, pretreatment thyroid status, female gender, a 20-Gy RT dose, and a history of hypertension. Nonpredictiv e factors included a history of tobacco use, diabetes mellitus, steroids, a nd prior cataracts. Only 16% required surgical intervention to preserve the ir vision or restore binocular vision. Twenty-two patients (12%) developed cataracts after irradiation (median 11 years). No patient developed a tumor within the RT field during the follow-up period (range 1-29 years). Ninety -eight percent of patients were pleased with their results, and 2% believed their symptoms progressed despite RT. Conclusions: Retrobulbar irradiation (20 Gy) is safe and effective treatmen t for progressive Graves' ophthalmopathy, with a 96% overall response rate, 98% patient satisfaction rate, and no irreparable long-term sequelae, with follow-up extending 29 years. The most common late effect observed was cat aract development, which occurred more frequently in older patients and was reversible with extraction. Elective surgical intervention after RT should be withheld until patients have demonstrated a plateau in response. (C) 20 01 Elsevier Science Inc.