ORIGINAL INVESTIGATION
Anti-inflammatory and Antioxidant Effects of Selenium on
Orbital Fibroblasts of Patients With Graves Ophthalmopathy
Bo-Yeon Kim*, Sun-Young Jang†, Dug-Hyun Choi*, Chan-Hee Jung*, Ji-Oh Mok*,
and Chul-Hee Kim, M.D., PH.D.*
*Division of Endocrinology and Metabolism, Department of Internal Medicine; and †Department of Ophthalmology,
Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea.
Purpose: In the present study, the authors investigated the
effects of selenium on inflammation, hyaluronan production,
and oxidative stress in primary cultured orbital fibroblasts of
patients with Graves ophthalmopathy (GO).
Methods: Orbital adipose/connective tissue specimens
were obtained during the course of orbital surgery for patients
with GO (n = 7) and other noninflammatory problems (n = 5).
After incubation with various concentrations of sodium
selenite for 48 hours, supernatants from primary cultures were
collected. Hyaluronan and cytokine levels were measured using
commercially available enzyme-linked immunosorbent assay
kits. To determine the effect of selenium on reactive oxygen
species (ROS) production stimulated by H2O2 (100 μM) for 30
minutes, the cells were pretreated with various concentrations
of sodium selenite for 60 minutes.
Results: Interleukin (IL)-6 and tumor necrosis factor-
alpha levels were significantly higher in orbital fibroblasts of
patients with GO than in orbital fibroblasts of control patients.
Hyaluronan production was suppressed by selenium in cultured
orbital fibroblasts of patients with GO. Inflammatory cytokines
such as IL-1α, IL-8, and tumor necrosis factor-alpha were
suppressed by selenium in cultured orbital fibroblasts of patients
with GO. IL-1β and IL-6 were not suppressed by selenium in
cultured orbital fibroblasts of patients with GO. Selenium
pretreatment reduced intracellular ROS generation stimulated
by H2O2 in cultured orbital fibroblasts of patients with GO.
Conclusions: In conclusion, hyaluronan production,
inflammatory cytokines, and intracellular ROS generation were
suppressed by selenium in cultured orbital fibroblasts of patients
with GO. Several inflammatory cytokines may be suppressed by
selenium in cultured orbital fibroblasts of patients with GO. This
study provide the basis for use of selenium in the treatment of GO.
(Ophthalmic Plast Reconstr Surg 2021;37:476–481)
G raves disease (GD) is an autoimmune disease of the thy-
roid gland in which autoantibodies bind to the thyrotropin
receptor on thyroid follicular cells, thereby activating gland
Accepted for publication December 2, 2020.
This work was supported by the Soonchunhyang University Research
Fund.
The authors have no financial or conflicts of interest to disclose.
Supplemental digital content is available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s website (www.op-rs.com.).
Address correspondence and reprint requests to Chul-Hee Kim, M.D.,
Ph.D., Division of Endocrinology and Metabolism, Department of Internal
Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang
University College of Medicine, 170 Jomaru-ro, Wonmi-gu, Bucheon 14584,
Korea. E-mail: byby815@schmc.ac.kr
DOI: 10.1097/IOP.0000000000001931
476 Ophthalmic Plast Reconstr Surg, Vol. 37, No. 5, 2021
Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
function and leading to excess production of thyroid hor-
mones. Up to 50% of patients with GD develop pathologic
manifestations localized in the eyes, Graves ophthalmopathy
(GO).1,2 The mechanism in the pathogenesis of GO has not yet
been elucidated. The pathogenesis of GO in GD substantially
lies on the presence of inflammatory cell infiltrate composed
of activated T cells that produce cytokines [interleukin (IL)-1,
tumor necrosis factor-alpha (TNF-α), interferon-gamma (IFN-
γ)], which in turn, activate secretion of glycosaminoglycans
from orbital fibroblasts, further inducing orbital fibrosis and
edema.3 Current evidence points to orbital fibroblasts as the
target cells in GO, which secrete large amounts of hyaluronan
in response to various cytokines.4,5 In addition, accumulating
evidence has shown that oxidative stress plays an important
role in the pathogenesis of GO. Reactive oxygen species (ROS)
contributes to cellular proliferation in GO orbital fibroblasts.6
Increased extracellular levels of ROS-elicited oxidative dam-
age have been noted in the blood,7 urine,8,9 and fibroadipose
tissues10 from patients with GO. GD is characterized by
the presence of increased oxidative stress in both acute and
chronic phases of the disease.11,12 Recent studies provide evi-
dence in support of the bioavailable antioxidants role in orbital
fibroblasts from patients with GO.13,14 A recent clinical trial
showed a beneficial effect of the antioxidant agent selenium in
GO.15 A recent study showed an antioxidant action of selenium
in orbital fibroblasts, which provides a cellular basis for the
effects of selenium in vivo in patients with GO.16
Selenium is an essential cofactor required to activate sev-
eral enzyme systems in humans.9 Selenium is integrated into the
polypeptide chains as the 21st amino acid, and proteins that con-
tain selenocysteine are called selenoproteins. The key metabolic
function of selenium has therefore been attributed to its role in
this enzymatic cofactor selenocysteine.17–20 Several studies have
confirmed that selenium induced inhibition of thyroid cancer
cell growth.21–24 Selenium has also been found to be beneficial in
thyroid associated ophthalmopathy, which is the most common
extrathyroidal manifestation of thyroid disease.15 Wertenbruch
et al.17 demonstrated low thyroid stimulating hormone recep-
tor antibody levels in patients who had high serum selenium
levels with remission of GD. Growing evidence supports that
the selenium-containing enzymes and their antioxidant capac-
ity modify the autoimmune mechanism.25 Selenium deficiency
affects both the cell-mediated and humoral immunity, which
are linked to the inflammatory processes involved in the pro-
duction of ROS.26 ROS production increases the expression of
proinflammatory cytokines through up-regulation of nuclear
factor-kappa B activity.27 This may be the mechanism by which
selenium exerts its beneficial effects in GO.
The authors’ study was based on the hypothesis that
hyaluronan production, ROS production, and inflammation
 Ophthalmic Plast Reconstr Surg, Vol. 37, No. 5, 2021 Selenium in Orbital Fibroblasts of GO
are higher in orbital fibroblasts of patients with GO than in
normal orbital fibroblasts of control patients, and they can be
suppressed by sodium selenite in orbital fibroblasts of patients
with GO. In the present study, the authors investigated the
effects of selenium on inflammation, hyaluronan production,
and oxidative stress in primary cultured orbital fibroblasts of
patients with GO.
METHODS
Subjects. Patients with GO who visited the Department of Endocrinolo-
gy, Soonchunhyang University Bucheon Hospital from January 2013 to
December 2015 were enrolled in this study. Patients who had undergone
a thorough evaluation for GO with a regular follow up were included in
this study. Individuals diagnosed with diabetes mellitus, chronic liver
disease, infection, chronic inflammatory disease, or malignancy were
excluded. Orbital adipose/connective tissue specimens were obtained
during the course of orbital decompression surgery for protosis correc-
tion in GO patients (n = 7, 5 women and 2 men). Medical history, smok-
ing history, and type of treatment for GO were reviewed. Diagnosis of
GO was made by an experienced oculoplasty ophthalmologist (S.-Y.J.)
based on clinical ophthalmic examination using the following criteria:
history taking, slit-lamp examination, visual acuity, intraocular pres-
sure, exophthalmometry measurement with a Hertel exophthalmometer,
Hess screen test, binocular single vision test, and a CT scan. Clinical
activity score of all patients was less than three points. All patients were
euthyroid at the time of surgery and had not been treated with steroids
or radiation within at least 3 months. Normal orbital adipose/connective
tissue specimens were collected during the course of orbital surgery for
other noninflammatory problems from patients with no prior history of
thyroid disease and with no clinical evidence of GO (n = 5, 3 women
and 2 men). This study was approved by the Institutional Review Board
of Soonchunhyang University Bucheon Hospital (IRB number: SCH-
BC_IRB_2020-01-017), and also conformed to the ethical guidelines
of the World Medical Association Declaration of Helsinki. All patients
gave written informed consent.
Priamary Cell and Tissue Culture Protocols. For primary cell culture,
tissue explants were minced and placed directly in plastic culture dishes
in Dulbecco modified Eagle medium containing 20% fetal bovine se-
rum, penicillin (100 U/mL), and streptomycin (100 mg/L), allowing
preadipocyte fibroblasts to proliferate. After fibroblasts had grown out
from the explants, monolayers were passaged serially by gentle treat-
ment with trypsin/EDTA, and cultures were maintained in 80-mm flasks
containing Dulbecco modified Eagle medium with 10% fetal bovine se-
rum and antibiotics. Cell cultures were grown in a humidified 5% CO2
incubator at 37°C. Cells were stored in liquid N2 until needed and used
between the third and seventh passage. Supernatants from the cultures
were collected and subjected to enzyme-linked immunosorbent assays
(ELISAs).
Measurement of Hyaluronan by ELISA. After incubation with vari-
ous concentrations of sodium selenite for 48 hours, supernatants from
tissue cultures were collected. Hyaluronan was measured using a com-
mercially available ELISA kit (Quantikine ELISA Hyaluronan Immu-
noassay; R&D Systems Inc., Minneapolis, MN, U.S.A.) according to
the manufacturer’s instructions. Absorbance of reactions was measured
at 405 nm, and the percentage of binding was calculated for each sam-
ple. The concentrations of hyaluronan in the samples were determined
using a standard binding curve generated with known amounts of hy-
aluronan. Samples were diluted 1:10 before analysis. The average of
triplicate assays was determined.
Measurement of Inflammatory Cytokines by ELISA. After incu-
bation with various concentrations of sodium selenite for 48 hours,
© 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. 477
Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
supernatants from tissue cultures were collected. IL-1α, IL-1β, IL-6,
IL-8, and TNF-α concentrations were measured using a commercially
available ELISA kit (Millipore Human Cytokine/Chemokine Mag-
netic Bead Panel; Millipore, Billerica, MA, U.S.A.) according to the
manufacturer’s instructions. Specimens were analyzed by Multiplex
Analyst software (Millipore). The average of triplicate assays was
determined.
Measurement of Intracellular ROS. ROS release was determined
with 5-(and 6)-chloromethyl-2′, 7′-dichlorodihydrofluorescein diace-
tate, acetyl ester (CM-H2DCFDA; Invitrogen, Eugene, OR, U.S.A.).
The cells were seeded at a density of 5 × 105 cells per well in 6-well
plates to a total final volume of 2 mL. To determine the effect of sele-
nium on ROS production stimulated by H2O2 (100 μM) for 30 minutes,
the cells were pretreated with various concentrations of sodium sel-
enite (0, 5, 10, 50, 100, 500 nM) for 60 minutes. The culture medium
was then removed, and the cells were washed with phosphate-buffered
saline (PBS), incubated with 10 μM CM-H2DCFDA at 37°C for 30
minutes, and then stimulated with H2O2 for 30 minutes. The cells were
then trypsinized, washed, and resuspended in PBS and analyzed by
flow cytometry (FACS LSRII; BD Biosciences, Franklin Lakes, NJ,
U.S.A.).
Statistical Analysis. All experiments were performed at least 3 times.
Data are presented as the mean ± SD. SPSS 26.0 for Windows (SPSS
Inc., Armonk, NY, U.S.A.) was used for statistical analysis. The Mann–
Whitney U test was used to compare measured variables between nor-
mal and GO orbital tissues. Effects of sodium selenite on hyaluronan
and cytokine levels were analyzed using the Mann–Whitney U test for
each level of sodium selenite and the significance level was set at 0.01
(=0.05/5) with Bonferroni correction. A p value of <0.05 was consid-
ered statistically significant.
RESULTS
The basal characteristics of the participants with GO (n = 7)
are presented in Table 1, Supplemental Digital Content 1, http://links.
lww.com/IOP/A277. The mean age of patients and duration of GD were
41.1 ± 16.3 years and 50.4 ± 43.5 months, respectively. The mean body
mass index (BMI) was 22.7 ± 4.5 kg/m2. No significant differences were
found in hyaluronan levels in culture medium between orbital fibro-
blasts from patients with GO and control patients (Fig. 1A). Hyaluronan
production was suppressed by sodium selenite (50, 100, and 500 nM)
in cultured orbital fibroblasts of patients with GO in a dose-dependent
manner (Fig. 1B). IL-6 and TNF-α levels were significantly higher in
orbital fibroblasts of patients with GO than in orbital fibroblasts of con-
trol patients (213.8 ± 65.9 vs. 110.5 ± 9.9 pg/mL, p < 0.001 and 1.9
± 0.1 vs. 1.2 ± 0.1 pg/mL, p = 0.001) (Figs. 2A and 3A). No signifi-
cant differences were found in IL-1α, IL-1β, and IL-8 levels between
orbital fibroblasts of patients with GO and control patients (Figs. 4A,
5A, and 6A). IL-1α was suppressed by sodium selenite (10, 50, 100,
and 500 nM) in cultured orbital fibroblasts of patients with GO. TNF-
α was suppressed by sodium selenite (5, 10, 50, 100, and 500 nM)
in cultured orbital fibroblasts of patients with GO. IL-1α and TNF-α
were suppressed by sodium selenite in cultured orbital fibroblasts of
patients with GO in a dose-dependent manner (Figs. 3B and 4B). IL-8
was suppressed by sodium selenite (100 and 500 nM) in cultured orbital
fibroblasts of patients with GO. However, suppression of IL-8 levels
by sodium selenite was not dose-dependent (Fig. 6B). IL-1β and IL-6
were not suppressed by sodium selenite in cultured orbital fibroblasts of
patients with GO (Figs. 2B and 5B). When cultured orbital fibroblasts of
patients with GO were stimulated by H2O2 (100 μM) for 30 minutes, in-
tracellular ROS generation in cultured orbital fibroblasts was increased.
Selenium pretreatment (sodium selenite 5, 10, 50, 100, and 500 nM)
reduced intracellular ROS generation in cultured orbital fibroblasts of
patients with GO, stimulated by H2O2. There was no difference in ROS
 B.-Y. Kim et al. Ophthalmic Plast Reconstr Surg, Vol. 37, No. 5, 2021

FIG. 1.  A, Hyaluronan levels in culture medium of orbital fibroblasts from control (n = 3) and patients with Graves ophthalmopathy
(GO) (n = 3). Data are presented as mean ± SD. A p value was obtained by the Mann–Whitney U test. B, Effect of sodium selenite on
hyaluronan levels in culture medium of orbital fibroblasts from patients with GO (n = 3). Data are presented as mean ± SD. p values
were obtained by the Mann–Whitney U test. The significance level was set at 0.01 (=0.05/5) with Bonferroni correction.

FIG. 2.  A, Interleukin (IL)-6 levels in culture medium of orbital fibroblasts from control (n = 3) and patients with Graves ophthalmopa-
thy (GO) (n = 3). Data are presented as mean ± SD. A p value was obtained by the Mann–Whitney U test. B, Effect of sodium selenite
on IL-6 levels in culture medium of orbital fibroblasts from patients with GO (n = 3). Data are presented as mean ± SD. p values were
obtained by the Mann–Whitney U test. The significance level was set at 0.01 (=0.05/5) with Bonferroni correction.

generation depending on the concentration of sodium selenite (Figure 1,
Supplemental Digital Content 1, http://links.lww.com/IOP/A278).
DISCUSSION
The results of this study showed that hyaluronan produc-
tion, inflammatory cytokines such as IL-1α, IL-8, and TNF-α,
and intracellular ROS generation were suppressed by sodium
selenite in cultured orbital fibroblasts of patients with GO. IL-6
and TNF-α levels were significantly higher in orbital fibroblasts
of patients with GO than in normal orbital fibroblasts of control
patients. Contrary to expectations, no significant difference was
found in hyaluronan levels between cultured orbital fibroblasts
of patients with GO and control patients.
In previous studies, it was reported that orbital fibro-
blasts are the target cells in GO, and orbital fibroblasts secrete
large amounts of hyaluronan in response to inflammatory cyto-
kines.3–5,28 Many studies showed that oxidative stress plays an
important role in the pathogenesis of GO.7–10
The authors’ study showed that no significant differences
were found in IL-1α, IL-1β, and IL-8 levels between orbital
fibroblasts of patients with GO and control patients and IL-6 and
TNF-α levels were significantly higher in orbital fibroblasts of
patients with GO than in orbital fibroblasts of control patients.
In the authors’ study, only IL-6 and TNF-α levels were signifi-
cantly higher in the GO fibroblast cultures and that only TNF-α
of these 2 elevated cytokines is suppressed by sodium selenite.
The finding of increased TNF-α levels in orbital fibroblasts
of patients with GO is similar to the results obtained in pre-
vious studies.29,30 Overall, there are many contradictory results
regarding the association between inflammatory cytokines and
GO, likely reflecting different genetic patterns of susceptibil-
ity among different ethnic groups. Regarding the association
between inflammatory cytokines and GO, further studies are
needed.
In patients with GO, decompression surgery can be per-
formed irrespective of the progression of the GO, but it is recom-
mended to try medical treatment first if possible, and then perform

478 © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.

Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
 Ophthalmic Plast Reconstr Surg, Vol. 37, No. 5, 2021 Selenium in Orbital Fibroblasts of GO

FIG. 3.  A, Tumor necrosis factor (TNF)-α levels in culture medium of orbital fibroblasts from control (n = 3) and patients with Graves
ophthalmopathy (GO) (n = 3). Data are presented as mean ± SD. A p value was obtained by the Mann–Whitney U test. B, Effect of
sodium selenite on TNF- α levels in culture medium of orbital fibroblasts from patients with GO (n = 3). Data are presented as mean ±
SD. p values were obtained by the Mann–Whitney U test. The significance level was set at 0.01 (=0.05/5) with Bonferroni correction.

FIG. 4.  A, Interleukin (IL)-1α levels in culture medium of orbital fibroblasts from control (n = 3) and patients with Graves ophthalmop-
athy (GO) (n = 3). Data are presented as mean ± SD. A p value was obtained by the Mann–Whitney U test. B, Effect of sodium selenite
on IL-1α levels in culture medium of orbital fibroblasts from patients with GO (n = 3). Data are presented as mean ± SD. p values were
obtained by the Mann–Whitney U test. The significance level was set at 0.01 (=0.05/5) with Bonferroni correction.

decompression surgery during the stable period. Although the
authors tried to include the subjects in cases that were in the stable
phase of the disease, the authors cannot be certain of the state of
the disease for each of the cases. They believed that the behavior
of the cells and their response to both H2O2 and selenium were
different according to the state of GO and there may be significant
difference in the responses to selenium and oxidative stress based
on the phase of the disease. Moreover, this may also account for
the unexpected lack of difference between the hyaluronan levels
in GO and normal controls.
Oxidative stress plays an important role in the pathogen-
esis of GO. Bednarek et al.7 reported that apart from the influ-
ence of thyroid metabolic status, it is orbital inflammation that
triggers changes in blood extracellular indices of ROS metabo-
lism. Hondur et al.10 showed that oxidative stress and antioxi-
dant activity are enhanced in orbital fibroadipose tissues in GO.
In several studies, it was reported that serum sele-
nium levels are lower in patients with GO.31,32 Also, the serum
selenium level is lower in patients with GD33. Selenium status
affects both the cell-mediated and humoral aspects of immune
function, which are linked to the inflammatory processes
involved in the production of ROS and redox control processes.
ROS production increases the expression of proinflammatory
cytokines.26 Selenium deficiency induced oxidative stress in ani-
mal models.34–37 This may be the mechanism by which selenium
exerts its beneficial effects in GO. Abedelahi et al.38 showed
that sodium selenite improves the in vitro follicular develop-
ment by reducing the ROS level and increasing the total antioxi-
dant capacity and glutathione peroxidase activity. In this study,
selenium pretreatment reduced intracellular ROS generation in
cultured orbital fibroblasts of patients with GO, stimulated by
H2O2. There was no difference in ROS generation depending on
the concentration of sodium selenite. There have been previous
reports on the effects of selenium in cultured orbital fibroblasts
of patients with GO. Marcocci et al.15 reported that selenium
supplementation significantly improved quality of life, reduced

© 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. 479
Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
 B.-Y. Kim et al. Ophthalmic Plast Reconstr Surg, Vol. 37, No. 5, 2021

FIG. 5.  A, Interleukin (IL)-1β levels in culture medium of orbital fibroblasts from control (n = 3) and patients with Graves ophthalmop-
athy (GO) (n = 3). Data are presented as mean ± SD. A p value was obtained by the Mann–Whitney U test. B, Effect of sodium selenite
on IL-1β levels in culture medium of orbital fibroblasts from patients with GO (n = 3). Data are presented as mean ± SD. p values were
obtained by the Mann–Whitney U test. The significance level was set at 0.01 (=0.05/5) with Bonferroni correction.

FIG. 6.  A, Interleukin (IL)-8 levels in culture medium of orbital fibroblasts from control (n = 3) and patients with Graves ophthalmopa-
thy (GO) (n = 3). Data are presented as mean ± SD. A p value was obtained by the Mann–Whitney U test. B, Effect of sodium selenite
on IL-8 levels in culture medium of orbital fibroblasts from patients with GO (n = 3). Data are presented as mean ± SD. p values were
obtained by the Mann–Whitney U test. The significance level was set at 0.01 (=0.05/5) with Bonferroni correction.

ocular involvement, and slowed progression of the disease in
patients with GO. It is assumed that the beneficial effects of
selenium supplementation on GO are probably due to its anti-
oxidant and anti-inflammatory properties. The results showed
that there was no statistically significant difference in hyaluro-
nan levels between cultured orbital fibroblasts of patients with
GO and controls. Lack of a statistically significant difference
in hyaluronan levels may be related to the small sample size of
this study. Moreover, the authors found the previous study that
cannot show that GO fibroblasts produce higher levels of hyal-
uronan than normal fibroblasts even when in the stable phase.39
Many questions regarding the effects of selenium on GO
remain unanswered. Although in vitro studies have been carried
out using a small sample size, the authors’ study showed the
anti-inflammatory and antioxidant effects of selenium on orbital
fibroblasts of patients with GO. It remains unknown whether
selenium can show clinical benefits in a clinical setting. The
authors think that their results may not be generalizable to all
GO subgroups and the results may be different, based on sele-
nium status, maybe particular genetic subgroups. However, they
believe that the results of their study on selenium are noteworthy
as these new data provide the rationale for clinical studies to
prove the potential usefulness of selenium in GO as an adjunc-
tive treatment.
In conclusion, hyaluronan production, inflammatory
cytokines, and intracellular ROS generation were suppressed
by selenium in cultured orbital fibroblasts of patients with GO.
Several inflammatory cytokines may be suppressed by sele-
nium in cultured orbital fibroblasts of patients with GO. This
study provide the basis for use of selenium in the treatment
of GO.
REFERENCES
1. Garrity JA, Bahn RS. Pathogenesis of graves ophthalmopa-
thy: implications for prediction, prevention, and treatment. Am J
Ophthalmol 2006;142:147–153.

480 © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.

Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
 Ophthalmic Plast Reconstr Surg, Vol. 37, No. 5, 2021 Selenium in Orbital Fibroblasts of GO
2. Kuriyan AE, Phipps RP, Feldon SE. The eye and thyroid disease.
Curr Opin Ophthalmol 2008;19:499–506.
3. Weetman AP. Graves’ disease. N Engl J Med 2000;343:1236–1248.
4. Bahn RS. Graves’ ophthalmopathy. N Engl J Med 2010;362:726–738.
5. Prabhakar BS, Bahn RS, Smith TJ. Current perspective on the
pathogenesis of Graves’ disease and ophthalmopathy. Endocr Rev
2003;24:802–835.
6. Tsai CC, Wu SB, Kao SC, et al. The protective effect of antioxidants
on orbital fibroblasts from patients with Graves’ ophthalmopathy in
response to oxidative stress. Mol Vis 2013;19:927–934.
7. Bednarek J, Wysocki H, Sowiński J. Oxidative stress peripheral
parameters in Graves’ disease: the effect of methimazole treat-
ment in patients with and without infiltrative ophthalmopathy. Clin
Biochem 2005;38:13–18.
8. Tsai CC, Kao SC, Cheng CY, et al. Oxidative stress change by sys-
temic corticosteroid treatment among patients having active graves
ophthalmopathy. Arch Ophthalmol 2007;125:1652–1656.
9. Tsai CC, Cheng CY, Liu CY, et al. Oxidative stress in patients with
Graves’ ophthalmopathy: relationship between oxidative DNA
damage and clinical evolution. Eye (Lond) 2009;23:1725–1730.
10. Hondur A, Konuk O, Dincel AS, et al. Oxidative stress and antioxi-
dant activity in orbital fibroadipose tissue in Graves’ ophthalmopa-
thy. Curr Eye Res 2008;33:421–427.
11. Ademoğlu E, Ozbey N, Erbil Y, et al. Determination of oxidative
stress in thyroid tissue and plasma of patients with Graves’ disease.
Eur J Intern Med 2006;17:545–550.
12. Negro R. Selenium and thyroid autoimmunity. Biologics
2008;2:265–273.
13. Rotondo Dottore G, Ionni I, Menconi F, et al. Antioxidant effects of
β-carotene, but not of retinol and vitamin E, in orbital fibroblasts
from patients with Graves’ orbitopathy (GO). J Endocrinol Invest
2018;41:815–820.
14. Rotondo Dottore G, Ionni I, Menconi F, et al. Action of three
bioavailable antioxidants in orbital fibroblasts from patients with
Graves’ orbitopathy (GO): a new frontier for GO treatment? J
Endocrinol Invest 2018;41:193–201.
15. Marcocci C, Kahaly GJ, Krassas GE, et al; European Group on
Graves’ Orbitopathy. Selenium and the course of mild Graves’ orbi-
topathy. N Engl J Med 2011;364:1920–1931.
16. Rotondo Dottore G, Leo M, Casini G, et al. Antioxidant actions of
selenium in orbital fibroblasts: a basis for the effects of selenium in
Graves’ orbitopathy. Thyroid 2017;27:271–278.
17. Przybylik-Mazurek E, Zagrodzki P, Kuźniarz-Rymarz S, et al.
Thyroid disorders-assessments of trace elements, clinical, and labo-
ratory parameters. Biol Trace Elem Res 2011;141:65–75.
18. Zinoni F, Birkmann A, Stadtman TC, et al. Nucleotide sequence and
expression of the selenocysteine-containing polypeptide of formate
dehydrogenase (formate-hydrogen-lyase-linked) from Escherichia
coli. Proc Natl Acad Sci U S A 1986;83:4650–4654.
19. Böck A, Forchhammer K, Heider J, et al. Selenoprotein syn-
thesis: an expansion of the genetic code. Trends Biochem Sci
1991;16:463–467.
20. Schomburg L. Selenium, selenoproteins and the thyroid gland: inter-
actions in health and disease. Nat Rev Endocrinol 2011;8:160–171.
21. Kato MA, Finley DJ, Lubitz CC, et al. Selenium decreases thyroid
cancer cell growth by increasing expression of GADD153 and
GADD34. Nutr Cancer 2010;62:66–73.
© 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. 481
Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
22. Lukas J, Drabek J, Lukas D, et al. The epidemiology of thyroid
cancer in the Czech Republic in comparison with other coun-
tries. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub
2013;157:266–275.
23. Glattre E, Nygård JF, Aaseth J. Selenium and cancer preven-
tion: observations and complexity. J Trace Elem Med Biol
2012;26:168–169.
24. Jonklaas J, Danielsen M, Wang H. A pilot study of serum selenium,
vitamin D, and thyrotropin concentrations in patients with thyroid
cancer. Thyroid 2013;23:1079–1086.
25. Taylor EW. Selenium and cellular immunity. Evidence that sele-
noproteins may be encoded in the +1 reading frame overlapping
the human CD4, CD8, and HLA-DR genes. Biol Trace Elem Res
1995;49:85–95.
26. Hardy G, Hardy I, Manzanares W. Selenium supplementation in the
critically ill. Nutr Clin Pract 2012;27:21–33.
27. Tolando R, Jovanovic A, Brigelius-Flohé R, et al. Reactive oxy-
gen species and proinflammatory cytokine signaling in endothelial
cells: effect of selenium supplementation. Free Radic Biol Med
2000;28:979–986.
28. Khalilzadeh O, Noshad S, Rashidi A, et al. Graves’ ophthalmopathy:
a review of immunogenetics. Curr Genomics 2011;12:564–575.
29. Kamizono S, Hiromatsu Y, Seki N, et al. A polymorphism of the
5’ flanking region of tumour necrosis factor alpha gene is associ-
ated with thyroid-associated ophthalmopathy in Japanese. Clin
Endocrinol (Oxf) 2000;52:759–764.
30. Bednarczuk T, Hiromatsu Y, Seki N, et al. Association of tumor
necrosis factor and human leukocyte antigen DRB1 alleles with
Graves’ ophthalmopathy. Hum Immunol 2004;65:632–639.
31. Khong JJ, Goldstein RF, Sanders KM, et al. Serum selenium sta-
tus in Graves’ disease with and without orbitopathy: a case-control
study. Clin Endocrinol (Oxf) 2014;80:905–910.
32. Dehina N, Hofmann PJ, Behrends T, et al. Lack of association
between selenium status and disease severity and activity in patients
with Graves’ ophthalmopathy. Eur Thyroid J 2016;5:57–64.
33. Bülow Pedersen I, Knudsen N, Carlé A, et al. Serum selenium is
low in newly diagnosed Graves’ disease: a population-based study.
Clin Endocrinol (Oxf) 2013;79:584–590.
34. Tsuji PA, Carlson BA, Anderson CB, et al. Dietary selenium levels
affect selenoprotein expression and support the interferon-γ and IL-6
immune response pathways in mice. Nutrients 2015;7:6529–6549.
35. Yu J, Yao H, Gao X, et al. The role of nitric oxide and oxidative
stress in intestinal damage induced by selenium deficiency in chick-
ens. Biol Trace Elem Res 2015;163:144–153.
36. Zhang Z, Gao X, Cao Y, et al. Selenium deficiency facilitates inflam-
mation through the regulation of TLR4 and TLR4-related signaling
pathways in the mice uterus. Inflammation 2015;38:1347–1356.
37. Sheng PF, Jiang Y, Zhang ZW, et al. The effect of Se-deficient diet
on gene expression of inflammatory cytokines in chicken brain.
Biometals 2014;27:33–43.
38. Abedelahi A, Salehnia M, Allameh AA, et al. Sodium selenite
improves the in vitro follicular development by reducing the reactive
oxygen species level and increasing the total antioxidant capacity
and glutathione peroxide activity. Hum Reprod 2010;25:977–985.
39. Yoon JS, Lee HJ, Choi SH, et al. Quercetin inhibits IL-1β-induced
inflammation, hyaluronan production and adipogenesis in orbital
fibroblasts from Graves’ orbitopathy. PLoS One 2011;6:e26261.