Treatment by rituximab on six Grave's ophthalmopathies resistant to corticosteroids

Graves' ophthalmopathy occurs in 50% of Graves' disease cases. Treatment is based on smoking cessation, and control of the euthyroidism and ocular repercussions associated with the disease. The active orbital forms are treated with glucocorticoids. Non-validated therapies have also been recently tested. Rituximab has been effectively used several times to treat corticosteroid-resistant Graves' ophthalmopathy associated with an optic neuropathy, but its use could be proposed only in inflammatory ophthalmopathies after failure of the corticosteroids. We present six cases treated since early 2012 at the University Hospital Center of Tours, France.

Six patients were treated at the University Hospital Center of Tours, France, between September 2012 and April 2014. The patients had a Mourits' score greater than three after treatment with corticosteroids and/or a severe NOSPECS score and/or orbital inflammation resistant to maximal treatment with intravenous injections of methylprednisolone and an optic neuropathy. They twice received one gram of rituximab by slow intravenous injection two weeks apart. Efficacy was assessed by a decrease of the orbital inflammatory clinical Mourits' score, and visual acuity and visual field testing.

The inflammatory score of patients improved and treatment helped to stop the progression of the sequelae due to neuropathy. The orbital inflammatory clinical score, and the visual acuity and visual field improved but orbital decompression was necessary to complete the treatment.

Rituximab has been used for the treatment of active corticosteroid-resistant Graves' ophthalmopathies. We also had positive results on patients with visual threat and optic neuropathy, when combined with surgical decompression.