Personalized Treatment With Local Administration Of Corticosteroid For Thyroid Associated Ophthalmopathy

Objective:The purpose of this study is to evaluate the efficiency and safety of personalized treatment with local injection of corticosteriod for thyroid-associated ophthalmopathy(TAO)in different stages.Method:A total of 48 eyes of 32 patients suffered with TAO who were admitted to the Second Hospital of Jilin University from September 2017 to October 2018 were enrolled.After ocular evaluation,we adopted three different kinds of personalized treatment with locally injecting corticosteroid for these patients.For group A,16 patients with mild TAO showed obvious retraction of upper eyelid and intermittent diplopia.A total of 24 eyes were treated with subconjunctival injection of triamcinolone acetonide(20 mg)each time.Furthermore,according to the orbital CT images,the thickening rectus muscles were treated with periorbital injection of triamcinolone acetonide(20 mg per muscle).The patients normally accepted one injection per month and for 6 months of continuous treatment.For group B,total 6patients including 7 eyes showed markedly thickening and fibrosis in inferior rectus muscle,causing vertical motility restriction.These patients were treated with intramusclar injection of triamcinolone acetonide by separating inferior rectus via conjunctival approach under direct visual field exposure.For group C,patients showed severe proptosis,which led to exposed keratitis or optic neuropathy.A total10 patients including 17 eyes were treated with endoscopy assisted orbital decompression combined with medial rectus muscle injection of triamcinolone acetonide.Result:After local treatment with corticosteroid injection,24 eyes of 16 patients in group A showed significant improvement in the symptoms of upper eyelid retraction and proptosis compared with that before operation(P<0.05),and the difference was with a statistical significance.A total of 8 patients in group A had obvious diplopia before the treatment,while the symptoms of diplopia improved in 7 patients after treatment,and the total efficiency reached 87.5%.Among them,5 patients showed complete relief in diplopia.For group B including 7 eyes of 6 patients,the area of anterior segment and middle segment of inferior rectus muscle in coronal images of CT after operation were significantly reduced compared with that in pre-treatment.The difference was statistically significant(P<0.05).The cross sectional area of inferior rectus muscle in the posterior segments was reduced compared with that in pretreatment,but the difference was not statistically significant(P>0.05).The proptosis in group B were significantly improved,and the difference was statistically significant compared with the pre-treatment(P<0.05).The vertical diplopia after treatment were also improved compared with that before treatment,and the efficiency was about 67%.For the group C including 17 eyes of 10 patients,cross-sectional area of medial rectus muscle in the anterior segment and middle segment and posterior segment from coronal CT images was significantly reduced after treatment.The difference was with a statistical significance compared with that in the pre-treatment(P<0.05).The clinical activity score was significantly lower than that in the pre-treatment,and the difference was statistically significant(P<0.05).Conclusion:After personalized treatment with local corticosteroid injection,the upper sacral conjunctiva injection of triamcinolone acetonide can effectively relieve the symptoms of upper eyelid retraction,vertical diplopia.Especially,in this study,we developed two innovative operations,including intramusclar injection with triamcinolone acetonide by separating inferior rectus muscle via conjunctival approach and endoscopy assisted orbital decompression combined with intramusclar injection with triamcinolone acetonide.These personalized treatment may significantly reduce CAS score,improve proptosis,control the thickening rectus muscles without obvious side effects.Therefore,personalized treatment with local corticosteroid injection is aneffective and safe therapy for controlling TAO.However,due to the small number of cases,the safety and effectiveness of the treatment still require a large amount of further verification.