![]() ![]() The anecdotal experience of those who use this delivery mechanism suggests that injected steroids do provide symptom relief. The pertinent question is whether steroid injections can achieve the improvement in symptoms that we observe with oral corticosteroids, without an unacceptable rate of local complications, and with decreased systemic side effects. We should not require studies of injected steroids to show proof that they fundamentally change the disease. Whether the temporary improvement observed with corticosteroid therapy affects the final outcome of the disease is a fascinating and unanswered question, but at least the temporary improvement offered by corticosteroids often allows these patients to resume daily activities. Corticosteroids have been a mainstay of treatment, and often provide rapid improvement in symptoms and in clinical evidence of inflammation. ![]() On the other hand, no clinician who cares for patients with Graves’ orbitopathy would likely dispute the efficacy of corticosteroids in ameliorating the acute inflammatory features of the disease. I am not aware of any studies of steroid injections, including the pilot study published here by Ebner et al, that definitively answer the question of efficacy of steroid injections relative to disease outcome. 12, 20Įfficacy is a difficult thing to measure in Graves’ orbitopathy the heterogeneity of the disease and the tendency for spontaneous improvement, create a requirement for carefully controlled studies with adequate numbers of patients in order to assess and compare treatment options. Slow injection using the small gauge needle is also important in order to minimise the risk of intravascular injection forcing retrograde flow of particulate matter into the retinal circulation. Particularly in the anterior orbital location, with slow injection, I have not observed and would not expect a 1 ml injection to create a vision threatening increase in orbital pressure. Triamcinolone acetonide (Kenalog) is manufactured in a 40 mg/ml concentration, so no more than 1 ml of fluid is needed. Perhaps because the medication is not in contact with the globe, severe elevation of intraocular pressure is not typically seen (although I would be careful in recommending orbital steroid injections in patients with significant glaucoma). Also, the small short needle is well tolerated by patients: by using distraction techniques and a gentle touch, injections can be given almost painlessly. A half inch needle is used (I prefer a 27 gauge needle to allow more easy passage of the particulate injection) and the risk of perforating the globe is remote. For orbital injections, the medication is placed just inside the septum near the orbital rim. The technique for orbital injections is substantially different from retrobulbar injection. Retrobulbar or sub-Tenon’s injections are given with a long needle, and the medication is very close to or in direct contact with the globe. However, I suggest that reluctance to use orbital steroid injections derives its legacy from complications of retrobulbar steroid injections used to treat intraocular processes. ![]() In addition to the systemic complications of steroids, injection around the eye also poses the risk of local complications including globe perforation, 1– 3 intractable elevated intraocular pressure, 4, 5 conjunctival or corneoscleral melting, 6– 8 vascular occlusion from embolisation or pressure induced optic nerve compression, 9– 16 proptosis or fat atrophy, 17– 19 depigmentation, and granuloma related to the methyl cellulose vehicle of the depot injection. Compared to oral steroids, they were considered the ugly sister.Ĭertainly, corticosteroids are a potentially dangerous medicine with a long track record of proved ability to cause significant complications. As I subsequently travelled to different institutions as a visiting speaker, I was surprised therefore to find that in many programmes orbital steroids were never used, either because of concerns about safety or concerns about efficacy. During my training under Norman Shorr, MD, at the Jules Stein Eye Institute, UCLA, I observed frequent use of orbital steroid injections to treat orbital inflammatory disease including Graves, and I also learned about steroid injections from William Stewart, MD, in San Francisco. Orbital steroid injections for Graves’ orbitopathy and other inflammatory disease of the orbit have had a somewhat chequered past. ![]()
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