J. Endocrinol. Invest. 13: 489-492, 1990
HLA-DR4 associated response to corticosteroids in Graves' ophthalmopathy patients R. van der Gaag*, W. M. Wiersinga**, L. Koornneef***, M. P. Mourits***, M. F Prummel**, A. Berghout**, R.R.P. de Vries****, G.M.T. Schreuder, and J. D'Amaro**** *Department of Ophthalmo-Immunology, The Netherlands Ophthalmic Research Institute, Amsterdam, **Division of Endocrinology, Department of Internal Medicine, Academic Medical Centre, Amsterdam, ***Orbital Centre, Department of Ophthalmology, Academic Medical Centre, Amsterdam, and ****Department of Immunohematology and Bloodbank, University Hospital, Leiden, The Netherlands ABSTRACT. Fifty-seven patients with severe Grav:;s' ophthalmopathy were treated with corticostt;iroids. Therapeutic outcome was assessed according to predetermined criteria as response (n 37) or non-response (n 20) to therapy. Patients were typed for HLA-A, -B, -C, -DR and DQ. HLA-DR4 was completely absent in the 20 non-responder patients (corrected p value = 0.042). In the responder group 14 of the 37 patients were HLA-DR4 positive. This study shows that in Graves' ophthalmopathy patients the presence of
HLA-DR4 is associated with a good response to corticosteroid therapy. The frequency of HLA-DR4 in the Graves' ophthalmopathy population as a whole, however, was not different from normal (25% versus 26%). But as reported previously, the frequency of HLA-DR3 was significantly increased in the Graves' ophthalmopathy patients when compared to healthy blood donors (47% versus 24%, corrected p value = 0.02). No significant deviations were found in the HLA-A, -B, or -C loei.
INTRODUCTION Graves' ophthalmopathy is considered to be an organ specific autoimmune disease strongly associated with Graves' hyperthyroidism (1). Evidence for its autoimmune pathogenensis relies on the presence of circulating antibodies to orbital antigens and Iymphocytic infiltration in the extraocular eye muscles and the orbital connective tissue, but its pathogenic mechanism remains unclear (2). If left untreated, the disease may run a self-limiting course with a fibrotic end stage and many disfiguring features. Medical treatment is aimed at interfering with the natural course of the disease and limitation or improvement of the symptoms. Reduction of inflammation may be obtained by corticosteroid therapy or orbital Irradiation (3). These treatment modalities are not satisfactory in all patients since only two out of three patients show an improvement. Prediction of treatment outcome is difficult as the
responder and non-responder groups do not differ with respect to age, disease duration or severity (3). Factors predicting which patients will benefit from therapy would permit to spare approximately one third of the patients from the harmful side effects of therapy. Graves' hyperthyroidism is reported to be associated with the histocompatibility antigens HLA-B8 and HLA-DR3 in caucasoids (4, 5). The same associations have been reported for Graves' ophthalmopathy by Frecker et al. (6) but not by others (7). An association with HLA-Cw3 has also been reported (8). In Graves' hyperthyroidism relapse after treatment has been associated with the presence of HLA-DR3 (9, 10), but other reports dispute this (11,
=
=
12).
The present study was undertaken to investigate whether the typing of histocompatibility antigens could be of use for the prediction of the response to corticosteroid therapy in patients with Graves' ophthalmopathy.
Key-words HLA-DR4. Graves' ophthalmopathy. corlicosteroid Correspondence: Dr R. van der Gaag. Department 01 Ophthalmo-Immunology, The Netherlands Ophthalmie Research Institute. PO Box 12141, 1100 AC Amsterdarn. The Netherlands.
PATIENTS AND METHODS The patients presented here were studied, in two consecutive clinical trials, for their response to cor-
Reeeived January 8, 1990; accepted March 19. 1990.
489
ILf. van der Gaag, WM Wiersinga, L. l 0.5 0.28
Treatment with T 4 and carbimazol (n = 18); T 4 alone (n = 3). Treatment with T 4 and carbimazol (n = 10); T 4 alone (n = 2); carbimazol alone (n = 3).
ticosteroids (3, 13). Consecutive patients were assessed using the NOSPECS classification as described by Werner (14). From this, the Total Eye Score (TES) was calculated as being the sum of each NOSPECS class present times the grade in that cl ass. For this purpose grades a, b, and c were substituted by 1, 2, and 3 respectively (13). Selection for treatment was made according to prefixed criteria and treatment was performed according to a predesigned protocol, in a prospective manner (3, 13). At the end of treatment the patients were again assessed using a combination of the NOSPECS classification and clinical criteria defined by Donaldson et al. (15). The response was graded (3), and the patients were assigned to responder or non-responder groups, All the patients, except for two who were not caucasoid, were typed for HLA. Thirty seven patients (65%) had a fair, good or excellent response (= responders) to corticosteroids and 20 (35%) remained unchanged or got worse during therapy (= non-responders). An overview of the main clinical characteristics of the 57 patients ente red in this study is given in Table 1, More clinical details have been published by Wiersinga et al. (3) and Prummel et al. (13). The HLA-A, -B and -C antigens were typed according to the National Institutes of Health technique (16) and the HLA-DR and -DQ loci by a two colour fluorescence Iymphocyte cytotoxicity assay (17), Five hundred
and four healthy Dutch caucasoid blood donors served as controls. HLA-A (n = 12), HLA-B (n = 22), HLA-C (n = 7), HLA-DR (n = 10) and HLA-DQ (n = 3) antigens were typed, To check whether a bias had been introduced by typing only those patients selected for corticosteroid treatment, we also typed 53 caucasoid Graves' ophthalmopathy patients who presented over the same time periOd but were not medically treated (18). These 53 patients did not meet the inclusion criteria for corticosteroid treatment because they had already been treated elsewhere, because surgical intervention was necessary or because their symptoms were too mild to require treatment Statistical analysis was performed using one of the following test where appropriate: the Fisher exact test for small numbers, the Chi square test with Yates' correction, the Students' t test or the Mann Whitney test When the corrected p value was used, it was calculated using the following formula: pe = 1 - (1 - pu)"' Where pu is the uncorrected p value and n the number of antigens tested. RESULTS HLA-DR4 was not present in any of the 20 nonresponders. In the responder group 14 of the 37 patients were HLA-DR4 positive (Table 2), In the total group of 57 patients treated with corticosteroids the frequency of HLA-DR4 was normal (25%), when compared to healthy blood donors (26%). The results of this study, concerning 57 patients, show that the specificity (1 00%) and the positive predictive value (100%), of HLA-DR4 positivity and response to corticosteroids are high, The sensitivity (38%) and the negative predictive value (47%) are. however,low. The frequency of HLA-DR3 in these 57 Graves'
Table 2 Corre/ation between HLA OR4 and the response 10 eortieosteroid Iherapy in 57 Graves' ophtha/mopathy patients. Responders 37 (65%) HLA DR4 positive HLA DR4 negative 1
(3~372)
15 (75%)2
14 23
Non~responders
20 (35%)
o 20
Pu = 0.001 1 Pe = 0.042
Fisher exact test (two tailed)
490
HLA-DR4 in Graves' ophthalmopathy
patients with Graves' hyperthyroidism, those who were HLA-DR4 positive had a lower risk of developing of ophthalmopathy. Although we did not find an under-representation of HLA-DR4 in our Graves' ophthalmopathy patients, there might be immunological and genetical differences between HLA-DR4 positive and negative patients which affect the therapeutic outcome of corticosteroid treatment. Prediction of the therapeutic result of a drug with severe side effects, such as corticosteroids, is of great importance in the management of patients. Selection of potential non-responders could spare these patients from unnecessary exposure to corticosteroids and permit earlier instigation of other treatment modalities such as orbital radiotherapy or surgery. Apart from the association of HLA-DR4 and a good response to corticosteroids reported in this paper, we published data (20, 21) concerning the possibility of using the degree of inflammation as a predictive parameter for response to therapy. As yet neither the clinically defined activity score, nor the presence of HLA-DR4, nor the presence of monocyte migration inhibition factor (MIF) in serum were sensitive enough to be used as a predictive parameter for the individual patient. Finally, although HLA-DR4 positivity increases the likelihood of a favorable response to corticosteroids, we should bear in mind that HLA-DR4 negative patients still benefit from corticosteroid treatment in approximately 50% of the cases. Maybe that a combination of clinical, genetical and immunological predictive parameters might help in predicting the response to corticosteroids in Graves' ophthalmopathy patients.
ophthalmopathy patients was significantly increased compared to normal controls: 47% versus 24% (pe = 0.02). No significant deviations were found in the HLA-A, -8, or -C loci. Furthermore, HLA-DR3 was not specifically associated with outcome of therapy. Fifteen (41 %) of the 37 responders and 12 (57%) of the 20 non-responders were HLA-DR3 positive (p = 0.084). The 57 patients selected for corticosteroid treatment did not differ from the 53 patients presenting over the same time period with respect to the frequency of HLA-DR3 or HLA-DR4. HLA-DR3 was present in 40% of the group not undergoing steroid treatment compared to 47% in the "corticosteroid-group" (p = 0.5), for HLA-DR4 this was respectively 36% and 25% (p = 0.25). DISCUSSION The results of this study show that a favorable response to corticosteroid therapy in Graves' ophthalmopathy patients is significantly associated with HLA-DR4, which was completely absent in nonresponders. Since that association has not been previously reported, that result cannot be considered as a confirmatory one. After correction for the 44 broad HLA-A, -8, -C, -DR and -00 antigens which we examined in our analysis the p value retains its significance level. We feel that the extreme preponderance of HLA-DR4 in the responders to corticosteroid therapy needs investigation by others, to ascertain if they can verify our results. The frequency of HLA-DR4 in our Graves' ophthalmopathy patients population as a whole does not differ however, from that in healthy blood donors. This study also confirms earlier reports (6) that in Graves' ophthalmopathy patients the frequency of HLA-DR3 is significantly higher than in normal controls. With respect to the severity of symptoms prior to treatment and the duration of disease, the responder group did not differ from the non-responder group (3, 13). In this study non-responders to corticosteroids or patients whose symptoms still required further treatment, were subsequently treated with 20 Gy orbital radiotherapy (3) or given a combination of low dose prednisone and cyclosporin A (13). Response to these treatment modalities was found in some of the patients, but no significant association with any HLA antigen was seen (unpublished observations ). Frecker et al. (19) report that in a population of
ACKNOWLEDGMENTS Financial support lor this study was provided in part by The Netherlands Association lor Prevention 01 Blindness.
REFERENCES 1. Wiersinga WM, Smit 1., Van der Gaag R, Koornneef
L Temporal relationship between onset of Graves' ophthalmopathy and onset of thyroidal Graves' disease. J. Endocrinol. Invest. 11: 615, 1988. 2.
Kendall-Taylor P. The pathogenesis of Graves' ophthalmopathy. Clin. Endocrinol. Metab. 14: 331, 1985.
3. Wiersinga WM, Smit 1., Schuster-Uittenhoeve A.U., Van der Gaag R., Koornneef L. Therapeutic outcome of prednisone medication and
491
R. van der Gaag, W.M Wiersinga, L. Koornneef, et al.
01 orbital irradiation in patients with Graves' ophthalmopathy. Ophthalmologica 197: 75, 1988.
Graves' disease: immunological and immunogenetic indicators 01 relapse. Br. Med. J. 296: 1292, 1988.
4. Allannic H., Fauchet R, Lorcy Y., Heim J., Gueguen M., Leguerrier AM., Genetet B. HLA and Graves' disease: an association with HLAORw3. J. Clin. EndocrinoL Metab. 51: 863, 1980.
13. Prummel M.F., Mourits M.P., Berghout A, Krenning E.P., Van der Gaag R., Koornneel L., Wiersinga WM. Prednisone versus Cyclosporine in the treatment 01 Graves' ophthalmopathy. A randomized clinical trial. N. EngL J. Med. 321: 1353, 1989.
5. Farid N.R., Bear J.C. The human major histocompatibility complex and endocrine disease. Endocr. Rev. 2: 50, 1981.
14. Werner S.C. Modilication 01 the classilication 01 the eye changes 01 Graves' disease: recommendations 01 the ad hoc committee 01 the American Thyroid Association. J. Clin. Endocrinol. Metab. 44: 203, 1977.
6. Frecker M., Stenszky V., Balazs C., Kozma L., Kraszits E., Farid N.R. Genetic lactors in Graves' ophthalmopathy. Clin. EndocrinoL (Oxf.) 25: 479,1986.
15. Oonaldson S.S., Bagshaw MA, Kriss J.P. Supervoltage orbital radiotherapy lor Graves' ophthalmopathy. J. Clin. Endocrinol. Metab. 37: 276, 1973.
7. Weetman AP., So AK., Warner CA, Foroni L, Fells P, Shine B. Immunogenetics 01 Graves' ophthalmopathy. Clin. Endocrinol. (Oxl.) 28: 619, 1988.
16. Mittal KD., Mickey M.R, Singal O.P., Terasaki PI Serotyping lor homotransplantation. XVIII. Relinement 01 microdroplet Iymphocyte toxicity test. Transplantation 6: 913, 1968.
8. Mayr WR., Ludwig H. Schernthaner G., Holer R HLA-CW3 in thyrotoxicosis patients with and without endocrine ophthalmopathy. Tissue Antigens 7: 243, 1976.
17. Van Rood J.J., Van Leeuwen A, Ploem J.S. Simultaneous detection 01 two cell populations by two-colour Iluorescence and application to the recognition 01 ß-cell determinants. Nature 262: 795, 1976.
9. Bech K., Lumholtz B., Nerup J., Thomsen M., Platz P., Ryder L.P., Svejgaard A, Siersbaek-Nielsen K., Hansen J.M, Larsen J.H. HLA antigens in Graves' disease. Acta EndocrinoL (Copenh.) 86: 510, 1977.
18. Wiersinga WM, Smit T., Van der Gaag R., Mourits M.P., Koornneel L. Clinical presentation 01 Graves' ophthalmopathy. Ophthalmic Res. 21: 73, 1989. 19. Frecker M., Mercer G., Skanes V.M., Farid N.R. Major histocompatibility complex (MHC) lactors predisposing to and protecting against Graves' eye disease. Autoimmunity 1: 307, 1988.
10. McGregor AM., Smith B.R., Hall R, Peterson M.M., Miller M., Oewar P.J. Prediction 01 relapse in hyperthyroid Graves' disease. Lancet 2: 1101, 1980. 11. Schleusen er H., Schwander J., Holl G., Badenhoop K, Hensen J, Finke R, Schernthaner G., Mayr W.R., Kotulla P. 00 HLA-OR typing and measurement 01 TSH-receptor antibodies help in the prediction 01 the clinical course 01 Graves' thyrotoxicosis after antithyroid drug treatment? Acta EndocrinoL (Copenh.) (SuppL) 281: 318, 1987.
20. Van der Gaag R, Broersma L., Mourits M.P., Koornneel L. Wiersinga WM., Prummel M.F., Berghout A Circulating monocyte migration inhibitory lactor in serum 01 Graves' ophthalmopathy patients a parameter lor disease activity? Clin. Exp. ImmunoL 75: 275, 1989. 21. Mourits M.P., Koornneel L., Wiersinga WM., Prummel M.F., Berghout A Van der Gaag R. Clinical criteria lor the assessment 01 disease activity in Graves' ophthalmopathy: a novel approach. Br. J. OphthalmoL 73: 639, 1989.
12. Oe Bruin TWA, Bolk J.H., Bussemaker JK, Stijner T, Schreuder GMT, Oe Vries R.RP, Van der Heide O.
492
HLA-DR4 associated response to corticosteroids in Graves' ophthalmopathy patients R. van der Gaag*, W. M. Wiersinga**, L. Koornneef***, M. P. Mourits***, M. F Prummel**, A. Berghout**, R.R.P. de Vries****, G.M.T. Schreuder, and J. D'Amaro**** *Department of Ophthalmo-Immunology, The Netherlands Ophthalmic Research Institute, Amsterdam, **Division of Endocrinology, Department of Internal Medicine, Academic Medical Centre, Amsterdam, ***Orbital Centre, Department of Ophthalmology, Academic Medical Centre, Amsterdam, and ****Department of Immunohematology and Bloodbank, University Hospital, Leiden, The Netherlands ABSTRACT. Fifty-seven patients with severe Grav:;s' ophthalmopathy were treated with corticostt;iroids. Therapeutic outcome was assessed according to predetermined criteria as response (n 37) or non-response (n 20) to therapy. Patients were typed for HLA-A, -B, -C, -DR and DQ. HLA-DR4 was completely absent in the 20 non-responder patients (corrected p value = 0.042). In the responder group 14 of the 37 patients were HLA-DR4 positive. This study shows that in Graves' ophthalmopathy patients the presence of
HLA-DR4 is associated with a good response to corticosteroid therapy. The frequency of HLA-DR4 in the Graves' ophthalmopathy population as a whole, however, was not different from normal (25% versus 26%). But as reported previously, the frequency of HLA-DR3 was significantly increased in the Graves' ophthalmopathy patients when compared to healthy blood donors (47% versus 24%, corrected p value = 0.02). No significant deviations were found in the HLA-A, -B, or -C loei.
INTRODUCTION Graves' ophthalmopathy is considered to be an organ specific autoimmune disease strongly associated with Graves' hyperthyroidism (1). Evidence for its autoimmune pathogenensis relies on the presence of circulating antibodies to orbital antigens and Iymphocytic infiltration in the extraocular eye muscles and the orbital connective tissue, but its pathogenic mechanism remains unclear (2). If left untreated, the disease may run a self-limiting course with a fibrotic end stage and many disfiguring features. Medical treatment is aimed at interfering with the natural course of the disease and limitation or improvement of the symptoms. Reduction of inflammation may be obtained by corticosteroid therapy or orbital Irradiation (3). These treatment modalities are not satisfactory in all patients since only two out of three patients show an improvement. Prediction of treatment outcome is difficult as the
responder and non-responder groups do not differ with respect to age, disease duration or severity (3). Factors predicting which patients will benefit from therapy would permit to spare approximately one third of the patients from the harmful side effects of therapy. Graves' hyperthyroidism is reported to be associated with the histocompatibility antigens HLA-B8 and HLA-DR3 in caucasoids (4, 5). The same associations have been reported for Graves' ophthalmopathy by Frecker et al. (6) but not by others (7). An association with HLA-Cw3 has also been reported (8). In Graves' hyperthyroidism relapse after treatment has been associated with the presence of HLA-DR3 (9, 10), but other reports dispute this (11,
=
=
12).
The present study was undertaken to investigate whether the typing of histocompatibility antigens could be of use for the prediction of the response to corticosteroid therapy in patients with Graves' ophthalmopathy.
Key-words HLA-DR4. Graves' ophthalmopathy. corlicosteroid Correspondence: Dr R. van der Gaag. Department 01 Ophthalmo-Immunology, The Netherlands Ophthalmie Research Institute. PO Box 12141, 1100 AC Amsterdarn. The Netherlands.
PATIENTS AND METHODS The patients presented here were studied, in two consecutive clinical trials, for their response to cor-
Reeeived January 8, 1990; accepted March 19. 1990.
489
ILf. van der Gaag, WM Wiersinga, L. l 0.5 0.28
Treatment with T 4 and carbimazol (n = 18); T 4 alone (n = 3). Treatment with T 4 and carbimazol (n = 10); T 4 alone (n = 2); carbimazol alone (n = 3).
ticosteroids (3, 13). Consecutive patients were assessed using the NOSPECS classification as described by Werner (14). From this, the Total Eye Score (TES) was calculated as being the sum of each NOSPECS class present times the grade in that cl ass. For this purpose grades a, b, and c were substituted by 1, 2, and 3 respectively (13). Selection for treatment was made according to prefixed criteria and treatment was performed according to a predesigned protocol, in a prospective manner (3, 13). At the end of treatment the patients were again assessed using a combination of the NOSPECS classification and clinical criteria defined by Donaldson et al. (15). The response was graded (3), and the patients were assigned to responder or non-responder groups, All the patients, except for two who were not caucasoid, were typed for HLA. Thirty seven patients (65%) had a fair, good or excellent response (= responders) to corticosteroids and 20 (35%) remained unchanged or got worse during therapy (= non-responders). An overview of the main clinical characteristics of the 57 patients ente red in this study is given in Table 1, More clinical details have been published by Wiersinga et al. (3) and Prummel et al. (13). The HLA-A, -B and -C antigens were typed according to the National Institutes of Health technique (16) and the HLA-DR and -DQ loci by a two colour fluorescence Iymphocyte cytotoxicity assay (17), Five hundred
and four healthy Dutch caucasoid blood donors served as controls. HLA-A (n = 12), HLA-B (n = 22), HLA-C (n = 7), HLA-DR (n = 10) and HLA-DQ (n = 3) antigens were typed, To check whether a bias had been introduced by typing only those patients selected for corticosteroid treatment, we also typed 53 caucasoid Graves' ophthalmopathy patients who presented over the same time periOd but were not medically treated (18). These 53 patients did not meet the inclusion criteria for corticosteroid treatment because they had already been treated elsewhere, because surgical intervention was necessary or because their symptoms were too mild to require treatment Statistical analysis was performed using one of the following test where appropriate: the Fisher exact test for small numbers, the Chi square test with Yates' correction, the Students' t test or the Mann Whitney test When the corrected p value was used, it was calculated using the following formula: pe = 1 - (1 - pu)"' Where pu is the uncorrected p value and n the number of antigens tested. RESULTS HLA-DR4 was not present in any of the 20 nonresponders. In the responder group 14 of the 37 patients were HLA-DR4 positive (Table 2), In the total group of 57 patients treated with corticosteroids the frequency of HLA-DR4 was normal (25%), when compared to healthy blood donors (26%). The results of this study, concerning 57 patients, show that the specificity (1 00%) and the positive predictive value (100%), of HLA-DR4 positivity and response to corticosteroids are high, The sensitivity (38%) and the negative predictive value (47%) are. however,low. The frequency of HLA-DR3 in these 57 Graves'
Table 2 Corre/ation between HLA OR4 and the response 10 eortieosteroid Iherapy in 57 Graves' ophtha/mopathy patients. Responders 37 (65%) HLA DR4 positive HLA DR4 negative 1
(3~372)
15 (75%)2
14 23
Non~responders
20 (35%)
o 20
Pu = 0.001 1 Pe = 0.042
Fisher exact test (two tailed)
490
HLA-DR4 in Graves' ophthalmopathy
patients with Graves' hyperthyroidism, those who were HLA-DR4 positive had a lower risk of developing of ophthalmopathy. Although we did not find an under-representation of HLA-DR4 in our Graves' ophthalmopathy patients, there might be immunological and genetical differences between HLA-DR4 positive and negative patients which affect the therapeutic outcome of corticosteroid treatment. Prediction of the therapeutic result of a drug with severe side effects, such as corticosteroids, is of great importance in the management of patients. Selection of potential non-responders could spare these patients from unnecessary exposure to corticosteroids and permit earlier instigation of other treatment modalities such as orbital radiotherapy or surgery. Apart from the association of HLA-DR4 and a good response to corticosteroids reported in this paper, we published data (20, 21) concerning the possibility of using the degree of inflammation as a predictive parameter for response to therapy. As yet neither the clinically defined activity score, nor the presence of HLA-DR4, nor the presence of monocyte migration inhibition factor (MIF) in serum were sensitive enough to be used as a predictive parameter for the individual patient. Finally, although HLA-DR4 positivity increases the likelihood of a favorable response to corticosteroids, we should bear in mind that HLA-DR4 negative patients still benefit from corticosteroid treatment in approximately 50% of the cases. Maybe that a combination of clinical, genetical and immunological predictive parameters might help in predicting the response to corticosteroids in Graves' ophthalmopathy patients.
ophthalmopathy patients was significantly increased compared to normal controls: 47% versus 24% (pe = 0.02). No significant deviations were found in the HLA-A, -8, or -C loci. Furthermore, HLA-DR3 was not specifically associated with outcome of therapy. Fifteen (41 %) of the 37 responders and 12 (57%) of the 20 non-responders were HLA-DR3 positive (p = 0.084). The 57 patients selected for corticosteroid treatment did not differ from the 53 patients presenting over the same time period with respect to the frequency of HLA-DR3 or HLA-DR4. HLA-DR3 was present in 40% of the group not undergoing steroid treatment compared to 47% in the "corticosteroid-group" (p = 0.5), for HLA-DR4 this was respectively 36% and 25% (p = 0.25). DISCUSSION The results of this study show that a favorable response to corticosteroid therapy in Graves' ophthalmopathy patients is significantly associated with HLA-DR4, which was completely absent in nonresponders. Since that association has not been previously reported, that result cannot be considered as a confirmatory one. After correction for the 44 broad HLA-A, -8, -C, -DR and -00 antigens which we examined in our analysis the p value retains its significance level. We feel that the extreme preponderance of HLA-DR4 in the responders to corticosteroid therapy needs investigation by others, to ascertain if they can verify our results. The frequency of HLA-DR4 in our Graves' ophthalmopathy patients population as a whole does not differ however, from that in healthy blood donors. This study also confirms earlier reports (6) that in Graves' ophthalmopathy patients the frequency of HLA-DR3 is significantly higher than in normal controls. With respect to the severity of symptoms prior to treatment and the duration of disease, the responder group did not differ from the non-responder group (3, 13). In this study non-responders to corticosteroids or patients whose symptoms still required further treatment, were subsequently treated with 20 Gy orbital radiotherapy (3) or given a combination of low dose prednisone and cyclosporin A (13). Response to these treatment modalities was found in some of the patients, but no significant association with any HLA antigen was seen (unpublished observations ). Frecker et al. (19) report that in a population of
ACKNOWLEDGMENTS Financial support lor this study was provided in part by The Netherlands Association lor Prevention 01 Blindness.
REFERENCES 1. Wiersinga WM, Smit 1., Van der Gaag R, Koornneef
L Temporal relationship between onset of Graves' ophthalmopathy and onset of thyroidal Graves' disease. J. Endocrinol. Invest. 11: 615, 1988. 2.
Kendall-Taylor P. The pathogenesis of Graves' ophthalmopathy. Clin. Endocrinol. Metab. 14: 331, 1985.
3. Wiersinga WM, Smit 1., Schuster-Uittenhoeve A.U., Van der Gaag R., Koornneef L. Therapeutic outcome of prednisone medication and
491
R. van der Gaag, W.M Wiersinga, L. Koornneef, et al.
01 orbital irradiation in patients with Graves' ophthalmopathy. Ophthalmologica 197: 75, 1988.
Graves' disease: immunological and immunogenetic indicators 01 relapse. Br. Med. J. 296: 1292, 1988.
4. Allannic H., Fauchet R, Lorcy Y., Heim J., Gueguen M., Leguerrier AM., Genetet B. HLA and Graves' disease: an association with HLAORw3. J. Clin. EndocrinoL Metab. 51: 863, 1980.
13. Prummel M.F., Mourits M.P., Berghout A, Krenning E.P., Van der Gaag R., Koornneel L., Wiersinga WM. Prednisone versus Cyclosporine in the treatment 01 Graves' ophthalmopathy. A randomized clinical trial. N. EngL J. Med. 321: 1353, 1989.
5. Farid N.R., Bear J.C. The human major histocompatibility complex and endocrine disease. Endocr. Rev. 2: 50, 1981.
14. Werner S.C. Modilication 01 the classilication 01 the eye changes 01 Graves' disease: recommendations 01 the ad hoc committee 01 the American Thyroid Association. J. Clin. Endocrinol. Metab. 44: 203, 1977.
6. Frecker M., Stenszky V., Balazs C., Kozma L., Kraszits E., Farid N.R. Genetic lactors in Graves' ophthalmopathy. Clin. EndocrinoL (Oxf.) 25: 479,1986.
15. Oonaldson S.S., Bagshaw MA, Kriss J.P. Supervoltage orbital radiotherapy lor Graves' ophthalmopathy. J. Clin. Endocrinol. Metab. 37: 276, 1973.
7. Weetman AP., So AK., Warner CA, Foroni L, Fells P, Shine B. Immunogenetics 01 Graves' ophthalmopathy. Clin. Endocrinol. (Oxl.) 28: 619, 1988.
16. Mittal KD., Mickey M.R, Singal O.P., Terasaki PI Serotyping lor homotransplantation. XVIII. Relinement 01 microdroplet Iymphocyte toxicity test. Transplantation 6: 913, 1968.
8. Mayr WR., Ludwig H. Schernthaner G., Holer R HLA-CW3 in thyrotoxicosis patients with and without endocrine ophthalmopathy. Tissue Antigens 7: 243, 1976.
17. Van Rood J.J., Van Leeuwen A, Ploem J.S. Simultaneous detection 01 two cell populations by two-colour Iluorescence and application to the recognition 01 ß-cell determinants. Nature 262: 795, 1976.
9. Bech K., Lumholtz B., Nerup J., Thomsen M., Platz P., Ryder L.P., Svejgaard A, Siersbaek-Nielsen K., Hansen J.M, Larsen J.H. HLA antigens in Graves' disease. Acta EndocrinoL (Copenh.) 86: 510, 1977.
18. Wiersinga WM, Smit T., Van der Gaag R., Mourits M.P., Koornneel L. Clinical presentation 01 Graves' ophthalmopathy. Ophthalmic Res. 21: 73, 1989. 19. Frecker M., Mercer G., Skanes V.M., Farid N.R. Major histocompatibility complex (MHC) lactors predisposing to and protecting against Graves' eye disease. Autoimmunity 1: 307, 1988.
10. McGregor AM., Smith B.R., Hall R, Peterson M.M., Miller M., Oewar P.J. Prediction 01 relapse in hyperthyroid Graves' disease. Lancet 2: 1101, 1980. 11. Schleusen er H., Schwander J., Holl G., Badenhoop K, Hensen J, Finke R, Schernthaner G., Mayr W.R., Kotulla P. 00 HLA-OR typing and measurement 01 TSH-receptor antibodies help in the prediction 01 the clinical course 01 Graves' thyrotoxicosis after antithyroid drug treatment? Acta EndocrinoL (Copenh.) (SuppL) 281: 318, 1987.
20. Van der Gaag R, Broersma L., Mourits M.P., Koornneel L. Wiersinga WM., Prummel M.F., Berghout A Circulating monocyte migration inhibitory lactor in serum 01 Graves' ophthalmopathy patients a parameter lor disease activity? Clin. Exp. ImmunoL 75: 275, 1989. 21. Mourits M.P., Koornneel L., Wiersinga WM., Prummel M.F., Berghout A Van der Gaag R. Clinical criteria lor the assessment 01 disease activity in Graves' ophthalmopathy: a novel approach. Br. J. OphthalmoL 73: 639, 1989.
12. Oe Bruin TWA, Bolk J.H., Bussemaker JK, Stijner T, Schreuder GMT, Oe Vries R.RP, Van der Heide O.
492
