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.


Graves, Lid Retraction, Orbital Inflammation, Proptosis, Steroid Injection

1. Wang Y, Smith TJ. Current concepts in the molecular pathogenesis of thyroid associated ophthalmopathy. Invest Ophthalmol Vis Sci 2014;55:1735–1748.

2. Bahn RS. Emerging pharmacotherapy for treatment of Graves’ disease. Expert Rev Clin Pharmacol 2012;5:605–607.

3. Bartalena L, Baldeschi L, Boboridis K, Eckstein A, Kahaly GJ, Marcocci C, et al. European Group on Graves’ Orbitopathy (EUGOGO). The 2016 European thyroid association, European group on Graves’ orbitopathy guidelines for the management of Graves’ orbithopathy. Eur Thyroid J 2016;5:9–26.

4. Menconi F, Profilo MA, Leo M, Sisti E, Altea MA, Rocchi R, et al. Spontaneous improvement of untreated mild Graves’ ophthalmopathy: Rundle’s curve revisited. Thyroid 2014;24:60–66.

5. Wiersinga WM. Graves’ orbitopathy: management of difficult cases. Indian J Endocrinol Metab 2012;16:S150–S152.

6. Perumal B, Meyer DR. Treatment of severe thyroid eye disease: a survey of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). Ophthalmic Plast Reconstr Surg 2015;31:127–131.

7. Marcocci C, Bartalena L, Tanda ML, Manetti L, Dell’Unto E, Rocchi R, et al. Comparison of the effectiveness and tolerability of intravenous or oral glucocorticoids associated with orbital radiotherapy in the management of severe Graves’ ophthalmopathy; results of a prospective, single-blind, randomized study. J Clin Endocrinol Metab 2001;86:3562–3567.

8. Stiebel-Kalish H, Robenshtok E, Hasanreisoglu M, Ezrachi D, Shimon I, Leibovici L. Treatment modalities for Graves’ ophthalmology: systematic review and metaanalysis. J Clin Endocrinol Metab 2009;94:2708–2716.

9. Hamed-Azzam S, Mukari A, Feldman I, Saliba W, Jabaly- Habib H, Briscoe D. Fornix triamcinolone injection for thyroid orbitopathy. Graefes’ Arch Clin Exp Opthalmol 2015;253:811–816.

10. Chee E, Chee SP. Subconjunctival injection of triamcinolone in the treatment of lid retraction of patients with thyroid eye disease: a case series. Eye 2008;22:311–315.

11. Xu D, Liu Y, Xu H, Li H. Repeated triamcinolone acetonide injection in the treatment of upper lid retraction in patients with thyroid associated ophthalmopathy. Can J Ophthlmol 2012;47:34–41.

12. Lee SJ, Rim TH, Jong SY, Kim CY, Shin DY, Lee EJ, et al. Treatment of upper eyelid retraction related to thyroidassociated ophthalmopathy using subconjunctival triamcinolone injections. Graefes’ Arch Clin Exp Ophthalmol 2013;251:261–270.

13. Pooniathalang A, Preechawat P, Charoenkul W, Tangtrakul P. Retrobulbar injection of triamcinolone in thyroid associated orbithopathy. J Med Assoc Thai 2005;88:345–349.

14. Ebner R, Devoto MH, Weil D, Bordaberry M, Mir C, Martinez H, et al. Treatment of thyroid associated ophthalmopathy with periocular injections of triamcinolone. Br J Ophthalmol 2004;88:1380–1386.

15. Jung BY, Kim YD, The results of periocular injections of triamcinolone for thyroid orbitopathy. J Korean Opthalmol Soc 2007;48:1163–1169.

16. Khafagy A. Repeated retrobulbar injections of triamcinolone acetonide for thyroid orbitopathy. Med J Cairo Univ 2011;79:195–198.

17. Bordaberry M, Marques DL, Pereira-Lima JC. Repeated peribulbar injections of triamcinolone acetonide: a successful and safe treatment for moderate to severe Graves’ opthalmopathy. Acta Ophthalmol 2009;87:58–64.

18. Yakopsen V, Carrasco J, Sharma P, Rabinowitz P, stefanyszyn M. Effect of intraorbital steroid injections on intraocular pressure in thyroid eye disease. J Thyroid Disorders Ther 2015;4:173.

19. Goldberg RA. Orbital steroid injections. Br J Ophthalmol 2004;88:1359–1360.

20. Alkawas AA, Hussein AM, Shahien EA. Orbital steroid injection versus oral steroid therapy in management of thyroid- related ophthalmopathy. Clin Exp Ophthalmol 2010;38:692–697.

21. Mourits MP, Prummel MF, Wiersinga WM, Koomneef L. Clinical activity score as a guide in the management of patients with Graves’ ophthalmopathy. Clin Endocrinol 1997;47:9–14.

22. Dolman PJ, Rootman J. VISA classification for Graves’ orbitopathy. Ophthalmic Plas Reconstr Surg 2006;22:319–324.

23. Werner SC. Classification of the eye changes of Graves’ disease. Am J Ophthalmol 1969;68:646–648.

24. Barrio-Barrio J, Sabater A, Bonet-Farriol E, Velazquez- Villoria A, Galofre JC. Graves’ ophthalmopathy: VISA versus EUGOGO classification, assessment and management. J Ophthalmol 2015;249125.

25. Zang S, Ponto KA, Kahaly GJ. Intravenous glucocorticoids for Graves’ orbithopathy: efficacy and morbidity. J Clin Endocrinol Metab 2011;96:320–332.

26. Chundury RV, Weber AC, Perry JD. Orbital radiation therapy in thyroid eye disease. Ophthalmic Plast Reconstr Surg 2016;32:83–89.

27. Kim JW, Han SH, Son BJ, Rim TH, Keum KC, Yoon JS. Efficacy of combined orbital radiation and systemic steroids in the management of Graves’ orbitopathy. Graefes’ Arch Clin Exp Ophthalmol. 2016;254:991–998.

28. Li YJ, Luo Y, He WM, Li P, Wang F. Clinical outcomes of Graves’ ophthalmopathy treated with intensity modulated radiation therapy. Radiat Oncol 2017;12:171–178.

29. Strianese D, Iuliano A, Ferrera M, Comune C, Baronissi I, Napolitano P, et al. Methotrexate for the treatment of thyroid eye disease. J Ophthalmol 2014; 128903.

30. Tanikawa T, Okada Y, Tanaka Y. Intravenous Cyclophosphamide pulse therapy is effective for refractory Graves’ ophthalmopathy. J UOEH 2006;28:185–191.

31. Chalvatzis NT, Tzamalis AK, Kalantzis GK, El- Hindy N, Dimitrakos SA, Potts MJ. Safety and efficacy of combined immunosuppression and orbital radiotherapy in thyroidrelated restrictive myopathy: two- center experience. Eur J Ophthalmol 2014;24:953–959.

32. Stan MN, Garrity JA, Carranza Leon BG, Prabin T, Bradley EA, Bahn RS. Randomized controlled trial of Rituximab in patients with Graves’ orbithopathy. J Clin Endocrinol Metab 2015;100:432–441.

33. Ben Simon GJ, Syed HM, Douglas R, Schwartz R, Goldberg RA, McCann JD. Clinical manifestations and treatment outcome of optic neuropathy in thyroid-related orbitopathy. Ophthalmic Surg Las Im 2006;37:284–290.