Transconjunctival Triamcinolone Injection for Upper Lid Retraction in Thyroid Eye Disease—A New Injection Method

Triamcinolone acetonide and botulinum toxin A for upper eyelid retraction in thyroid-associated ophthalmopathy

To evaluate the therapeutic effect of combining subconjunctival botulinum toxin A (BTX-A) with periorbital triamcinolone acetonide (TA) injections in treating upper eyelid retraction (UER) due to thyroid-associated ophthalmopathy (TAO). Fifty eyes with TAO-related UER were randomized into two groups. Group 1 received TA alone, while group 2 received BTX-A plus TA. Marginal reflex distance (MRD1) and graine sign (GS) were measured at baseline and post-injection intervals. Elevated intraocular pressure incidence was monitored. Group 1 showed significant MRD1 reductions at 1, 3, and 6 months (P < 0.05) and a GS increase at 3 months (P < 0.05). Group 2 exhibited quicker MRD1 reductions at 1 week, 1, 3, and 6 months (P < 0.05) and earlier GS improvements at 1 week, 1, and 3 months (P < 0.05). Group 2 had lower MRD1 and higher GS values one week post-initial injection (P < 0.001 and P = 0.013, respectively) and a lower incidence of elevated intraocular pressure compared to group 1 (P < 0.05). In a six-month study, patients treated with BTX-A and TA for TAO-related UER experienced a faster therapeutic onset and sustained efficacy with reduce the total dose of multiple local TA injections and fewer side effects like elevated intraocular pressure.The trial registration number is ChiCTR2300077958, with the date of registration being 24/11/2023 (retrospectively registered).

Alpha-1 antagonist treatment for eyelid retraction in patients with thyroid eye disease-a prospective pilot study

BACKGROUND

Sympathetic overstimulation of Müller's muscle is a suggested mechanism underlying upper eyelid retraction in thyroid eye disease (TED). We examined the effect of tamsulosin, an alpha-1 antagonist, on eyelid retraction in patients with TED.

METHODS

A single-centre prospective study. Patients with TED and associated eyelid retraction were treated with oral 0.4 mg/day tamsulosin for 3 months. Upper eyelid margins-to-reflex distance (MRD1), vertical palpebral fissure height (PFH), subjective improvement, signs and symptoms of dry eye, and lubricants use were assessed at baseline and at each subsequent visit.

RESULTS

Eleven suitable patients (mean age 47.5 ± 9.68, 8 females) enrolled in the study. Three patients discontinued the drug due to mild adverse effects (dizziness, bradycardia, nausea, and gastrointestinal distress), which resolved immediately upon stopping treatment. The other eight patients tolerated the drug well and reported no side effects. Five patients experienced an objective improvement in eyelid position and subjective improvement in eye discomfort. The mean MRD1 decreased by -1.04 ± 0.81 mm (P = 0.015), and mean PFH decreased by -1.46 ± 1.33 mm (P = 0.039). Mean duration of tamsulosin treatment was 84.63 ± 71.9 days. Patients discontinued the drug due to no improvement in MRD1 (n = 3), referral for eyelid surgery with stable inactive TED (n = 2), treatment with intravenous methylprednisolone due to worsening active TED (n = 2), and patient choice after 5 months of treatment with spontaneous resolution of symptoms (n = 1).

CONCLUSIONS

Tamsulosin is a safe potential treatment for eyelid retraction in TED and can be used as a temporary alternative therapeutic approach for patients unsuitable for surgery.

Triamcinolone injection in the treatment of lid retraction for thyroid-associated ophthalmopathy: A systematic review

INTRODUCTION AND OBJECTIVES

Lid retraction is one of the most common symptoms of Thyroid-Associated Ophthalmopathy (TAO), which potentially precipitates various complications, such as dry eyes, exposure keratopathy, and cosmetic concerns. Local corticosteroid injections, such as triamcinolone, have been proposed as a choice of treatment for TAO. This approach may be a favorable alternative for patients intolerant to the systemic effects of high-dose methylprednisolone. However, the efficacy of this intervention remains unestablished. Hence, our review aims to evaluate the efficacy of triamcinolone injection in reducing lid retraction.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline and was conducted in three databases (PubMed, Science Direct, and ProQuest). This review included studies that use local triamcinolone injections for patients with thyroid-associated ophthalmopathy. The outcome of interest in this review is lid retraction parameters.

RESULTS

From six studies, a total of 392 patients were included. All studies showed significant improvement in lid retraction in the patient who received triamcinolone (all p < 0.05) as shown by ΔMRD (-0.93 mm in 1 month and -1.38 mm in 3 months), ΔMLD (-1.98 mm at 6 months), and Δpalpebral fissure height (-1.68 in 1 month). The majority of studies showed rapid improvement in lid retraction in the first month of therapy.

CONCLUSION

Triamcinolone injection is an effective therapy for lid retraction related to thyroid-associated ophthalmopathy.

Morphological and Histological Changes Following Triamcinolone Injection Alone or Mixed Injection of Triamcinolone and Botulinum Toxin in Upper Eyelid

OBJECTIVE

The purpose of this experiment was to evaluate the functional and histologic changes in the upper eyelid muscles after injection of triamcinolone acetonide (TA) alone or TA combined with botulinum toxin A (Botox or BTXA) in the cynomolgus monkey model.

METHODS

Twenty eyes of 10 cynomolgus monkeys were divided into 4 groups: 3 experimental groups (1, 2, and 3) and the control group (group 4) based on the injection type. In group 1, 0.5 mL of TA (Kenalog 40 mg/mL) was administered subconjunctivally (between the conjunctiva and the Müller muscle) with a 26 G needle to the inverted upper eyelid of one eye. In group 2, the same procedure was done with 0.5 mL TA injected into the other upper eyelid. After that, 5 UI/0.1 mL Botox was injected transcutaneously into the suborbicularis oculi space in the middle third of the upper eyelid 3 mm above the center of the superior tarsal border. In group 3, a subconjunctival of 0.5 mL TA was administered to the inverted upper eyelid of one eye 3 times: the injection day, 2 weeks, and 6 weeks after the first injection, whereas a normal saline injection of the same volume was administered one time to the other eye at the injection day in group 4 (control group). Follow-up was done to evaluate the clinical changes in eyelid position at 2, 6, and 12 weeks after injection. Hematoxylin-eosin and Masson trichrome were used to assess the levator or Muller muscle histology and measure the fiber diameter.

RESULTS

During the clinical follow-up, there were no major complications observed in any monkeys. The macroscopic appearance of the upper lid on the biopsy day did not differ among groups 1, 2, and 4. There were no cases in these groups that had subconjunctival TA deposit 3 months after injection. Conversely, in group 3, there were 3/5 eyes showing the subconjunctival TA deposit at the last examination.No specific changes in the marginal reflex distance 1, marginal reflex distance 2 (MRD2), and lid crease were noted in either TA alone injection groups 1, 3, and 4. In contrast, there was a significant decrease in marginal reflex distance 1 at 2 weeks (P = 0.003) and 6 weeks (P = 0.005) after TA injection in group 2 in comparison to the baseline.In terms of MRD2, while in group 2, there were significant differences between the pre-MRD2 and the post-MRD2 till the 2 weeks after injection (P = 0.006), then it became insignificant from the sixth week afterward. In contrast, at 2 weeks after injection, MRD2 was reduced in both TA-injected groups 1 and 3, but the observed difference was not significant in both groups. At 6 and 12 weeks, MRD2 fluctuation was not remarkable in these 2 groups and there were no significant differences in comparison to the baseline (P > 0.05).Histological evaluation showed that Müller muscle does not attach directly to the superior border of the tarsus, but it changes to the tendon before attaching to the tarsal plate. In addition, there were no statistical differences in levator muscle fiber diameter and Müller muscle fiber diameter between the 4 groups, with P = 0. 621 and P = 0.695, respectively.

CONCLUSION

Triamcinolone acetonide combined with BTXA showed better results in decreasing upper eyelid height than TA alone in normal monkey eyelids due to its predictable effect. In addition, there were no differences between the side effects and the histology results between the 4 groups. Therefore, TA combined with BTXA may become a promising treatment for selective thyroid eyelid retraction and could offer an alternative to surgery and its complications.

Peri-levator Betamethasone Versus Triamcinolone Injection in Management of Thyroid Eye Disease-related Upper Eyelid Retraction Without Proptosis

PURPOSE

To compare the efficacy of peri-levator injection of both betamethasone and triamcinolone in the management of thyroid eye disease-related upper eyelid retraction without proptosis.

METHODS

This prospective, double-blind, randomized clinical trial was conducted at Assiut University Hospital, Upper Egypt in the period between December 2021 and October 2023. The study included 47 patients (56 eyes) and was divided into 2 groups. In group A, 1 ml betamethasone was injected into the peri-levator area, while in group B, 1 ml triamcinolone was injected. The injection was repeated every month for up to 5 injections if there was an improvement in margin reflex distance 1 (MRD1). The injection was stopped if MRD1 reached the normal value or if 2 successive injections caused no improvement in MRD1. The postinjection outcome was divided into: 1) effective if MRD1 reached the normal ≤4.5 mm; 2) partially effective if MRD1 was improved but did not reach the normal; and 3) ineffective if there was no improvement in MRD1. The follow up ranged from 6 to 20 months.

RESULTS

In group A, the injection was effective in 26 eyes (92.9%) and partially effective in 2 eyes (7.1%). In group B, the injection was effective in 17 eyes (60.7%), partially effective in 6 eyes (21.4%), and ineffective in 5 eyes (17.9%). The mean number of injections was significantly lower in group A than in group B: 1.61 ± 0.50 versus 2.36 ± 1.16.

CONCLUSIONS

This study results suggest that betamethasone is more effective with a smaller number of injections than triamcinolone in the management of thyroid eye disease-related upper eyelid retraction.

Nonsurgical management of upper eyelid retraction in thyroid eye disease

Upper eyelid retraction (UER) is the most common sign of thyroid eye disease (TED) and may result in lagophthalmos and exposure keratopathy. Measures to address UER are varied and include conservative treatment, surgical intervention, and injections of botulinum toxin, hyaluronic acid (HA) filler, and triamcinolone acetonide (TA). Our article will discuss the various nonsurgical aspects of managing TED-related UER, focusing on the injections of botulinum toxin, HA filler, and TA to the upper eyelid, which have all been reported to be effective in improving UER in both active and inactive states of TED. Individual response may vary, and repeated injections may be necessary.

Percutaneous triamcinolone injection for upper eyelid retraction in thyroid eye disease

Purpose

To evaluate percutaneous triamcinolone (TA) injection efficacy in treating upper eyelid retraction (UER) for Australian thyroid eye disease (TED) patients.

Methods

We conducted a retrospective analysis across 8 years and multiple diverse Australian centres identified UER patients who received TA injections. A single operator administered 40mg/1ml TA through upper eyelid skin. Assessments at 4-6 weeks and subsequent eyelid measurements gauged treatment response and complications.

Results

24 patients and 25 eyelids were included in the study. 91.6% were female, mean age 40.8 ± 10.3 years with mean follow-up of 17.5 months (± 18.5). Pre-treatment MRD1 was 6.2mm ± 1.4, and we observed a mean improvement of 2.2mm from pre-treatment to post-treatment (p<0.001). The mean UER measurement before treatment (defined as MRD1 - 4.0mm) was 3.0mm ± 1.3 (range, 0-6mm). After treatment, the mean UER measurement was -0.1mm. Quality of life (QOL) assessment improved significantly, from pre-treatment score of 4.13 ± 2.4 to post-treatment 8.0 ±1.7 (p<0.001).

Conclusions

Percutaneous injection of TA is an effective and safe treatment option for UER in patients with TED. This technique can be performed without upper eyelid eversion, which makes it more tolerable for patients and less complex for the operator compared to the transconjunctival injection approach. Our results show a significant improvement in MRD1 and UER, as well as patient QOL. Moreover, we found a low rate of complications (4.2% induced ptosis) and no cases of raised intraocular pressure. Percutaneous TA injection can greatly reduce the need for eyelid lowering surgery in this patient population.

[Interdisciplinary Management of Orbital Diseases]

Diagnosis and therapy of orbital diseases is an interdisciplinary challenge, in which i.e. otorhinolaryngologists, ophthalmologists, radiologists, radiation therapists, maxillo-facial surgeons, endocrinologists, and pediatricians are involved. This review article describes frequent diseases which both, otolaryngologists and ophthalmologists are concerned with in interdisciplinary settings. In particular the inflammatory diseases of the orbit including orbital complications, autoimmunological diseases of the orbit including Grave´s orbitopathy, and primary and secondary tumors of the orbit are discussed. Beside describing the clinical characteristics and diagnostic steps the article focusses on the interdisciplinary therapy. The review is completed by the presentation of most important surgical approaches to the orbit, their indications and possible complications. The authors tried to highlight the relevant facts despite the shortness of the text.

Current Therapeutic Approaches for Graves' Orbitopathy - are Targeted Therapies the Future?

Graves' orbitopathy is an autoimmune disease of the orbit that most frequently occurs with Graves' hyperthyroidism. The occurrence of autoantibodies directed against the TSH receptor (TRAb) is of central importance for the diagnosis and pathogenesis. These autoantibodies are mostly stimulating, and induce uncontrolled hyperthyroidism and tissue remodelling in the orbit and more or less pronounced inflammation. Consequently, patients suffer to a variable extent from periocular swelling, exophthalmos, and fibrosis of the eye muscles and thus restrictive motility impairment with double vision. In recent decades, therapeutic approaches have mainly comprised immunosuppressive treatments and antithyroid drug therapy for hyperthyroidism to inhibit thyroid hormone production. With the recognition that TRAb also activates an important growth factor receptor, IGF1R (insulin-like growth factor 1 receptor), biological agents have been developed. Teprotumumab (an inhibitory IGF1R antibody) has already been approved in the USA and the therapeutic effects are enormous, especially with regard to the reduction of exophthalmos. Side effects are to be considered, especially hyperglycaemia and hearing loss. It is not yet clear whether the autoimmune reaction (development of the TRAb/attraction of immunocompetent cells) is also influenced by anti-IGF1R inhibiting agents. Recurrences after therapy show that the inhibition of antibody development must be included in the therapeutic concept, especially in severe cases.

Update on the surgical management of Graves' orbitopathy

Graves' orbitopathy (GO) is a complex autoimmune disorder of the orbit that causes the eye to appear disfigured. GO is typically associated with Graves' disease, an inflammatory autoimmune condition that is caused by thyrotropin receptor autoantibodies. Although our knowledge of the pathophysiology of GO has improved, its exact pathogenesis remains unclear. Some patients suffer from disfigurement, double vision, and even vision loss rather than hyperthyroidism. The disease severity and activity prompt different treatments, as the signs of GO are heterogeneous, so their management can be very complex. Despite medical advances, the first-line treatment for moderate-to-severe active GO is still glucocorticoids, while surgery can be critical for the treatment of chronic inactive GO. Surgery is sometimes required in the acute phase of the disease when there is an immediate risk to vision, such as in dysthyroid optic neuropathy. Most surgeries for GO are rehabilitative and subdivided into three categories: decompression, strabismus repair, and lid surgery. This review is a basic overview of the field, with up-to-date knowledge of the surgical techniques for GO. We review and summarize recent literature on the advances in surgery for GO to provide up-to-date insights on the optimal surgical treatment for GO.

Management of Thyroid Eye Disease: A Consensus Statement by the American Thyroid Association and the European Thyroid Association

Thyroid eye disease (TED) remains challenging for clinicians to evaluate and manage. Novel therapies have recently emerged, and their specific roles are still being determined. Most patients with TED develop eye manifestations while being treated for hyperthyroidism and under the care of endocrinologists. Endocrinologists, therefore, have a key role in diagnosis, initial management, and selection of patients who require referral to specialist care. Given that the need for guidance to endocrinologists charged with meeting the needs of patients with TED transcends national borders, and to maximize an international exchange of knowledge and practices, the American Thyroid Association and European Thyroid Association joined forces to produce this consensus statement.

Management of thyroid eye disease: a Consensus Statement by the American Thyroid Association and the European Thyroid Association

Thyroid eye disease (TED) remains challenging for clinicians to evaluate and manage. Novel therapies have recently emerged, and their specific roles are still being determined. Most patients with TED develop eye manifestations while being treated for hyperthyroidism and under the care of endocrinologists. Endocrinologists, therefore, have a key role in diagnosis, initial management, and selection of patients who require referral to specialist care. Given that the need for guidance to endocrinologists charged with meeting the needs of patients with TED transcends national borders, and to maximize an international exchange of knowledge and practices, the American Thyroid Association and European Thyroid Association joined forces to produce this Consensus Statement.

Hyaluronic acid gel injection for dysthyroid upper eyelid retraction in Asian patients

PURPOSE

To evaluate the role of hyaluronic acid (HA) filler injection in the management of upper eyelid retraction (UER) in thyroid eye disease (TED).

METHODS

Retrospective interventional series of all patients with TED who had undergone HA injection, from February 2011 to April 2013 by a single surgeon (Y-DK) in a tertiary medical institution. Outcome measures: Mean margin reflex distance 1 (MRD1) pre- and post-filler.

RESULTS

There was a total of 13 patients and 17 eyes included in the study. The injection dosage for 15 eyes was 0.5 ml, one patient had 0.35cc on the right eye and 0.65cc on the left eye. Mean MRD1 at presentation was 6.21 mm. There was a mean decrease in MRD1 of 2.01 mm (p < .001) at 1 month post filler, 2.06 mm (p < .001) at 6 months post filler and 2.61 mm (p < .001) at 1 year post filler. There was no correlation between pre-filler MRD1 and change in MRD1 at various time points post-filler, nor any correlation between pre-filler upper scleral show (USS) and change in USS post-filler. There was also no correlation found between clinical activity score (CAS) and change in MRD1, as well as duration of thyroid eye disease (TED) and change in MRD1. Complications included mild upper lid lumpiness on downgaze (n = 4, 23.5%) which improved but persisted with time. There were no untoward intravascular or vision-threatening complications.

CONCLUSION

Transconjunctival HA injection is an effective treatment option for TED-related UER in both active and inactive TED patients in an East Asian population, with a potentially long-lasting effect.

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.

A survey of current practices by the British Oculoplastic Surgery Society (BOPSS) and recommendations for delivering a sustainable multidisciplinary approach to thyroid eye disease in the United Kingdom

Background

The Royal College of Physicians (RCP) and Thyroid Eye Disease Amsterdam Declaration Implementation Group (TEAMeD-5) have the common goal of improving access to high quality care for thyroid eye disease (TED). The TEAMeD-5 programme recommends all patients with moderate-to-severe TED should have access to multidisciplinary clinics (MDT)  with combined Ophthalmology and Endocrinology expertise.

Methods

The British Oculoplastic Surgery Society represents oculoplastic surgeons who usually lead TED care in the UK. A two-stage survey of the membership was conducted to ascertain current practice of existing resources.

Results

Seventy percent (45/65) of respondents in Survey 1 were aware of current RCP guidance, but only 49% (22/45) rated it as a good means of improving access to comprehensive TED service. Sixty percent (39/65) of respondents are working in a multidisciplinary TED clinic with co-location of ophthalmologists and endocrinologists. Care for TED appears not to be provided in a multidisciplinary context in up to 31% (20/65). Thirty five (54%) of the respondents rated their relationship with endocrinology colleagues as good. Best practice guidelines recommend routine quality of life assessments but only 6/28 (21%) of respondents use this modality in current practice. Six percent (4/65) of areas appear not to be using intravenous steroids. In many areas (25%, 16/65), second-line immunosuppression is provided in a different trust and in 8% (5/65), it appears not to be used at all.

Conclusion

This survey is a ‘snapshot’ of current TED management in the UK and findings suggest scope for improvement. We recommend a framework for more robust collaboration across specialties and propose standards endorsed by multidisciplinary stakeholder societies.

Course of upper eyelid retraction in thyroid eye disease

AIMS

To evaluate the natural course of upper eyelid retraction (UER) in patients with thyroid eye disease (TED) and factors affecting its course.

METHODS

Retrospective non-interventional cohort study in a single tertiary institution from March 2006 to March 2015 on patients with TED with (1) unilateral or bilateral UER within 6 months from initial presentation, and (2) no prior interventions nor surgical treatment for their UER. Main outcomes and measures were mean margin reflex distance 1 (MRD1) and factors associated with UER improvement.

RESULTS

There were a total of 61 patients and 81 eyes (41 unilateral and 20 bilateral UER). Mean age was 42.3±15.1 years. Mean MRD1 decreased from 6.1 mm at presentation to 4.8 mm at 12 months, and 4.4 mm at 24 months. The proportion of eyes with normalisation of lid height increased from 0% at presentation to 22.2% at 6 months, 37.0% at 12 months and 49.4% at 24 months. Mean time to normalisation of MRD1 was 18.0±12.4 months. A positive family history of TED was found to be associated with a 6.2 times lower likelihood of normalisation. Change in exophthalmometry, clinical activity score and thyroid-stimulating immunoglobulin were significantly correlated to change in MRD1 (p<0.05). There was no correlation between change in MRD1 and thyroid-stimulating hormone receptor antibodies.

CONCLUSION

An improved knowledge of the natural history of UER in TED will allow us to better decide and evaluate the optimal management for such patients.