In keeping with the tradition at the University of Pisa of producing well-conceived and pertinent investigations of Graves orbitopathy (GO), Rotondo Dottore et al1 are to be commended for their thought-provoking study published in this issue of JAMA Ophthalmology regarding the presence of T and B cells in this perplexing disease. Since the 1980s, the role of T and B cells has been investigated in the orbits of patients with GO.2 It was initially thought that the infiltration was exclusively in the extraocular muscles with minimal involvement in the adipose tissue2; since then, there have been numerous studies demonstrating not only lymphocytes but also macrophages within the orbital fat and perivascular interstitial space of these patients.3 Because of these findings, immunosuppressive agents became a mainstay of treating patients with GO.4 However, it has become evident to clinicians managing the disease that the efficacy of these medications is dramatically higher during the active, inflammatory phase compared with the inactive phase.4 Moreover, there are increasing numbers of patients who are not only refractory to corticosteroids, but also intolerant of long-term corticosteroid use. Hence, the question has been raised whether therapy directed at lymphocytes is optimal for GO.
Freitag SK, Lee NG. Lymphocyte Expression in Graves Orbitopathy. JAMA Ophthalmol. 2018;136(6):620–621. doi:10.1001/jamaophthalmol.2018.1240
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