Intravenous immunoglobulins treatment of patients with Graves' ophthalmopathy

Graves' ophthalmopathy is an autoimmune disease manifested as exophthalmus, lid lag and diplopia. As in the accompanying autoimmune thyroid disease, there is an autoimmune homoral and cellular attack on the orbita, mainly the retro-orbital tissues. Steroids are the comerstone of therapy. We reviewed the evidence for a similar therapeutic effect of I.V., immunoglobulins (IVIGs) and their better side affect profile as compared to steroids. We also described an impressive therapeutic success with IVIG given to a patient with resistant ophthalmopathy. The clinical picture of Graves' ophthalmopathy is attributed to a pathologic hyper - activation of orbital fibroblasts, deposition of collagen and glycosaminoglycans in the extra-cellular matrix and eventually fibrosis. These are mediated by leucoregulin, IL-1, IFN-gamma, and TGF-beta - all secreted by lymphocytes and mast cells in the retorbital space. Another mode of cell activation is by binding of autoantibodies (presumably thyroid stimulating Ab's) to an antigenic determinant on the surface of fibroblasts. I.V. immunoglobulins, known today to be active in a variety of autoimmune processes, exert their effects on autoantibodies, complement, phagocytic cells etc. IVIG's also inhibit orbital lymphocytes and fibroblasts through inhibition of IL-1 or/and TGF-beta.