Steroid-induced ptosis: case studies and histopathologic analysis

Management of eyelid retraction related to thyroid eye disease

Eyelid retraction related to thyroid eye disease (TED) is a challenging condition. It is one of the main clinical signs and a major diagnostic criterion in TED. This condition may threaten vision due to exposure keratopathy, in addition to its esthetic alterations, which may lead to psychosocial implications and affect the patient's quality of life. Although it is more commonly observed in the upper eyelid, it may be present on both the upper and lower lids. Numerous surgical and nonsurgical treatment modalities have been described and will be reviewed in this article. Management should be based on an individual patient assessment, taking into consideration the disease stage, severity, and clinician experience.

Factors associated with the development of blepharoptosis after pars plana vitrectomy surgery

PURPOSE

To determine the incidence and risk factors for developing blepharoptosis after vitrectomy surgery.

METHODS

This prospective observational study conducted in patients who had vitrectomy surgery at the University of California, San Francisco. The patients' eyelids were photographed before, surgery and follow-up visits at 1 day, 1 week, 1 month, 3 months, and 6 months after surgery. Levator excursion (LE), palpebral fissure (PF) height and marginal reflex distance 1 (MRD1) changes from baseline were evaluated. Operative parameters associated with lid parameter changes were analyzed.

RESULTS

Thirty-eight eyes were enrolled in the study. Multivariate analysis performed for PF changes from pre-operative were -0.47 mm, 0.33 mm, and 0.09 mm at 1 week, 1 month and 6 months after surgery, respectively (p-value 0.1, 0.2, and 0.8). The mean change of LE from preoperative was -0.44 mm, -0.15 mm, and 0.35 mm at 1 week, 1 month and 6 months after surgery, respectively (p-value 0.3, 0.7 and 0.4). The reduction of MRD1 at 1 week, 1 month and 6 months after surgery were -0.08 mm, -0.13 mm and -0.01 mm, respectively (p = .003, p = .6 and 0.9). Triamcinolone usage was associated with reduction of MRD1 and LE.

CONCLUSION

Blepharoptosis presents most during the first week after surgery. The possibility of developing transient changes in eyelid position after vitrectomy surgery should be discussed with patients.

A randomized clinical trial of triamcinolone acetonide injection for suppression of inflammation after blepharoptosis surgery

This study aimed to determine the effectiveness of triamcinolone acetonide in suppressing inflammation after blepharoptosis surgery. The study was designed as prospective, randomized, two medical centers' clinical trial. Thirty-two patients with involutional blepharoptosis of the same degree in both eyelids underwent bilateral transcutaneous levator advancement. At the end of the surgery, 4 mg/0.1 ml of triamcinolone acetonide was injected into a randomly selected upper eyelid. The fellow eyelid was not injected and was used as control. Facial photographs were taken on day 1, week 1, month 1, and month 3, and the degree of inflammation, the margin reflex distance 1 (MRD-1), and levator function (LF) between the two eyelids of each patient were compared. The primary outcome was the selection of the less inflamed eyelid decided by the majority of three individuals unrelated to the study. MRD-1 and LF were analyzed for secondary outcomes. As a result, the injected eyelid was judged to be the less inflamed eyelid in all cases. The MRD-1 in the postoperative period less than 1 month was significantly larger in the injected eyelids than the control eyelids (P<0.03). The postsurgical MRD-1 at month 3, the postsurgical LF at all postsurgical examination times were not statistically different. Adverse complications by the injection, including ptosis, levator dysfunction, increase of the intraocular pressure, and visual disturbance were not observed. In conclusion, a triamcinolone acetonide injection after ptosis surgery is both safe and effective in reducing the early postsurgical inflammation and helpful in an earlier return to a daily routine for the patients.

Topical Corticosteroid Use Associated With Increased Degree of Ptosis and Rate of Ptosis Repair Failure

PURPOSE

To compare the degree of ptosis and the risk of ptosis repair failure among patients with and without a history of topical corticosteroid use.

METHODS

Retrospective, case-controlled study examining topical corticosteroid use among adults with ptosis who underwent external levator advancement/resection (ELR) or Müller muscle conjunctival resection with at least 3 months postoperative follow-up. Comparative statistical analyses of surgical outcomes were performed amongst patients with and without history of topical corticosteroid use.

RESULTS

A total of 240 patients (406 eyelids) met study criteria, of which 36 patients (44 eyelids) had history of topical corticosteroid use. Mean preoperative margin reflex distance was 0.20 mm and 0.58 mm for topical corticosteroid and non-corticosteroids users (p = 0.01). Mean preoperative levator function was 9.78 mm and 10.38 mm for topical corticosteroid and non-corticosteroid users (p = 0.02). The rate of ptosis repair failure was 30% and 16% in patients with and without a history of topical corticosteroid use (odds ratio 2.25, 95% confidence interval 1.10-4.55; p = 0.03). The rate of recurrence per surgical type in eyelids with and without history of topical corticosteroid use was: external levator advancement/resection 11/27 (41%) and 48/266 (18%) (odds ratio = 3.12, confidence interval 1.36-7.15 0; p = 0.01); Müller muscle conjunctival resection 2/17 (12%) and 9/96 (9%) (odds ratio 1.29, confidence interval 0.25-6.56; p = 0.76).

CONCLUSIONS

Topical corticosteroid use is associated with more severe presenting ptosis and increased rates of ptosis repair failure. Compared to Müller muscle conjunctival resection, there is a significantly higher rate of ptosis repair failure in patients undergoing external levator advancement/resection.

Corticosteroid eyedrops induced blepharoptosis and atrophy of levator muscle

PURPOSE

The purpose of the study is to analyze the incidence, manifestations, and treatment of blepharoptosis caused by long-term use of corticosteroid eyedrops.

METHODS

Retrospective case series include 46 patients with a history of using corticosteroid eyedrops unilaterally for at least 2 months. The palpebral fissure, MRD1, and levator function were evaluated.

RESULTS

Among 46 patients, the differences of mean MRD1 (p < 0.0005), palpebral fissure height (p < 0.0005), and levator function (p = 0.003) between eyes with and without corticosteroid eyedrops application were significant. Ptosis existed in 40 out of 46 eyes with corticosteroid; the differences of the mean MRD1 (p < 0.0005) and palpebral fissure height (p = 0.001) between eyes with and without ptosis were significant. Nine patients underwent levator aponeurosis repair surgeries. Pathological examinations revealed mainly vascular fibers and few muscle fibers, as well as apoptosis of levator palpebrae muscle and Muller muscle.

CONCLUSION

Blepharoptosis is frequently observed after chronic corticosteroid eyedrops use in Chinese population.

Long-term effect of triamcinolone acetonide in the treatment of upper lid retraction with thyroid associated ophthalmopathy

AIM

To report the long-term outcomes of a large cohort of upper lid retraction patients treated with subconjunctival triamcinolone acetonide injections.

METHODS

This retrospective clinical study was conducted from 2009 to 2016. The documents of 97 patients (126 eyes) were reviewed. The patients were treated with subconjunctival triamcinolone acetonide injections monthly and evaluated pre- and post-treatment by taking measurements of the upper margin reflex distance (MRD1, the distance between the upper-lid margin and the pupil center), lid aperture, lagophthalmos and proptosis. The patients were divided into the cured group, the improved group and the ineffective group based on the final treatment effectiveness. The improved group and the ineffective group were combined into non-cured group.

RESULTS

The follow-up time was 23.45±14.86mo. Of the patients, 63 (64.9%) were assigned to the cured group, 22 (22.7%) in the improved group, 12 (12.4%) in the ineffective group. Injection times for cured group was 4.66±1.74, and for non-cured group was 5.17±2.08 (P≤0.05). The MRD1 was significantly reduced between baseline and 1mo after the initiation of treatment in the cured and improved groups (P<0.001). The values did not change significantly after 4mo for the improved group, while they continued to decrease in the cured group. In the ineffective group, the MRD1 did not significantly change after treatment. A statistically significant difference was observed between the baseline and post-treatment values of the mean muscle thickness (2.95±0.99 mm vs 2.04±0.63 mm, P<0.05) and surface area (27.27±10.5 mm²vs 18.3±7.04 mm², P<0.05) of the levator superioris with magnetic resonance imaging examination. Twelve patients (12.4%) relapsed after treatment and required additional subconjunctival injections. The main side effects included menstrual cycle disturbances (32%) and elevations of intra-ocular pressure (18.6%).

CONCLUSION

A repeated subconjunctival injection of triamcinolone is an effective and relatively safe treatment for upper lid retraction due to thyroid-associated ophthalmopathy. This is related to the anti-inflammation effect of the medicine and the levator thickness can become thinner. Patients must be monitored regularly for recurrences and side effects.

Ptosis induced by topical steroid eye drops: Two cases reports

RATIONALE

Ptosis is a rare complication of periocular steroid use. Studies report that local injections of steroids produce ptosis. We describe the first 2 cases of ptosis because of long-term treatment with topical steroid eye drops.

PATIENT CONCERNS

Two cases admitted to our hospital because of ptosis of their right eye after long-term treatment with topical steroid eye drops. Both of them had uncontrolled Posner-Schlossman syndrome.

DIAGNOSIS

Two cases were diagnosed as steroid-related ptosis.

INTERVENTIONS

Regulatory anti-inflammation therapy was prescribed for case 1, and after inflammation control, phacoemulsification was done for her. Six months after steroid withdrawal, the levator resection of the right eye was performed. Case 2 refused our advice of steroid reduction and ptosis surgery.

OUTCOMES

After surgery, case 1 retained a symmetrical appearance during a 1-year follow-up. In the surgery, we found thin levator muscles and slack levator palpebrae superioris aponeurosis (LPSA) in the affected eye. Postoperative transmission electron microscopy revealed typical signs of apoptosis in levator muscle cells.

LESSONS

We suggest topical application of steroids induces levator muscle apoptosis and LPSA weakness, and results in ptosis.

Bilateral inferior oblique muscle paresis after posterior subtenon injection of triamcinolone acetonide

Posterior subtenon injections of steroidal drugs are commonly used to treat various chorioretinal inflammatory diseases. Subsequent strabismus is rare, but it is associated with severe visual disturbance when present. We report a case of simultaneous bilateral inferior oblique muscle paresis in a 60-year-old man who developed it after receiving intravitreal injections of bevacizumab and posterior subtenon injections of triamcinolone acetonide for the treatment of diabetic macular edema. The patient complained of excessive pain during the injections, which were performed at the 6 o’clock position in both eyes. According to the literature, inferior oblique muscle paresis after posterior subtenon injections is rare. This complication may be prevented by proper selection of the injection site and paying attention to any unusual patient complaints during the procedure.

The functional and histopathologic change in the levator palpebrae superioris and Müller muscle after subconjunctival injection of triamcinolone acetonide

AIMS

The aim of this study was to evaluate the functional and histopathologic changes in the levator palpebrae superioris and Müller muscles after subconjunctival injection of triamcinolone acetonide (TA) in rabbits.

METHODS

Twenty-four white New Zealand rabbits were divided into 2 groups. In group A, a subconjunctival injection of 0.5 mL TA (40 mg/mL) was administered to the right eye, whereas a normal saline injection of the same volume was administered to the left eye. In group B, the same procedures were done with a 1.0-mL injection of TA or normal saline into each eyelid. Follow-up was done to evaluate the histopathologic changes in the levator and Müller muscles, changes in the mean transectional area of Müller muscle, and changes in upper-lid height (marginal reflex distance 1) at 1, 2, 4, and 6 weeks after injection. Western blot analyses were used to determine the levels of myosin light chain phosphorylation and α-smooth muscle actin, which are related to the contractility of Müller muscle.

RESULTS

No specific changes in marginal reflex distance 1 were noted in either group A or B. No significant histopathologic changes were found in the levator muscles. However, significant thinning of Müller muscle were found, and myosin light chain phosphorylation and α-smooth muscle actin levels were decreased. This was consistent with the histologic changes of Müller muscle observed in rabbits that received a TA injection. These changes were reversible and influenced by the volume of the injection.

CONCLUSIONS

Subconjunctival injection of TA into the upper eyelids appears to be temporally influential on both the functional and histopathologic changes of Müller muscle in rabbits. This may be explained by the effect of improvement in lid retraction regardless of the minimal specific change observed in the levator muscle.

Relative incidence of blepharoptosis subtypes in an oculoplastics practice at a tertiary care center

PURPOSE

In patients referred with blepharoptosis, the possibility of an underlying systemic cause for their ptosis can warrant a more detailed evaluation. The purpose of this study is to determine both the incidence and demographic characteristics associated with different types of ptosis in patients referred to the oculoplastics division at a tertiary care center.

METHODS

A retrospective chart review was performed on all patients referred to the oculoplastics division between 2007 and 2010. Final etiology for each patient's ptosis was determined based on history, standard eyelid measurements, and ancillary testing. Based on etiology, ptosis was categorized as aponeurotic, neurogenic, myogenic, traumatic, congenital, or mechanical. Demographics, including median age and sex were analyzed for patients in each category of ptosis.

RESULTS

Of the 251 patients, aponeurotic ptosis was the most common type of ptosis (60.2%), followed by traumatic (11.2%), congenital (10.4%), mechanical (8.8%), neurogenic (5.6%), and myogenic (4.0%). Of the neurogenic group, 35.7% of patients had cranial nerve 3 (CN 3) palsy, 28.6% had myasthenia gravis, 14.3% had aberrant regeneration, and 7.1% had Horner's syndrome. Thirty percent of the myogenic group had chronic progressive external ophthalmoplegia (CPEO). The congenital group had the youngest median age (10.5 years), yet the aponeurotic group had the oldest (62 years).

CONCLUSIONS

A significant proportion of patients referred with ptosis had more serious conditions such as neurogenic or myogenic ptosis. Thus, clinicians should maintain a high degree of suspicion and thoroughly evaluate all patients with ptosis in order to properly assess for underlying systemic associations.

Treatment of upper eyelid retraction related to thyroid-associated ophthalmopathy using subconjunctival triamcinolone injections

BACKGROUND

To evaluate the efficacy of subconjunctival triamcinolone injection for treating upper eyelid retraction caused by thyroid-associated ophthalmopathy (TAO).

METHODS

Prospective single blind randomized clinical trial. Patients diagnosed with TAO-associated eyelid retraction and/or swelling <6 months before study onset were randomly assigned to triamcinolone-injected (group I; 55 patients, 75 eyes) or observation-only (group II; 40 patients, 59 eyes) populations. Group I received 1-3 injections of 20 mg triamcinolone acetate into the subconjunctival eyelid, between the conjunctiva and Muller's muscle, at 3-week intervals. Group I was followed up at 3, 6, 9, and 24 weeks post-injection, and group II was evaluated at 9 and 24 weeks after initial visit. Eyelid swelling and retraction were each graded on a 0-3 scale. Treatment was stopped after 1-2 injections if both swelling and retraction resolved completely or if retraction and swelling scored 0/1 or 1/0 without functional or cosmetic patient concerns. Treatment success was defined at 9 and 24 weeks post-injection if eyelids were normal or when treatment was terminated because of early clinical resolution. We compared baseline clinical data between success and failure group evaluated at 9 and 24 weeks in group I, and investigated short-term and long-term success prognostic factor using multiple logistic regression analysis in each group I and II.

RESULTS

Swelling and retraction decreased significantly more in group I than in group II. Significantly more eyes had severe swelling (≥ grade 2) in group I (67 %) than in group II (34 %) upon initial evaluation (p < 0.01); this difference disappeared at 9 and 24 weeks. Fewer severely retracted eyes were observed in group I than in group II at 9 and 24 weeks (p < 0.01). Significantly more eyes in group I achieved success at both 9 and 24 weeks (59 %, 75 %) than in group II (39 %, 57 %) (p = 0.03, p = 0.04 respectively). Higher initial retraction grades (2-3) predicted a higher chance of post-injection failure versus the reference group (grade 0-1) at 9 and 24 weeks in group I, with adjusted odds ratios (aOR) 45.4 (95 % CI = 5.9-351.1, p < 0.01) and aOR 11.6 (95 % CI = 2.3-58.5, p < 0.01) respectively. Similarly in group II, initial retraction grade was associated with the failure at 9 and 24 weeks, with aOR 10.3 (95 % CI = 1.8-59.6, p < 0.01) and aOR 5.9 (95 % CI = 1.3-25.9, p < 0.05) respectively. Transient intraocular pressure elevation was observed in three eyes of two patients, although all ocular pressures were normalized within 1 month using anti-glaucoma medication.

CONCLUSIONS

Subconjunctival triamcinolone injections were very effective in resolving eyelid swelling and retraction in recent-onset TAO. However, the symptom-reducing effect of triamcinolone was modest and less effective in patients initially presenting with severe retraction grades. As intraocular pressure may rise after steroid injection at upper eyelid, the treatment should be avoided in patients suspected to have glaucoma.

Periocular corticosteroid injection in the management of uveitis in children

PURPOSE

To report the outcome of orbital floor corticosteroid injection (OFCI) in the management of uveitis in children.

METHODS

  A retrospective noncomparative interventional case series. The medical records of 15 consecutive children (19 eyes) with various forms of uveitis treated with OFCI of 40 mg/ml methylprednisolone acetate or a combination of 20 mg/0.5 ml Triamcinolone and 2 mg/0.5 ml dexamethasone were reviewed. Data were collected 6 months postinjection and included details of uveitis, best corrected visual acuity (BCVA), ocular inflammation, systemic therapy required and potential complications of OFCI.

RESULTS

The mean BCVA improvement was 0.18 logarithm of the minimum angle of resolution (p < 0.001), at a mean of 6 weeks (range, 4-20). Fourteen eyes (74%) had significant improvement in inflammation, 4-7 weeks post-OFCI, with a median of 4 weeks. Anterior uveitis was treated effectively in all eyes, vitritis resolved in all but one case and resolution of cystoid macular oedema was achieved in six eyes (55%). Uveitis relapsed in seven eyes (50%) after a median time of 4 months (range, 2-5 months). Four eyes (21%) underwent more than one injection. The dosage of immunosuppressive systemic therapy was reduced or able to be stopped in three patients (50%). Steroid-induced cataract was observed in four eyes (21%), 5 months post-OFCI. One patient developed cushingoid features 6 weeks post his second OFCI.

CONCLUSION

Corticosteroid orbital floor injections resulted in control of active uveitis and visual acuity improvement in most children. However, the effect might be transient and induce cataract formation.

Dehiscence of levator aponeurosis in ptosis after sub-Tenon injection of triamcinolone acetonide

OBJECTIVE

To report the incidence, intraoperative findings, and surgical outcome of secondary ptosis that developed after a sub-Tenon injection of triamcinolone acetonide (TA).

STUDY DESIGN

Retrospective, cross-sectional study.

PARTICIPANTS

One hundred forty-seven cases with a total of 286 sub-Tenon TA injections.

METHODS

The medical records of 163 eyes of 147 cases treated with a sub-Tenon injection of 10 mg or 20 mg TA were reviewed. The incidence of secondary ptosis (palpebral fissure >2 mm narrower than that of the fellow eye) after a sub-Tenon TA injection was determined. The preoperative levator function and margin reflex distance (MRD) of the affected eyes, and the intraoperative findings in eyes that underwent reconstructive surgery, were evaluated.

RESULTS

Eight eyes (5%) developed secondary ptosis after the injection and 6 eyes were treated by reconstructive surgery. The preoperative levator function of the affected eyes did not differ from that of the fellow eyes. Intraoperatively, no septal disruption or fat herniation was noted, but an aponeurotic disinsertion was identified and repaired with an advancement of the leading edge to the anterior tarsal plate. The surgery led to satisfactory results, with improvement of the MRD from -1.3 (SD 1.5) mm preoperatively to 2.3 (SD 0.5) mm postoperatively (p = 0.027). Additional sub-Tenon TA injections were required in 2 eyes after eyelid surgery but the ptosis did not worsen.

CONCLUSIONS

A sub-Tenon TA injection can occasionally cause ptosis by inducing a disinsertion of the levator aponeurosis. However, surgical reconstruction can lead to successful resolution of the ptosis.