Thyroid Eye Disease Differs at Presentation Among Black and White Patients
—This is one of the few studies to have investigated the manifestation and treatment of thyroid eye disease in Black populations. Compared with White patients, Black patients with thyroid eye disease presented with fewer features on clinical exam. Treatments were similar in both groups, however.
Compared to its presentation in White patients, active thyroid eye disease (TED) presents with fewer findings in Black patients. Nonetheless, the rate of decompression surgery and compressive optic neuropathy is similar in both patient groups, a recent study suggests.1
“To our knowledge, there have been no studies investigating the manifestations of TED or outcomes in the Black population in the United States,” first author Diane Wang, MD, Department of Ophthalmology, SUNY Downstate Medical Center and Kings County Medical Center, Brooklyn, New York, and Department of Ophthalmology, West Virginia University, Morgantown, West Virginia, and colleagues wrote in Frontiers in Ophthalmology.1
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In the study, the authors investigated disease prevalence, clinical presentation, and treatment of patients at Kings County Hospital and SUNY Downstate Medical Center which are hospitals serving a predominantly Black neighborhood in Brooklyn, New York.1
Study design and patients
This retrospective study included 80 patients with a diagnosis of thyroid eye disease treated between January 1, 2010, and July 31, 2021 (average age, 51.5 years; 78.8% women; 61.2% Black). The average age at presentation was lower for Black patients compared with White patients (48.1 years vs 56.8 years). A larger proportion of Black patients were uninsured or on Medicaid compared with White patients (46.8% vs 20.0%) among the 77 patients with a reported insurance status.1
Black and White patients had similar rates of previous diagnosis of Graves’ disease (81.6% vs 61.3%, respectively; P=0.04) and of previous endocrine monitoring (83.7% vs 77.4%, respectively; P=0.49). Among the 42 Black patients and 18 White patients who had available serum TSH levels within 6 months of presentation for TED, 26 (62%) and 12 (67%) were biochemically hyperthyroid, respectively.1
No significant differences were observed in the distribution of mild, moderate, or severe disease based on European Group on Graves’ Orbitopathy (EUGOGO) scores at baseline and among those who followed up at 0-3 months and 3-6 months between Black and White patients.1
Exam findings
Overall, the most common signs of TED were proptosis in Black patients (87.8%) and eyelid retraction in White patients (90.3%). No significant differences in the rate of extraocular movement limitation or subjective diplopia were observed between Black and White patients on initial presentation. Compared with White patients, significantly fewer Black patients had caruncular swelling (odds ratio 0.18), diplopia (odds ratio 0.20), and chemosis (odds ratio 0.24) at any time during follow-up.1
Significant associations were found via multivariate logistic regression analysis between White race and caruncular swelling (odds ratio 4.3), chemosis (odds ratio 3.5), and subjective diplopia (odds ratio 3.86). Age greater than 65 years was associated with a 7-fold increased likelihood of extraocular movement limitation.1
For all patients, the average follow-up was 12 months (range, 0–88 months), with an average 5.3 total visits. Longer follow-up was recorded for Black patients compared with White patients (15.9 months vs 5.9 months), although the total number of visits was not significantly different (6.5 visits vs 3.3 visits).1
No significant differences were found between Black and White patients in the rate of treatment with intravenous steroids (18.4% vs 16.1%), oral steroids (22.4% vs 48.4%), orbital radiation therapy (4.2% vs 3.2%), thyroidectomy (20.8% vs 19.4%), decompression surgery (16.7% vs 6.5%), or teprotumumab (22.9% vs 22.6%).1
Conclusions
In this first study of TED manifestations in a primarily Black population, the authors demonstrated that Black patients had a younger average age of TED presentation and a similar female-to-male ratio compared with White patients.1
“Of the exam findings that were assessed in our chart review, Black patients on average had less subjective diplopia, chemosis, and caruncular injection than White patients,” the authors noted in Frontiers in Ophthalmology. “Despite this, Black patients did not appear to have better outcomes.”1
Limitations of this study include the small sample size, retrospective nature, inability to assess timing from symptom onset to initial visit for all patients, and limited available data to determine reasons for the observed differences in follow-up.1
“In our study, Black patients with TED presented with fewer clinical exam features based on current classification guidelines, but had longer follow-up and underwent similar treatments as White patients,” the authors concluded in Frontiers in Ophthalmology.
“This may suggest there are additional factors influencing how the disease manifests and is treated in Black and White patients. Further studies are needed to explore these factors and determine whether the differences are related to biologic, socioeconomic, or other differences between the racial groups.”1
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