Repeated peribulbar injections of triamcinolone acetonide: a successful and safe treatment for moderate to severe Graves' ophthalmopathy

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.

A controlled clinical study on efficacy and safety of periocular triamcinolone acetonide injection for treating ocular myasthenia gravis

OBJECTIVE

To evaluate the efficacy and safety of peribulbar triamcinolone acetonide injection for treating ocular myasthenia gravis (OMG), with a comparison of traditional oral drug therapy.

METHODS

A total of 22 patients with OMG who received periocular triamcinolone acetonide injection (initially 20 mg weekly, then once per month later if symptoms were improved) from July 2019 to July 2022 were evaluated by a comparison of symptom degree before and after treatment. Adverse reactions were also monitored during the period of treatment. The period of follow-up was more than 6 months. Additionally, a comparison of the treatment efficacy between this periocular injection and traditional oral administration was performed in OMG patients.

RESULTS

After 4 weeks of treatment, the degree of ptosis in OMG patients decreased to -3.00 ± 0.69, compared to the value (-0.86 ± 1.32) before treatment. The degree of ophthalmoplegia also decreased from 3.12 ± 0.72 to 0.86 ± 0.88 (P < 0.001) after treatment. The achievement rates of minimal manifestations status (MMS)for ptosis and ophthalmoplegia after 4 week-treatment were 86.3% and 75%, respectively, while they were 50% and 30% in patients with traditional oral administration. There was statistically significant difference only in MMS (rather than symptom relief rate and generalization conversion rate) between two groups. No serious complications (except for intraorbital hematoma) were found in OMG patients during the treatment period.

CONCLUSION

Repeated peribulbar injection of triamcinolone acetonide can effectively alleviate the initial symptoms of OMG patients. However, the evaluation of its long-term efficacy is still needed.

CLINICAL TRIAL REGISTRY

This study has been clinically registered by Chinese Clinical Trial Registry (ChiCTR), first trial registration date:05/07/2019, registration number: ChiCTR1900024285.

Orbital corticosteroid injections for the treatment of active thyroid eye disease

Purpose

To study the efficacy of orbital injections of triamcinolone acetonide mixed 1:1 with dexamethasone in the treatment of active thyroid eye disease.

Methods

Patients that received orbital injection(s) of triamcinolone acetonide mixed 1:1 with dexamethasone for thyroid eye disease were included in this retrospective study. Demographic and clinical data were collected from the pre-treatment and 1 month follow up evaluations. Clinical data included subjective pain and diplopia scores, best-corrected visual acuity, Intraocular pressure, extraocular motility, clinical activity score, Hertel exophthalmometry, and upper eyelid margin to reflex distance.

Results

Fifteen patients, 33 orbital injections, were included in the study. The average patient age was 59.2 years (SD ± 13.0) and 89% female. Subjectively, 67% of patients reported improvement of orbital pain and pressure versus 28% stable and 5% worse (p <0.001). Post-procedure clinical activity score decreased from 3.84 to 3.00 (p = 0.0004). There were no significant differences in upper eyelid margin to reflex distance (4.1 ± 1.4 mm vs. 4.3 ± 2.6 mm, p = 0.45), Hertel exophthalmometry (21.7 ± 9.4 mm vs. 21.8 ± 7.6 mm, p = 0.56), or extraocular motility (21% improved vs. 72% stable and 7% worsening, p = 0.50). No steroid-responsive increases in intraocular pressure or injection-related complications were reported.

Conclusion

Orbital steroid injections can successfully reduce symptoms of TED and may be a reliable tool in the treatment of TED as a relatively safe, fast-acting, efficacious treatment option, particularly as a bridge to other therapies.

Periocular methotrexate versus periocular triamcinolone injections for active thyroid-associated orbitopathy: a randomized clinical trial

PURPOSE

To assess the efficacy and safety of periocular injections of methotrexate versus triamcinolone in the management of active thyroid-associated orbitopathy.

STUDY DESIGN

Prospective, double-masked, randomized clinical trial.

METHODS

Participants with bilateral active, moderate-to-severe thyroid-associated orbitopathy were randomly assigned to receive three periocular injections of 7.5 mg methotrexate in one orbit and three periocular injections of 20 mg triamcinolone in the contralateral orbit.

RESULTS

Among the enrolled 25 patients, 18 patients completed the study. A statistically significant reduction of the mean clinical activity score was detected in both arms (from 5.2 ± 0.89 at baseline to 0.9 ± 1.7 at study endpoint, p-value < 0.001 in the methotrexate arm, and from 5.1 ± 0.9 at baseline to 1 ± 1.7 at study endpoint, p-value < 0.001 in the triamcinolone arm), mean proptosis also decreased in both arms (from 25.2 ± 3.4 mm at baseline to 23.8 ± 3.7 mm at study endpoint, p-value = 0.01 in the methotrexate arm, and from 24.2 ± 3.06 mm at baseline to 23.2 ± 3.3 mm at study endpoint, p-value = 0.049 in the triamcinolone arm). Lid aperture and soft tissue signs improved significantly in both arms in comparison to baseline. A statistically significant reduction in the intraocular pressure was observed in the methotrexate arm but not in the triamcinolone arm. 88.9% of patients in both arms were overall responders at 6 months. There was no significant difference in mean CAS, proptosis, lid aperture or rate of responders between the two arms at any visit. Both drugs were found to be safe with minimal local and systemic complications.

CONCLUSION

Periocular injections of methotrexate represent an effective and safe alternative option for the management of active, moderate-to-severe thyroid-associated orbitopathy. Although no serious complications occurred during the 6-month follow-up, the possibility of late complications such as orbital fat atrophy cannot be ruled out.

Predictive Modeling of New-Onset Postoperative Diplopia Following Orbital Decompression for Thyroid Eye Disease

PURPOSE

To identify risk factors for the development of new-onset, postoperative diplopia following orbital decompression surgery based on patient demographics, clinical exam characteristics, radiographic parameters, and surgical techniques.

METHODS

We conducted a multi-center retrospective chart review of patients who underwent orbital decompression for thyroid eye disease (TED). Patient demographics, including age, gender, smoking history, preoperative exophthalmometry, clinical activity score (CAS), use of peribulbar and/or systemic steroids, and type of orbital decompression were reviewed. Postoperative diplopia was determined at a minimum of 3 months postoperatively and before any further surgeries. Cross-sectional area ratios of each extraocular muscle to orbit and total fat to orbit were calculated from coronal imaging in a standard fashion. All measurements were carried out using PACS imaging software. Multivariable logistic regression modeling was performed using Stata 14.2 (StataCorp, College Station, TX).

RESULTS

A total of 331 patients without preoperative diplopia were identified. At 3 months postoperatively, 249 patients had no diplopia whereas 82 patients developed diplopia. The average postoperative follow-up was 22 months (range 3-156) months. Significant preoperative clinical risk factors for postoperative diplopia included older age at surgery, proptosis, use of peribulbar or systemic steroids, elevated clinical activity score, and presence of preoperative compressive optic neuropathy. Imaging findings of enlarged cross-sectional areas of each rectus muscle to the overall orbital area also conferred a significant risk of postoperative diplopia. Regarding surgical factors, postoperative diplopia was more common among those undergoing medial wall decompression, bilateral orbital surgery, and balanced decompression, whereas endoscopic medial wall decompression was found to be relatively protective.

CONCLUSIONS

This study identifies risk factors associated with the development of diplopia following orbital decompression using multivariable data. This study demonstrates that several characteristics including age, clinical activity score, the cross-sectional muscle to orbit ratios, in addition to the type of orbital decompression surgery, are predictive factors for the development of new-onset postoperative diplopia.

Drug safety in thyroid eye disease - a systematic review

INTRODUCTION

The autoimmune-induced thyroid eye disease (TED) is a frequent extrathyroidal manifestation of Graves' disease and less frequently of Hashimoto's thyroiditis. Pathognomonic clinical signs, i.e. exophthalmos, double vision, and inflammation of the orbital tissue cause physical, ophthalmic, and socio-psychological limitations.

AREAS COVERED

PubMed and MeSH database were searched for specific guidelines, randomized controlled trials, prospective clinical studies, systematic reviews and meta-analyses pertaining to the safety profile of currently administered immunosuppressive agents for the treatment of TED. Occurred adverse events (AE), severe AE (SAE), side effects (SE), and severe SE (SSE) were classified according to the standardized medical dictionary for regulatory activities (MedDRA).

EXPERT OPINION

This novel systematic analysis offers an overview of potential AE, SAE and SE for currently recommended immunosuppressive drugs for the treatment of TED. Non-specific, anti-inflammatory drugs and more specific, targeted biologicals are treatment options for active and severe TED. Critical evaluation of the pertinent literature confirms an evidence-based, beneficial efficacy/risk ratio of the current first-line and second-line treatment recommendations endorsed by the European Society of Endocrinology. However, further large, well-conceived trials are mandatory to enhance our knowledge and experience with novel specific small molecules and/or monoclonal antibodies targeting the key autoantigens in TED.

Botox-A improve the thyroid-associated ophthalmopathy (TAO) orbital fibroblast activation through inhibiting the TGF-β/Smad signaling

The activation of orbital fibroblasts can result in fibrosis, finally contributing to thyroid-associated ophthalmopathy (TAO) progression. Although the effect of BTX-A on the treatment of TAO-related strabismus and upper eyelid retraction has long been recognized in clinical work, the underlying mechanism of BTX-A improving TAO-related strabismus and upper eyelid retraction has not been uncovered yet. In the present study, we successfully isolated and authenticated normal and TAO orbital fibroblasts. Compared with PBS, BTX-A and TACA exerted similar inhibitory effects on TAO orbital fibroblast proliferation and ECM production. TGF-β stimulation induced the proliferation and ECM production by TAO orbital fibroblast, which was significantly inhibited by BTX-A or TACA treatment. Under TGF-β stimulation, the inhibitory effects of BTX-A or TACA treatment on TAO orbital fibroblast proliferation and ECM production were reversed by TGF-β/Smad signaling agonist SRI-011381. Collectively, BTX-A inhibited TGF-β-induced TAO orbital fibroblast activation through inhibiting the TGF-β/Smad signaling. Considering that TACA shows no satisfactory curative effects on symptoms closely related to the function of extraocular muscles, such as eye movement and diplopia, BTX-A might be a promising agent in TAO treatment.

Fungal abscess after intra-orbital steroid injection: a case report

A 28-year-old male presented with gradually progressive swelling of the right lower eyelid along with a prominence of the eye for 6 months. He had received oral steroids and intraorbital triamcinolone acetonide injection in the inferior quadrant for active thyroid eye disease. External examination revealed right eye proptosis and swelling along the inferior orbital region. Magnetic resonance imaging showed an ill-defined soft tissue lesion in the inferior extraconal space and a bulky right inferior rectus. Histopathology of the biopsied material revealed inflammation with septate fungal filaments, identified as Aspergillus flavus on culture. He responded well to oral voriconazole despite a recurrence during the course of treatment. Intraorbital steroids are given for idiopathic and thyroid-associated orbital inflammation. This is a report of a rare complication of fungal orbital abscess following intraorbital corticosteroid injection in an immunocompetent young patient.

Sight-Threatening Graves' Ophthalmopathy during the Third Trimester of Pregnancy: A Case Report

Dysthyroid optic neuropathy is a severe manifestation of Graves' ophthalmopathy that can result in permanent vision loss. We report a 37-year-old pregnant woman with Graves' ophthalmopathy which was deteriorated to dysthyroid optic neuropathy in the third trimester of pregnancy. Diplopia, bilateral eye lid retraction, lid edema and proptosis were observed in the 29th week of gestation. Thyroid-stimulating hormone (TSH) level was decreased with a normal level of free triiodothyronine (FT3) and an upper normal level of free thyroxine (FT4). Anti-TSH receptor antibodies (16.2 IU/L, reference range < 2.0 IU/L) and thyroid stimulating antibody (4,443%, reference range < 120%) were positive. Magnetic resonance imaging (MRI) demonstrated a significant enlargement of the extraocular muscles with a high signal intensity on T2-weighted image. She was diagnosed as Graves' ophthalmopathy and subclinical hyperthyroidism, and followed without treatment. In the 34th week of gestation, the symptom of color vision abnormality appeared, suggesting dysthyroid optic neuropathy. She delivered a female infant during the 36th week of gestation. Four days after delivery, she had a spontaneous orbital pain. MRI showed that the extraocular muscles were more enlarged than the findings in the 29th week of gestation. FT3 and FT4 levels were mildly elevated. Dysthyroid optic neuropathy was diagnosed. She was treated with methylprednisolone pulse therapy and retrobulbar injections of betamethasone valerate, and the ocular symptoms improved. The present case shows that the glucocorticoid therapy performed one week after delivery is effective against Graves' ophthalmopathy which was deteriorated to dysthyroid optic neuropathy during the third trimester of pregnancy.

Treatment of Graves' ophthalmopathy

Graves' ophthalmopathy is an inflammatory disease with primary involvement of the extraocular muscles and the orbit. It encompasses the most common extra-thyroid manifestation in patients with Graves-Basedow disease. The underlying cause is molecular mimicry with the TSH receptor in ocular fibroblasts, leading to an immuno-mediated pathogenesis. Glucocorticoids at high doses are the cornerstone in moderate-severe cases. However, some patients are corticorresistant or intolerant. In recent years, therapeutic novelties have been described in terms of the dosage of the immunosuppressive treatments used, as well as the emergence of biological therapy in this field. The objective of this review is to update the treatment of Graves' ophthalmopathy, as well as to present alternative options in patients resistant or intolerant to glucocorticoids.

Local delivery of corticosteroids in clinical ophthalmology: A review

Locally administered steroids have a long history in ophthalmology for the treatment of inflammatory conditions. Anterior segment conditions tend to be treated with topical steroids whilst posterior segment conditions generally require periocular, intravitreal or systemic administration for penetration. Over recent decades, the clinical applications of periocular steroid delivery have expanded to a wide range of conditions including macular oedema from retino-vascular conditions. Formulations have been developed with the aim to provide practical, targeted, longer-term and more efficacious therapy whilst minimizing side effects. Herein, we provide a comprehensive overview of the types of periocular steroid delivery, their clinical applications in ophthalmology and their side effects.

Intraorbital Steroid Injection for Active Thyroid Ophthalmopathy

Purpose

To evaluate the effect of orbital steroid injections in patients with active thyroid ophthalmopathy resistant to or dependent on systemic steroids, or with complications related to systemic steroid use.

Methods

This prospective non-comparative case series includes 31 eyes of 17 patients with active thyroid ophthalmopathy and clinical activity score (CAS) of 3 or more, without compressive optic neuropathy or overt exposure keratopathy. All subjects had a history of previous systemic steroid use (with steroid resistance or dependence) or had developed complications related to steroids. A combination of steroids including triamcinolone acetonide 20 mg and dexamethasone 4 mg was injected in the upper and lower retroseptal orbital spaces three or four times at one-month intervals. The patients were examined periodically after each injection and at least three months after the last injection.

Results

Mean pre-injection CAS was 5.2 ± 1.3 which was improved to 1.6 ± 1 after the fourth injection (P< 0.001). Upper and lower lid retraction improved in 100% and 68.2% of the affected eyes, respectively. Strabismus completely resolved in one of five affected patients and the most significant improvement was observed in supraduction. Mean improvement in exophthalmos was 1.2 ± 1.1 mm. Visual acuity did not significantly change after the injections. Eyelid ecchymosis and/or subconjunctival hemorrhage was observed in 7.1% and intraocular pressure rise occurred in 8.8% of eyes.

Conclusion

Orbital steroid injections can be used for the treatment of active thyroid ophthalmopathy when the patient is resistant to or dependent on systemic steroids or has developed complications of systemic steroids.

Glucocorticoids in Graves' orbitopathy: mechanisms of action and clinical application

BACKGROUND

Graves' orbitopathy (GO) is the most frequent extrathyroidal manifestation of the autoimmune Graves' disease. GO significantly impacts quality of life and has a psycho-social morbidity. Inflammation and swelling of the orbital tissue often leads to proptosis, diplopia, and decrease of visual acuity. Due to the inflammatory background of the disease, glucocorticoids (GC) have been used as a first-line treatment for decades.

METHODS

PubMed and MeSH database were searched for original articles, clinical trials, reviews, and meta-analyses published between 1 January 2000 and 31 March 2020 and pertaining to both the mechanism of action and immunological effects of GC as well as to the treatment of GO by GC. The publications were evaluated according to their setting and study design.

RESULTS

GC act through genomic (trans-activation and trans-repression) and rapid non-genomic mechanisms. GC in general, and the intravenous (IV) administration of GC in particular, markedly decrease the activity and number of the most potent antigen-presenting dendritic cells. According to the internationally acknowledged European Thyroid Association Guidelines for the management of GO, weekly IVGC application over 12 weeks is recommended as first-line treatment for patients with active and severe GO. The daily and cumulative dose should be tailored according to clinical severity, for example, 4.5 g of IV methylprednisolone for the inflammatory component versus 7.5 g in the presence of diplopia and severe proptosis. Fast and significant improvements in orbital symptoms and signs are noted in 65-70% of patients. Long-term experience over decades, and worldwide availability at low cost, underline the clinical and therapeutic relevance of GC. Adverse events are rarely severe, dose-dependent, and usually reversible, hence easy to handle by medical investigators. Oral GC application on a daily basis is characterized by high bioavailability but reduced efficacy and increased toxicity.

CONCLUSION

IVGC still represents the standard of care in active/severe GO. Innovative biologicals, like monoclonal antibodies targeting the thyrotropin/Insulin-like growth factor-1 receptors or pro-inflammatory cytokines (e.g., Interleukin-6) should be compared with standard GC treatment with respect to short- and long-term efficacy, safety, costs, and global availability.

Life-threatening complications of high doses of intravenous methylprednisolone for treatment of Graves' orbitopathy

Background

Treatment of moderate to severe Graves' orbitopathy (GO) is based mainly on intravenous pulses of methylprednisolone. High doses of methylprednisolone can exert several adverse effects, some of which might be life-threatening. The objective of this study is to describe the most severe complications associated with intravenous administration of high doses of glucocorticoids, and to develop the patient examination standards prior to their qualification for the therapy.

Main body

In this paper, we describe the most severe, life-threatening complications of intravenous methylprednisolone and address their possible underlying mechanism. We also present recommendations and precautions which should be taken prior to initiation of intravenous pulses of methylprednisolone treatment for GO. To address risk of hepatic complications, we recommend regular monitoring of biochemical parameters of hepatic function. Additionally, assessment of the risk of cardiovascular events should be undertaken based on medical history, estimation of risk factors, and investigations, such as determination of thyroid hormones and thyroid-stimulating hormone levels, electrolyte and glucose concentrations, electrocardiogram examination and measurements of blood pressure.

Conclusions

An individualized safe and effective dose of intravenous methylprednisolone should be established for each patient with GO based on the vascular risk factors, comorbidities, and concomitant drugs. According to the European Group on Graves' Orbitopathy (EUGOGO) guidelines, cumulative doses of intravenous methylprednisolone should not exceed 8 g.

99mTc-DTPA SPECT/CT provided guide on triamcinolone therapy in Graves' ophthalmopathy patients

INTRODUCTION

Distinguishing between the active and inactive stages of Graves' ophthalmopathy (GO) is essential for making treatment decisions. 99mTc-DTPA SPECT/CT is sensitive in identifying inflammation in extraocular muscles of GO patients, which we designate 99mTc-DTPA-active. This study aimed to evaluate the response of 99mTc-DTPA-active GO patients to local immunosuppressive therapy.

MATERIALS AND METHODS

Sixty-four 99mTc-DTPA-active GO patients (89 eyes) were retrospectively analyzed. Forty-five patients (64 eyes) received repeated peribulbar triamcinolone injection, and 19 patients (25 eyes) received no immunosuppressive treatment. Ophthalmological assessment, including clinical activity score, eyelid retraction, eyelid aperture, proptosis, diplopia, and ocular mobility, was recorded before and after treatment.

RESULTS

Compared with untreated patients, the clinical activity score decreased significantly (P  < 0.001) while eye symptoms (soft-tissue swelling and eyelid retraction and aperture) improved significantly (P  = 0.02, P  < 0.001, P  < 0.001, respectively) in treated patients after six months. The inferior and medial recti were significantly smaller (P  < 0.001, P  < 0.001, respectively), and 99mTc-DTPA uptake in the two recti was significantly less (P  = 0.001, P  = 0.01, respectively) in treated patients than in untreated patients after 3 months.

CONCLUSION

Clinical activity score of < 3 does not indicate inactive GO, as revealed with 99mTc-DTPA SPECT/CT. Patients with 99mTc-DTPA-active GO can improve the symptoms with peribulbar triamcinolone injection.

Comparative Efficacy of Medical Treatments for Thyroid Eye Disease: A Network Meta-Analysis

Purpose

Numerous medical strategies have been proposed for the treatment of thyroid eye disease (TED); however, the best methods for standard treatment are still a matter of controversy. The purpose of this network meta-analysis was to integrate previous evidence to create hierarchies of comparative efficacy of eleven commonly used medical treatments for TED.

Methods

A comprehensive search of electronic scientific literature databases was performed and the data from randomized controlled trials (RCTs) comparing treatment outcomes for patients with active TED were selected. Treatment strategies included in this network meta-analysis were intravenous glucocorticoids (IVGC), oral glucocorticoids (OGC), orbital injection of glucocorticoids (OIGC), orbital radiotherapy (OR), intravenous glucocorticoids combined with orbital radiotherapy (IVGC + OR), oral glucocorticoids combined with orbital radiotherapy (OGC + OR), rituximab (RTX), somatostatin analogs, intravenous immunoglobulin (IVIG), teprotumumab, and cyclosporine. The outcomes were response rate, mean difference in proptosis reduction, and reduction in disease activity. A random-effects network meta-analysis using a frequent method was conducted in STATA.

Results

Twenty-three studies comprising a total of 1047 patients were included in the analysis. Inconsistency plots showed heterogeneity in the IVGC-Placebo-RTX loop to some extent (RoR = 8.029, P=0.075). Rankings of response rates were as follows: IVGC + OR, teprotumumab, IVGC, OGC + OR, RTX, OIGC, OR, IVIG, OGC, somatostatin, placebo, and cyclosporine. The rank probability analysis of proptosis reduction showed that teprotumumab was the most effective, followed by IVGC, IVGC + OR, OIGC, OGC, OGC + OR, OR, somatostatin, cyclosporine, and placebo.

Conclusions

IVGC, alone or combination with OR, and teprotumumab should be preferred as the most effective strategies for active moderate to severe TED. Teprotumumab showed profound effect on proptosis reduction. OIGC, OR, and somatostatin analogs showed some statistical benefit and can be employed as second-line treatment strategies. RTX is a promising biologic agent, but more RCTs are required to define its appropriate role in treating TED.

Orbital Decompression for Thyroid-Related Orbitopathy During the Quiescent Phase

PURPOSE

To describe historical and modern surgical approaches to orbital decompression in patients with thyroid-related orbitopathy in the quiescent phase.

METHODS

A literature review of published techniques using the National Institutes of Health PubMed database.

RESULTS

Historically, orbital decompression has been accomplished via transantral, transcranial, transnasal, and orbital approaches. Current techniques use predominately periocular incisions to achieve effective decompression and proptosis reduction. Based on exophthalmometry and desired proptosis reduction, the authors propose a graded surgical approach to decompression for thyroid orbitopathy beginning with fat reduction, followed by deep lateral orbit via a superior eyelid crease incision, then medial wall by retro-caruncular approach, then posterior medial orbital floor either via transconjunctival or swinging eyelid approach, and finally with lateral orbital rim removal by superior eyelid crease incision as needed. These approaches can result in a range of proptosis reduction of up to 10 mm.

CONCLUSIONS

A structured approach to orbital decompression results in predictable and effective outcomes in proptosis reduction.

Embolic retinal and choroidal vascular occlusion after peribulbar triamcinolone injection: A case report

RATIONALE

Retinal and choroidal vascular occlusion is a vision-threatening complication of therapeutic injections in the facial region. The early identification and early treatment are necessary to reduce the risk of harm to the patient.

PATIENT CONCERNS

We report an extremely rare case of embolic retinal and choroidal vascular occlusion after peribulbar triamcinolone injection in a patient with thyroid-associated ophthalmopathy.

DIAGNOSES

Central retinal artery occlusion.

INTERVENTIONS

First, we performed a fundus examination in the patient. Triamcinolone embolus was observed in both retinal and choroidal vessels. Anterior chamber paracentesis and ocular massage combined with venous injections of alprostadil and Ginaton as well as an acupoint injection of compound anisodine were performed immediately. Sublingual glyceryl trinitrate and intraocular pressure-lowering drugs were also administered. Fundus autofluorescence, optical coherence tomography-angiography, fundus fluorescein angiography (FFA), and indocyanine green angiography (ICGA) were also conducted to evaluate the patient's condition.

OUTCOMES

One month after the onset of the situation, the triamcinolone embolus had disappeared. The retinal edema and retinal blood perfusion were also improved. The patient's visual acuity had recovered from inexact light perception to 0.02.

LESSONS

Embolic retinal and choroidal vascular occlusion is vision-threatening disease. Measures such as careful aspiration before injecting in the facial region must be taken to avoid such complications.

Common Immunosuppressive Monotherapy for Graves' Ophthalmopathy: A Meta-Analysis

Background

Several immunosuppressive therapeutic regimens are widely used to treat Graves’ ophthalmopathy (GO), including oral glucocorticoids (OGC), intravenous glucocorticoids (IVGC), retrobulbar injections of glucocorticoids (ROGC) and orbital radiotherapy (OR). The priority among these is unknown. This meta-analysis investigated the efficacy and tolerability of the above regimens.

Methods

The PubMed, EMBASE, and Cochrane Library databases and the Chinese Biomedicine Database were searched up to November 18, 2014. Randomized controlled trials (RCTs) comparing monotherapies (OGC, IVGC, ROGC and OR) in patients with moderate-to-severe active GO were selected. The main efficacy measures were the response rate, the standard mean difference (SMD) in the reduction in the clinical activity score (CAS) and the mean difference (MD) in proptosis from baseline to the end of treatment. The main tolerability measure was the risk ratio (RR) for adverse events. The pooled estimates and 95% confidence intervals (95% CIs) were calculated using the RevMan software, version 5.1.

Results

Seven published RCTs involving 328 participants were included in the present meta-analysis, including IVGC versus OGC (3 trials), ROGC versus OGC (3 trials) and OR versus OGC (1 trial). IVGC was more effective than OGC in response rate (RR = 1.48, 95% CI = 1.18–1.87) and had an obvious CAS reduction (SMD = 0.69, 95% CI = 0.13–1.25). IVGC caused fewer adverse events than OGC. ROGC and OGC had no statistically significant difference in response rate (RR = 1.16, 95% CI = 0.94–1.42). OR also did not differ significantly compared with OGC (RR = 0.93, 95% CI = 0.54–1.60). ROGC and OR had fewer adverse events, such as weight gain, compared with OGC.

Conclusions

For patients with GO in the moderate-to-severe active phase, current evidence gave priority to IVGC, which had a statistically significant advantage over OGC and caused fewer adverse events. ROGC and OR did not provide greater efficacy than OGC, although better tolerability and fewer adverse events were shown.

Treatment of severe thyroid eye disease: a survey of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS)

PURPOSE

To evaluate the current practice patterns for the treatment of severe thyroid eye disease (TED) in the United States by conducting a survey of the American Society of Ophthalmic Plastic and Reconstructive Surgery.

METHODS

This is a questionnaire study. The survey encompassed the use of different modalities, including intravenous steroids, oral steroids, orbital decompression, orbital radiation, intraorbital steroid injections, and steroid-sparing biologic agents, in the treatment of severe TED. Specifics on the dosing regimens of steroids and types of decompression used were queried.

RESULTS

With regard to treatments used "at all" in the management of severe TED, 87% use oral steroids and 74% use intravenous steroids. Eighty-three percent use orbital decompression, 70% use radiation, 33% use biologic agents, and 28% use intraorbital steroid injections. Oral steroids were slightly preferred to intravenous steroids at 43% versus 40% for first-line treatment. Most responders (61%) chose 2-wall decompression as their preferred technique.

CONCLUSIONS

Severe TED can be a devastating disease leading to diplopia and vision loss. Treatment recommendations have varied and continue to evolve. The survey reported herein found that oral steroids were slightly preferred over intravenous steroids by the members of the American Society of Ophthalmic Plastic and Reconstructive Surgery, most of who practice in the United States. This is in contrast to survey results from European and Latin American physicians, which more strongly favored intravenous steroids. In addition, orbital decompression and orbital radiation still play significant roles in the management of severe TED.

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.

Repeated triamcinolone acetonide injection in the treatment of upper-lid retraction in patients with thyroid-associated ophthalmopathy

OBJECTIVE

To evaluate the efficacy and safety of repeated subconjunctival injections of triamcinolone in the treatment of upper-lid retraction with thyroid-associated ophthalmopathy.

DESIGN

Interventional controlled retrospective clinical study.

PARTICIPANTS

We studied 23 eyes in 15 patients as the nontreatment control group and 35 eyes in 21 patients as the treatment group.

METHODS

In the treatment group, triamcinolone acetonide was subconjunctivally injected into each lid as 4 doses of 20 mg at 1-month intervals. After the treatment, the eyes were divided into 2 groups, response and nonresponse, based on the improvement in margin reflex distance. The eyes of the nontreatment group received no medicine. The eyes were examined regularly.

RESULTS

The rate of spontaneous improvement in the nontreatment group was 17.4%. The mean rate of effectiveness was 68.6%. The improvement of upper-lid retraction was 2.31 mm (0 to 7 mm). The margin reflex distance was significantly smaller at 1 month after the initiation of treatment. Mean lid retraction time before treatment was 4.58 months in the response group versus 9.91 months in the nonresponse group. In the eyes presenting upper-lid retraction up to 6 months before treatment was initiated, the response rate was 83.3%. The response rate was only 36.4% when lid retraction developed more than 6 months before the procedure. The muscle thickness of the levator/superior rectus complex was significantly reduced after treatment in the response group (5.13 ± 0.85 mm at last follow-up vs. 5.69 ± 0.93 mm at baseline).

CONCLUSIONS

Repeated subconjunctival injection of triamcinolone is an effective and safe treatment for upper-lid retraction due to thyroid-associated ophthalmopathy.

Medical management of thyroid eye disease

Thyroid eye disease (TED) is the most common cause of orbital disease in adults. The immunologic pathogenesis of TED has been an area of active research and considerable progress has resulted in an expansion of therapeutic options. Although surgical intervention may be required, a majority of TED patients can be managed with medical therapies. Of medical therapies, glucocorticoids remain the agent of choice in the control of TED activity. The objective of this review is to discuss the paradigm and options in medical management of TED.

Orbital steroid injection versus oral steroid therapy in management of thyroid-related ophthalmopathy

BACKGROUND

The aim of this study was to evaluate the efficacy, safety and complications of orbital steroid injection versus oral steroid therapy in the management of thyroid-related ophthalmopathy.

METHODS

A total of 29 patients suffering from thyroid ophthalmopathy were included in this study. Patients were randomized into two groups: group I included 15 patients treated with oral prednisolone and group II included 14 patients treated with peribulbar triamcinolone orbital injection. Only 12 patients in both groups (16 female and 8 male) completed the study.

RESULTS

Both groups showed improvement in symptoms and in clinical evidence of inflammation with improvement of eye movement and proptosis in most cases. Mean exophthalmometry value before treatment was 22.6 ± 1.98 mm that decreased to 18.6 ± 0.996 mm in group I, compared with 23 ± 1.86 mm that decreased to 19.08 ± 1.16 mm in group II. Mean initial clinical activity score was 4.75 ± 1.2 and 5 ± 1.3 for group I and group II before treatment, respectively, which dropped to 0.83 ± 1.2 and 0.83 ± 1.02, 6 months after treatment, respectively. There was no change in the best-corrected visual acuity in both groups. There was an increase in body weight, blood sugar, blood pressure and gastritis in group I in 66.7%, 33.3%, 50% and 75%, respectively, compared with 0%, 0%, 8.3% and 8.3% in group II. No adverse local side effects were observed in group II.

CONCLUSION

Orbital steroid injection for thyroid-related ophthalmopathy is effective and safe. It eliminates the adverse reactions associated with oral corticosteroid use.

Hyperthyroidism, exophthalmos, and goiter: historical notes on the orbitopathy

BACKGROUND

Exophthalmos associated with goiter and/or symptoms of hyperthyroidism have been known since antiquity. It was not until around 1800 that a number of studies described this disorder in more detail.

SUMMARY

For many years the nature of the disease remained unclear and it was appreciated as either a cardiac or neurological disease. There was no agreement on treatment. Surgery on the thyroid, orbit, autonomous nerve system, and pituitary has been employed. Medical treatment was introduced around World War II. Later, as a consequence of the discovery of long-acting thyroid stimulator, it became apparent that Graves-Basedow's disease was an autoimmune disease and so was the exophthalmos, though many details of the pathophysiology remain in doubt.

CONCLUSIONS

This article presents a brief review of the history of the exophthalmos associated with thyroid disease.

Systemic absorption of triamcinolone acetonide after posterior sub-Tenon injection

PURPOSE

To study systemic absorption of triamcinolone acetonide (TA) after posterior sub-Tenon injection.

DESIGN

Prospective, interventional case series.

METHODS

The study was conducted in a tertiary care teaching hospital on 35 eyes in which posterior sub-Tenon injection of 40 mg TA was administered after conventional extracapsular cataract extraction. Patients who had received any systemic steroid over 6 weeks preceding the period of study or had inflammatory ocular conditions were excluded. Serum TA levels were estimated by high-performance liquid chromatography at 1, 2, 3, 24, and 48 hours and 1, 2, and 6 weeks after injection.

RESULTS

Significant levels of the drug were detected in 45.71% of samples (mean serum levels, 6.94 +/- 8.98 ng/ml; P < .001) at 1 hour after sub-Tenon injection, in 85.71% of samples (mean serum levels, 21.83 +/- 12.92 ng/ml; P < .001) at 2 hours after injection, in 100% of samples (mean serum levels, 47.14 +/- 12.20 ng/ml; P < .001) at 3 hours after injection, in 100% of samples (mean serum levels, 35.49 +/- 13.79 ng/ml; P < .001) at 24 hours after injection, in 62.86% of samples (mean serum levels, 10.46 +/- 10.69 ng/ml; P < .001) at 48 hours after injection, and in 28.57% of samples (mean serum levels, 3.74 +/- 6.45 ng/ml; P = .002) at 1 week after injection. The drug was not detected in any of the samples obtained 2 weeks and 6 weeks later.

CONCLUSIONS

Posterior sub-Tenon injection of 40 mg TA adds statistically significant quantities to physiologic concentration of corticosteroids in peripheral blood. This may be detrimental for patients having certain metabolic diseases like diabetes and preferably should be avoided or administered with caution.