Treatment of upper eyelid retraction associated with thyroid eye disease with subconjunctival botulinum toxin injection

OBJECTIVE: To study the effectiveness of botulinum toxin injections, via a subconjunctival approach, in the management of upper eyelid retraction associated with thyroid eye disease. DESIGN: Prospective, non-comparative, interventional case series. PARTICIPANTS: Eleven patients with upper scleral exposure associated with thyroid eye disease who declined conservative or conventional surgical management. INTERVENTION: One or more treatments with injections of botulinum toxin into the subconjunctival space at the superior margin of the tarsal plate, via a conjunctival approach. MAIN OUTCOME MEASURES: Upper eyelid position in relation to the upper limbus, patient satisfaction, and complications. RESULTS: All patients experienced some improvement in the amount of lid retraction after injections. The amount of lid lowering varied between patients and lasted between 1 and 40 months. A lid position acceptable to the patient was obtained in 10 patients. Four patients had ptosis lasting from 1 to 3 weeks, and three patients had transient diplopia lasting 1 day to 3 weeks. CONCLUSIONS: This subconjunctival method of botulinum toxin injection provides an effective treatment for upper eyelid retraction associated with thyroid eye disease that is easy to administer and well tolerated by patients with few side effects.     

Botulinum toxin injection-treatment of upper lid retraction in thyroid eye disease

OBJECTIVE: Upper lid retraction associated with thyroid eye disease may result in conjunctival and corneal exposure as well as in an esthetic problem. We evaluated the effect of botulinum toxin injections in order to lower the upper lid. METHODS: This prospective study included 19 eyes of 13 female patients presenting with scleral exposure aged 28-50 years. We injected 5-15 IE botulinum toxin A (Botox) transconjunctivally into the levator muscle. Lid position, negative side effects, and patient satisfaction were evaluated. RESULTS: Lid retraction improved from 2.4 mm (+/-1.4 mm) prior to injection to 0.5 mm (+/-2.3 mm) 4 weeks after injection. In 11 of 19 eyes 4 weeks after injection and in 8 of 14 eyes 12 weeks after injection scleral exposure had resolved. Diplopia did not occur and tear production was not influenced. Two eyes had transient ptosis. Lid lag increased from 0.34 (+/-0.6 mm) to 0.84 mm (+/-0.9 mm). Of 13 patients, 8 were satisfied with the result. CONCLUSION: Botulinum toxin A injection provides effective treatment especially in mild lid retraction and as a temporary solution for patients with unstable thyroid disease.     

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

ObjectiveTo evaluate the efficacy and safety of repeated subconjunctival injections of triamcinolone in the treatment of upper-lid retraction with thyroid-associated ophthalmopathy.DesignInterventional controlled retrospective clinical study.ParticipantsWe studied 23 eyes in 15 patients as the nontreatment control group and 35 eyes in 21 patients as the treatment group.MethodsIn 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.ResultsThe 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 7mm). 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).ConclusionsRepeated subconjunctival injection of triamcinolone is an effective and safe treatment for upper-lid retraction due to thyroid-associated ophthalmopathy.     

Stability of Eyelid Height After Graded Anterior-Approach Lid Lowering for Dysthyroid Upper Lid Retraction

Objective: To investigate the outcome of a modified anterior approach surgical procedure for the correction of primary upper eyelid retraction in thyroid eye disease.

Methods: A retrospective review of 52 consecutive cases (in 32 patients) of anterior-approach graded upper lid lowering for the treatment of primary eyelid retraction, carried out at Moorfields Eye Hospital between 2006–2009 was conducted. Measurements of upper margin-reflex distance (MRD), upper lid skin crease height and skin fold height were taken from clinical records and photographs. A comparison between pre-operative and both early and late post-operative measurements was conducted, with a maximal follow-up of 12 months. Surgery was considered successful when all of the following criteria were met; an upper lid margin covering 0.5–1.5?mm of the superior cornea in the 12 o’clock position, smooth eyelid contour, skin crease height within 6–10?mm or upper lid skin fold within 2–5?mm of the lid margin, symmetry of lid position (difference in MRD of <1?mm between both eyes) and patient satisfaction.

Results: A successful outcome was achieved in 86.5% (45/52) of lids with a single procedure. For the whole group, the mean MRD was 7.0?mm pre-operatively and 3.6?mm at 1 month after surgery. The corresponding values from photographic estimates were 6.5?mm and 3.6?mm, respectively. These values remained stable over the maximum follow-up period of 12 months. Under-correction occurred in 6/52 (11.5%) lids, one of which had persistent lateral flare, whereas over-correction occurred in 1/52 (2%).

Conclusions: The described surgical approach produces reasonably predictable and stable outcome for upper eyelid lowering in patients with thyroid eye disease.     

Botulinum toxin type a for dysthyroid upper eyelid retraction

PURPOSE: To evaluate the safety and efficacy of botulinum toxin type A for treatment of eyelid retraction resulting from thyroid eye disease (TED) during the inflammatory phase of the condition. METHODS: In this prospective, nonrandomized case series, 18 patients with inflammatory eyelid retraction caused by active TED received botulinum toxin type A injection (10, 5, or 2.5 U) for treatment of upper eyelid retraction. Botulinum toxin type A (Allergan, Irvine, CA, U.S.A.) was injected transconjunctivally just above the superior tarsal border in the elevator complex of the upper eyelid. RESULTS: Seventeen of 18 patients (94%) demonstrated a reduced marginal reflex distance (MRD1) after botulinum toxin injection. The average change in MRD1 of the treated eyelid after injection was -2.35 mm (range, 0 to -8.0 mm). Of the 27 eyelids injected, 33% had a 0- to 1-mm drop in eyelid height, 30% had a 1.5- to 2-mm decrease, 22% had a 2.5- to 3-mm decrease, and 15% had a greater than 3-mm decrease in eyelid height. None of the treated eyelids were noted to increase in height. One patient showed no alteration inafter treatment. One patient had clinically MRD1 significant ptosis and one patient reported worsening of preexisting diplopia after injection. Three patients undergoing unilateral injection had relative contralateral eyelid elevation. All untoward effects resolved spontaneously without sequelae. CONCLUSIONS:: Botulinum toxin type A may be used in the inflammatory stage of thyroid eye disease to improve upper eyelid retraction. Individual response to treatment is variable, but this modality should be considered as a temporizing measure until stability for surgery is reached.     

Botulinumtoxin bei Überfunktion der Tränendrüse, spastischem Entropium und Oberlidretraktion bei endokriner Orbitopathie

After proximal facial nerve lesions, misrouting of nerve fibres may cause the phenomenon of crocodile tears. Transconjunctival injections of botulinum toxin in the palpebral part of the lacrimal gland are the treatment of choice. An initial dose of 2.5 U of toxin is recommended, and injections may be repeated after 6 months if symptoms reoccur.Botulinum toxin A is also a highly effective temporary treatment for involutional (spasmodic) entropion until surgery is performed. A dose of 10 U of botulinum toxin is injected in the pretarsal part of the lower lid near the eyelashes.Botulinum toxin treatment is also effective for dysthyroid upper eye lid retraction, especially in instable thyroid disease or mild retraction. Slight transient ptosis may occur in some cases. Depending on the amount of retraction, a dose of 5 or 7.5 U of toxin is injected into the subconjunctival space at the superior margin of the tarsal plate.     

Botulinum toxin A treatment of overactive corrugator supercilii in thyroid eye disease

BACKGROUND/AIM—Patients with thyroid eye disease with upper eyelid retraction often develop overaction of the accessory muscles of eyelid closure, the glabellar muscles corrugator supercilii and procerus. The resultant glabellar furrowing (frown lines) contributes to the typical thyroid facies. The aim of this study was to evaluate the use of botulinum toxin A reversible chemodenervation of the glabellar muscles as adjunctive treatment in the rehabilitation of patients with thyroid eye disease.
METHODS—14 patients (13 females) ages 39-76 years (mean 52) with inactive thyroid eye disease and associated medial eyebrow ptosis and prominent glabellar frown lines were recruited. All patients had a history of upper eyelid retraction. Each patient was treated with a single botulinum toxin injection (Dysport 0.2 ml, 40 units) into each corrugator supercilii and sometimes procerus muscles as an outpatient procedure. The effectiveness and acceptability of the treatment was assessed clinically and from a patient questionnaire.
RESULTS—The injections were tolerated by 13/14 (93%) patients. There was resultant flattening of the glabellar region and improvement of medial eyebrow contour in all patients, with onset of paralysis within 1 week. All patients reported a subjective improvement in appearance. Side effects included one patient (7%) with reversible partial ptosis. The beneficial effect lasted 4-6 months, with a gradual return of function. Repeat treatment was indicated where there was persistent upper eyelid retraction and protractor overaction.
CONCLUSION—Botulinum toxin A chemodenervation of the glabellar muscles in these patients was effective and acceptable. Chemodenervation should be considered in the rehabilitation of patients with thyroid eye disease where there is upper eyelid retraction and overacting protractors resulting in a thyroid frown. Once the eyelid retraction has been successfully treated by surgery, the need for further glabella muscle chemodenervation is considerably reduced.

Keywords: botulinum toxin A; corrugator supercilii; frown lines; thyroid eye disease     

A single transcutaneous injection with Botox for dysthyroid lid retraction

PURPOSE: To evaluate the safety and efficacy of injections with botulinum toxin type A (BTTA,Botox), given transcutaneously, in the treatment of upper lid retraction associated with thyroid eye disease (TED). METHODS: A total of 15 patients (21 eyes) with a stable (TED) condition, and a euthyroid state, were enrolled into the study. There were 12 females and three males from ages 23 to 52 years. A single injection, at the centrally superior tarsal border transcutaneously, aiming at the levator aponeurosis and Müller muscle, was administered into each eyelid with 5-6 U of Botox. All patients were followed regularly for 4-6 months. Any complications, such as ptosis, diplopia, pain,or lid ecchymosis were recorded. RESULTS: All patients, except one, experienced much reduction of palpebral fissure. The mean difference of MRD1 between pre- and postinjections of Botox at the first week was -3.1 mm, and the effect remained, at least, for 2 months. There were temporary complications of ptosis in three patients and vertical diplopia in two patients, lasting 3-4 weeks. CONCLUSIONS: A single transcutaneous injection with Botox for the treatment of thyroid lid retraction is safe and effective. Some minor complications may occur, such as ptosis and diplopia; however, it may offer an alternative and temporary method for patients with dysthyroid lid retraction, who are waiting for a staged operation of either an orbital decompression or a strabismus surgery or both.     

Bilateral upper eyelid retraction in myasthenia gravis following thymectomy surgery

This article reports the case of a 45-year-old man with systemic myasthenia gravis who developed right upper eyelid ptosis. One month after thymectomy surgery, he developed bilateral upper eyelid retraction. Lid retraction in the absence of thyroid eye disease is uncommon in myasthenia gravis, although it can develop during periods of medical treatment and after thymectomy surgery. Exclusion of thyroid disease is essential before ascribing lid retraction to myasthenia gravis.     

A prospective evaluation of subconjunctival injection of triamcinolone acetonide for resistant anterior scleritis

PURPOSE: Prospective evaluation of the efficacy and safety of subconjunctival triamcinolone injections for resistant, nonnecrotizing, anterior scleritis. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Twelve eyes of 10 consecutive patients seen in the Doheny Eye Institute between August 1999 and December 2000 with diffuse, nonnecrotizing anterior scleritis that was resistant to systemic antiinflammatory therapy. Eyes with a history of steroid response were excluded. INTERVENTION: Subconjunctival injection of triamcinolone acetonide to the areas of maximal inflammation. MAIN OUTCOME MEASURES: Scleritis activity, adverse treatment effects, and number of systemic medications required at the end of the follow-up period. RESULTS: Within 1 to 14 days after injection, complete resolution of signs and symptoms was achieved in 11 eyes and partial resolution in 1 eye. Two patients had one recurrence each, 2.5 and 11 months after injection. Six of 10 patients were able to discontinue all systemic therapy (prednisone +/- immunosuppressive drugs); the remaining 4 needed continued oral therapy for systemic indications. Transient ocular hypertension and subconjunctival hemorrhage occurred in one eye each. Median follow-up period was 15 months. No eye developed necrotizing scleritis. CONCLUSIONS: Subconjunctival injection of triamcinolone acetonide is a safe and effective treatment for resistant, nonnecrotizing anterior scleritis. It provides rapid effect, is well tolerated, and may spare patients the significant complications and side effects of systemic corticosteroid and immunosuppressive therapy.     

The success rate of TED upper eyelid retraction reoperations

Although reoperation rates for upper lid retraction surgery for thyroid eye disease (TED) typically range between 8% and 23%, there is little literature describing the outcomes of these second operations. In this retrospective observational cohort study, all patients that underwent surgery for upper eyelid retraction over a 14-year period at a single institution were included. Cases were included if a second eyelid retraction surgery was performed during the study period. Success of surgery was defined as a marginal reflex distance (MRD1) of 2.5 to 4.5 mm in each eye and less than 1 mm difference in MRD1 between the eyes. Overcorrection and undercorrection were defined as above and below these bounds, respectively. 72 eyes in 49 patients were included in the study. The mean age was 56.6 (±11.5) years. By definition, all patients had at least 1 lid lengthening surgery for upper eyelid retraction, and at least 1 subsequent surgery. For this second surgery, 61 eyes (85%) underwent retraction surgery and 11 eyes (15%) underwent ptosis surgery. After this second operation, 31% were undercorrected and 33% were overcorrected. A third surgery was performed in 19 eyes (25%), 12 had surgery for residual retraction and 7 for ptosis. After the third operation 10% of eyes were under corrected and 11% were over corrected. Four patients underwent a fourth surgery: one for retraction and three for ptosis. Success was noted in 35% after the second surgery and 44% after the third. Surgical success in eyelid retraction surgery increases from a second to a third consecutive surgery, and residual asymmetry was roughly equally distributed between over- and undercorrection.     

Clinical trial to compare efficacy and side-effects of injection of posterior sub-Tenon triamcinolone versus orbital floor methylprednisolone in the management of posterior uveitis

AIM: To compare the efficacy and side-effects of posterior sub-Tenon injection of triamcinolone acetonide (Kenalog) with orbital floor injection of methylpredisolone acetate (Depomedrone) in the management of posterior uveitis. METHODS: Non-randomized comparative prospective clinical study. Sixty-four eyes from 60 consecutive patients with non-infectious posterior uveitis requiring treatment were allocated on an alternate 1:1 basis to receive either orbital floor methylprednisolone or sub-Tenon triamcinolone using standard procedures and assessed at 6 and 12 weeks. RESULTS: After five eyes of five patients who had received the same treatment bilaterally were excluded from the statistical analysis, 14 out of 29 eyes treated with orbital floor methylprednisolone and 10 out of the 30 eyes given sub-Tenon triamcinolone improved at 6 weeks. There was no statistically significant difference in the improvement rate between the two groups. However, two patients given triamcinolone had prolonged upper lid ptosis, which required surgery, and another two developed markedly raised intraocular pressure, neither of which occurred in the methylprednisolone-treated group. CONCLUSIONS: Although the two drugs and routes compared were of similar efficacy, lid ptosis occurred in the triamcinolone-treated but not the methylprednisolone group. This should be borne in mind when choosing the preferred route of delivery of periocular corticosteroid in the treatment of posterior uveitis.     

Postoperative subconjunctival corticosteroid injection to prevent pterygium recurrence

PURPOSE: To report the outcome of postoperative subconjunctival injection of triamcinolone in eyes that underwent pterygium surgery and were at risk for recurrence. METHODS: Twelve eyes of 11 patients with primary (7 eyes) or recurrent (5 eyes) pterygia underwent excision and conjunctival autografting (4 eyes, 33.3%), amniotic membrane grafting (6 eyes, 50%), or both (2 eyes, 16.6%). All of these eyes had signs that were considered to be risk factors for recurrence (conjunctival inflammation, hemorrhage, granuloma, and fibrovascular proliferation); accordingly, they also underwent subconjunctival injection of triamcinolone. RESULTS: Among the 11 patients, there were 8 (72.7%) men and 3 (27.3%) women; the mean age was 41 years (range, 20-56 years). In 5 (41.7%) eyes, the pterygium was graded as T2 (intermediate) and in 7 (58.3%) eyes was graded as T3 (fleshy). The time between surgery and the first injection ranged from 2 to 5 weeks (mean, 3.4 weeks), and 1-3 injections were necessary (mean, 1.7) to achieve the desired effect. After injection, 1 (8.3%) eye developed inflammation, and 2 (16.7%) eyes from another patient developed intraocular hypertension that was controlled with a topical beta-blocker. The follow-up after the last injection ranged from 8 to 36 months (mean, 14.5 months); only 1 recurrence (grade 3) occurred during this period. CONCLUSIONS: The postoperative use of subconjunctival triamcinolone seems to benefit patients at increased risk of pterygium recurrence. It is relatively safe and is accompanied by few complications, but controlled and prospective studies are necessary to confirm its efficacy.     

Graded full-thickness anterior blepharotomy for correction of upper eyelid retraction not associated with thyroid eye disease

PURPOSE: To evaluate the efficacy of graded full-thickness anterior blepharotomy for upper eyelid retraction of various causes not associated with Graves eye disease. METHODS: Twenty-one eyelids of 18 patients with upper eyelid retraction not caused by Graves eye disease were treated with graded full-thickness anterior blepharotomy. Preoperative and postoperative symptoms, midpupil to upper eyelid distance, lagophthalmos, and superficial punctuate keratopathy were evaluated. RESULTS: Upper eyelid retraction was due to facial nerve palsy in 4 patients (22%), overcorrected ptosis in 5 patients (28%), and cicatrix after trauma in 6 patients (33%). One patient each (6% each) had retraction from graft-versus-host disease, after blepharoplasty, and after orbicularis oculi myectomy for blepharospasm. At a mean of 10 months follow-up, presenting symptoms resolved or improved in 17 patients (94%) and remained unchanged in 1 patient (6%). Midpupil to upper eyelid distance, lagophthalmos, and superficial punctuate keratopathy all improved significantly (all p < 0.001). No surgical complications occurred. CONCLUSIONS: Graded full-thickness anterior blepharotomy is a safe, effective, and rapid technique for patients with symptomatic upper eyelid retraction due to etiologies other than Graves eye disease. This technique improves symptoms and signs of ocular exposure while addressing relative upper eyelid height symmetry and contour.     

Case-control study of subconjunctival triamcinolone acetonide injection vs intravenous methylprednisolone pulse in the treatment of endothelial corneal allograft rejection

PURPOSE: To assess the safety and effectiveness of treating corneal endothelial rejection with a subconjunctival injection of 20 mg triamcinolone acetonide in combination with topical application of 1% prednisolone acetate, as compared to treatment with an intravenous pulse of 500 mg methylprednisolone in combination with topical application of 1% prednisolone acetate. METHODS: A case-controlled study including a literature review was performed. Patients who presented with an initial episode of corneal endothelial rejection were treated with subconjunctival injection of 20 mg triamcinolone in combination with topically applied 1% prednisolone and were retrospectively matched for age and diagnosis to patients who received a single intravenous injection of 500 mg methylprednisolone in combination with topical 1% prednisolone. Patients were analysed regarding reversion of the rejection episode, intraocular pressure, and visual acuity after 1 year. RESULTS: Overall, the triamcinolone group had a better outcome regarding reversion of corneal transplant rejection (P=0.025), with 15 of 16 patients in the triamcinolone group having clear grafts, compared to only 10 of 16 patients in the methylprednisolone group. Intraocular pressure (IOP) was increased in both groups at day 30 (P=0.002), although there was no statistically significant difference in IOP between the groups (P=0.433). Visual acuity improved in both groups after 1 year (P=0.049), although slightly more improvement was observed in the triamcinolone group (P=0.002). CONCLUSIONS: The results observed in this case-controlled study suggest that the use of subconjunctival triamcinolone acetonide may benefit patients with corneal transplant rejection.     

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.     

Intravitreal triamcinolone acetonide treatment for serpiginous choroiditis

PURPOSE: To report the efficacy of intravitreal triamcinolone acetonide injection for acute treatment of a patient with serpiginous choroiditis. METHODS: A 50-year-old male patient with serpiginous choroiditis presenting with the complaint of decreased visual acuity in his right eye for the last 10 days. The best corrected visual acuity (BCVA) of the patient was counting finger from 1 meter. Fundus examination and fundus fluorescein angiography of right eye revealed active macular choroiditis in right eye. Intravitreal triamcinolone acetonide (4 mg/0.1 ml) was injected into vitreous, and the patient was followed with visual acuity testing, intraocular pressure measurement, and fundus examination, including fundus fluorescein angiography. RESULTS: Visual acuity of the patient improved to 20/100 after 2 weeks in spite of the triamcinolone crystals, and to 20/50 after 4 weeks with a single dose intravitreal triamcinolone acetonide injection. Complete resolution of the active lesion has been maintained during the 6 months of follow-up. CONCLUSIONS: Single dose intravitreal triamcinolone acetonide injection is sufficient for controlling the active lesions in serpiginous choroiditis. It needs further evaluation as an alternative treatment for achieving rapid and significant visual acuity recovery.     

Lower lid retraction in thyroid orbitopathy: lamellar shortening or proptosis?

To investigate any correlation between lower lid retraction and proptosis and also between lower lid retraction and lamellar length, as measured by fornix depth, in patients with thyroid eye disease (TED). One hundred and sixty-six eyes of 83 patients with TED were enrolled. The inferior fornix depth, Hertel exophthalmometry measurement, clinical activity score, and lower lid position were the main outcome variables. The correlation between lower lid position measurement and Hertel measurements and also between the lower lid position measurement and inferior fornix depth were evaluated using ANOVA and Pearson’s tests. The mean age of subjects in patients with and without lid retraction was 42.8 ± 1.5 and 47.7 ± 1.6 years, respectively (P = 0.4). The inferior fornix depth in patients with and without lower lid retraction was 11.8 ± 1.5 and 11.8 ± 1.3 mm, respectively (P = 0.960). Pearson’s analysis showed a significant correlation between the degree of proptosis and lower lid retraction in TED patients (P = 0.01). However, no significant correlation was found between the level of lower lid retraction and the fornix depth (P = 0.87). The main cause of lower lid retraction in TED is proptosis. The beneficial effect of orbital decompression on improvement of lower lid retraction must be considered during a stepwise surgical approach in TED patients.     

The TRH test: its value in the diagnosis of Graves' ophthalmopathy.

When a goiter or hyperthyroidism is absent, the diagnosis of ophthalmic Graves' disease is often difficult. We evaluated the thyrotropin (TSH) response to intravenously administered thyrotropin-releasing hormone (TRH) in fourteen patients presenting with proptosis or lid retraction. All of them had normal results with routine thyroid function tests and in most a T3 suppression test and orbital ultrasonography were performed. We found an absent or impaired response to TRH in the patients with Graves' ophthalmopathy which correlates well with their having a non-suppressible thyroid gland. Patients with orbital tumours, pseudotumours or congenital lid retraction responded normally to TRH. The TRH test was easier and as reliable as the T3 suppression test in the investigation of a patient with suspected Graves' disease.     

Conjunctival ulceration following triamcinolone injection

PURPOSE: To report conjunctival ulceration as a complication of periocular triamcinolone acetonide injection.Interventional case series. METHODS: Conjunctival ulceration was found in three patients who had anterior subtenon's or subconjunctival deposition of triamcinolone. Cultures from the ulcer edges were negative. RESULTS: Most of the triamcinolone extruded, and the conjunctival ulcers healed with minimal scarring. CONCLUSIONS: Conjunctival ulceration was a potential complication of periocular triamcinolone injection in three patients who had anterior subtenon's or subconjunctival deposition of the corticosteroid.