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Ophthalmic complications in juvenile Graves' Disease - clinic and therapeutic approaches.

Graves' Disease (GD) is the most common cause of juvenile thyrotoxicosis in children and adolescents. Regarding its treatment, there are wide differences between individual physicians' regimes and those of physicians in different countries. While Antithyroid Drugs (ATDs) remain the initial treatment of choice in almost all the medical centers in Europe, with surgery used mainly to deal with antithyroid failures, there is increasing interest, especially in US, in the use of radioiodine. Although there are data reporting no significant increase in thyroid neoplasia or gonadal injury in older children and adults receiving outpatient doses of radioiodine, endocrinologists and parents continue to shy away from this therapy, especially in Europe, in young children. Nor is there any increase in congenital abnormalities in the offspring of the adults. Thyroid Eye Disease (TED) is one of the most common manifestations of GD, the pathophysiology of which is not very well understood. However, studies by several investigators have begun to shed light on the many complex factors contributing to the development of ocular symptoms in TED. Thyroid ophthalmopathy in juvenile GD is more common but less severe and more likely to remit completely. Steroids and decompression surgery will very rarely be needed in early childhood. 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. Recent studies have shown successful therapy with the long-acting somatostatin analogues (SM-a), octreotide and lanreotide in adult patients with active TED. The rationale of this therapy is based on recent studies in which somatostatin receptors have been identified within the orbital tissues in TED, both in vitro and in vivo. We recently had the opportunity to treat 3 adolescents with moderately severe TED with SM-a. All had increased clinical activity scores (CAS) and were euthyroid on ATD at the time of initiation of treatment. They received 20 mg octreotide (sandostatin- LAR) i.m. one injection every 30 days for 4 months. Their ophthalmopathies improved substantially and CAS decreased in all the patients. In view of the encouraging therapeutic results in these 3 pediatric patients, SM-a may prove to be a valuable treatment in juvenile ophthalmopathy and a good alternative to corticosteroids. The results using SM-a in the treatment of TED seem promising, but studies with larger numbers of patients are needed before we reach any final conclusions.
Gerasimos E Krassas

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