Treatment of Upper Eyelid Retraction Related to Thyroid-associated Ophthalmopathy Using Subconjunctival Triamcinolone Injections
Condition: Thyroid-associated Ophthalmopathy
MeSH terms: Eye Diseases; Graves Ophthalmopathy; Thyroid Diseases
Study type: Interventional
Phase: Phase 4

Summary: 
      Thyroid-associated ophthalmopathy (TAO) is an autoimmune process that can affect the orbital
      and periorbital tissues and the thyroid gland. Periorbital inflammation can cause swelling,
      fatty infiltration, and scarring of the eyelid muscles resulting in eyelid retraction and
      upper scleral exposure, which is the most common clinical features of TAO.Even with mild
      eyelid retraction and swelling, most patients become disappointed and depressed due to their
      cosmetically unacceptable appearance, and they are unwilling to wait for spontaneous
      resolution or a clinically inactive period for surgical intervention. Thus, most
      ophthalmologists and endocrinologists recommend surgery in the chronic burnt-out stage.
      Several treatment options have been described for correction of eyelid retraction, including
      Botox and filler injection, and surgeries in the burnt-out stage such as lowering the upper
      lid by recessing the levator muscle, excision of Müller's muscle, introducing a spacer, or
      myotomies.Surgical options have significant risks as well as an unpredictable course and
      outcome in some cases. Several authors have reported that subconjunctival botulinum toxin
      injection provides an immediate, effective treatment by reducing excessive levator function
      in patients who suffer from disfiguring eyelid appearance and do not want to wait for surgery
      for upper eyelid retraction.Botox treatment is usually temporary. However, unwanted ptosis,
      although temporary, was observed in five out of 24 patients (20.8%) in the study by Costa,
      which may be even more disappointing and cosmetically unacceptable to some patients.Recently,
      hyaluronic acid gel fillers, which were injected into the subconjunctival levator-Muller
      plane, demonstrated efficacy in managing Graves' eyelid retraction in three patients.However,
      complications such as a lumps, fluid buildup, and skin pigment darkening may occur using this
      technique.Steroid treatment represents a well-established TAO management strategy due to its
      anti-inflammatory and immunosuppressive actions. However, multiple systemic side effects such
      as diabetes, infection, hypertension, osteoporosis, and stomach ulcers are major drawbacks of
      systemic steroid treatment. Due to limitations of systemic steroid treatment, several studies
      reported TAO improvement with periorbital injections of methylprednisolone and triamcinolone,
      primarily focusing on reducing proptosis and diplopia. So far, however, only a single small
      case series study has suggested that an injection of 20 mg triamcinolone into the
      subconjunctival region of the lid, between the conjunctiva and Muller's muscle, improves
      upper eyelid retraction within 1 month in three of the four patients. The investigators are
      not aware of any study designed to demonstrate the treatment efficacy of locally administered
      triamcinolone to improve eyelid retraction and swelling in a prospective manner. Therefore,
      we aimed to evaluate both the short-term and long-term effects of subconjunctival
      triamcinolone injections in treating eyelid retraction and inflammatory swelling caused by
      TAO.
    


Intervention name(s): subconjunctival triamcinolone injection
Intervention type(s): Drug
Intervention description(s): Patients are randomized into two groups: Injection (Group 1) and observation-only controls (Group II). In Group I, patients were treated with 1-3 injections of 20 mg triamcinolone acetate using a 30-gauge needle into the subconjunctival region of the lid between the conjunctiva and Muller's muscle. Injections were stopped after 1-2 injections if both swelling and retraction resolved completely, or if one eye scored 0 and the contralateral eye scored 1, and there existed no patient concern after physician inquiry regarding function and cosmetic appearance.
Intervention MeSH terms: Triamcinolone
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: thyroid-associated ophthalmopathy; triamcinolone; retraction; swelling