Peri‐levator palpebrae superioris triamcinolone injection for the treatment of thyroid eye disease‐associated upper eyelid retraction

Upper eyelid retraction is the most common presenting sign in patients with thyroid eye disease (TED). The aetiology of eyelid retraction is controversial and likely multifactorial. Upper eyelid retraction can be attributed to overaction, contraction and fibrosis of the levator palpebrae superioris (LPS) muscle and Müller’s muscle, as well as scarring and/or inflammation of the septum and anterior lamella. Additionally, the LPS/superior rectus (LPS/SR) muscle complex may over-contract to compensate for a restrictive process involving the inferior rectus muscle. Clinically, upper lid retraction may result in lagophthalmos and exposure keratopathy, a known indication for surgical intervention in TED. Furthermore, patients with upper eyelid retraction are frequently concerned with the change in their physical appearance, which has psychosocial implications and can affect their quality of life. Management of upper eyelid retraction in patients with active TED is somewhat limited and typically includes the use of frequent ophthalmic lubricants or eyelid taping. Surgical management is reserved for patients with vision-threatening complications or those in the fibrotic phase of the disease seeking rehabilitative surgery. Surgical correction of upper lid retraction is relatively complex with difficult to predict outcomes. The use of subconjunctival botulinum toxin to the upper eyelid has been reported but is both costly and may be less effective in the congestive phase of TED. Recent reports of subconjunctival corticosteroid injections have shown to be effective in reducing upper lid retraction, especially in patients in the congestive phase of TED. Given the histopathological changes found within the LPS/SR muscle complex, the authors propose a modified technique of injecting tiramcinolone around the involved LPS muscle complex in patients in with TED-associated upper eyelid retraction. In our technique, the eyelids are prepped with 5% povidone-iodine. A 50:50 mixture of triamcinolone acetonide (40 mg/mL) and 1% lignocaine with 1:100 000 adrenaline is prepared. A total of 2 mL of the solution is injected using a 25-g, 1.5-inch needle. A tongue depressor or Jaeger lid plate is used to displace the globe inferiorly. The needle is introduced percutaneously superior to the globe and advanced to a depth of approximately 15 mm where the injection is delivered. An eye pad is then taped over the eyelid for approximately 15 min after which visual acuity is checked. Injections are repeated at 4–6-week intervals depending on clinical response. Davies and colleagues found a statistically significant increase in the mean cross-sectional area of LPS in patients with unilateral upper lid retraction, suggesting that LPS inflammation and enlargement is the primary mechanism of TED-associated upper eyelid retraction. The use of local corticosteroids for treating upper lid retraction has shown promising results using the subconjunctival route. Xu et al. reported an improvement of upper lid retraction of 2.31 mm with radiographic evidence of reduction in size of the LPS/SR muscle complex after three monthly injections. Further series have demonstrated significant improvements in upper lid retraction and lagophthalmos. Series using the subconjunctival route suggest that there is a window period for treatment response; and patients in the congestive phase respond better than those in the fribrotic stage. In our early experience, we have had patients present with early-onset upper lid retraction that have responded after a single injection (Fig. 1). Other patients with more severe retraction have required further injections. The maximum number of injections we have performed on a single patient is Figure 1. Case of a 24 year-old woman with a history of Graves’ disease presenting with 3 months of thyroid eye disease-associated upper eyelid retraction in the right eye. (a) Pre-injection marginal reflex distance in the right eye measured 8 mm. (b) Six weeks after a single triamcinolone injection to the LPS muscle complex, her marginal reflex distanc had decreased to 5 mm.