Proptosis after retrobulbar corticosteroid injections.This report describes retrobulbar steroid injection clinical, radiographic, and histopathologic findings in patients with proptosis secondary to lipomatosis after retrobulbar corticosteroid deca steroid injections. Five patients who developed symptomatic unilateral proptosis after steroid injection were studied and the literature was reviewed. No previous description was found in the literature. All five cases were studied with computed tomography, and two cases were confirmed with histopathology. No fibrosis or granulomatous retrobulbar steroid injection was identified.
Orbital steroid injections
Preinjection and postinjection images. A, Clinical view of patient 2 shows right upper eyelid edema. B, T1-weighted axial magnetic resonance image shows inflammation of the right lacrimal gland and superior rectus complex.
C and D, Postinjection images 6 weeks after the last injection show resolution of signs clinically and radiologically, respectively. Axial computed tomographic scans show left lateral rectus myositis A , which resolved after corticosteroid injection B. Copyright American Medical Association. The injection was repeated at 4-week intervals if complete resolution was not achieved.
Patients were assessed for local and systemic complications of corticosteroid injection. Visual acuity, fundus examination, intraocular pressure, blood pressure, and serum glucose levels were measured at each visit. In 4 patients, an orbital mass was noted; in 6 patients, the lacrimal gland was involved dacryoadenitis. Substantial improvement 1 patient or complete resolution 8 patients was noted during a follow-up of 9. Idiopathic orbital inflammation IOI refers to benign noninfective inflammatory conditions of the orbit without identifiable local or systemic cause.
Histopathologic analysis usually reveals a nonspecific, chronic, polymorphic inflammatory infiltrate, but sclerosing and nonspecific granulomatous variants may also be seen.
Local corticosteroid injections are an attractive alternative, especially because ophthalmologists are familiar with the procedure. While periocular corticosteroid injections are an established treatment for intraocular inflammation, to our knowledge, there are few reports in the literature about their use in orbital inflammatory conditions.
Patients with a blind contralateral eye, glaucoma, ocular hypertension, or bilateral orbital inflammation were excluded from the study. This study was approved by the institutional review board, and all patients gave written informed consent before treatment. Data collected in the study group included initial clinical signs and symptoms, findings at physical examination and at computed tomography or magnetic resonance imaging, and final outcome.
Patients were assessed for local and systemic complications of corticosteroid injection including visual acuity, fundus examination, intraocular pressure, systemic blood pressure, and serum glucose levels. Follow-up examination was performed at 1 and 4 weeks after each orbital corticosteroid injection.
Follow-up visits were at 1 and 4 weeks. The decision to repeat the injection at 4 weeks was based on the clinical response and signs of an active inflammatory process.
If no response was noted 4 weeks after the injection, the treatment was not repeated. The demographic data and clinical characteristics of the 10 patients are given in the Table. There were 5 men and 5 women, with a mean age of In most patients, onset of IOI was subacute.
Eyelid edema, ptosis, mild proptosis, globe displacement, and impairment of motility were common findings. At imaging, the disease process was found to involve the lacrimal gland in 4 patients, the lacrimal gland and superior rectus muscle in 2 patients Figure 1 , the superior rectus muscle in 2 patients, the lateral rectus muscle in 1 patient Figure 2 , and the inferomedial orbit in 1 patient. Histologic analysis revealed nonspecific, nongranulomatous, chronic inflammation in 5 patients, sclerosing inflammation in 3 patients, and nonspecific granulomatous inflammation in 2 patients.
Intralesional or perilesional triamcinolone acetonide was injected in all 10 patients. Based on clinical findings, repeated injections were given in 4 patients, all of whom demonstrated an excellent response. Five patients had complete resolution of symptoms after a single injection. One patient did not respond to the first injection and refused further treatment. There were no signs of recurrence over a mean follow-up of 9.
The only complication noted was an isolated episode of nausea and vomiting that developed a few hours following the injection in 1 patient. None of the patients demonstrated increased intraocular pressure or any systemic complications as a result of corticosteroid treatment. None of the patients had diabetes mellitus. Idiopathic orbital inflammation was treated with intraorbital injection of triamcinolone acetonide in 10 patients in our unit during a 5-year period.
Intraorbital injection of corticosteroids sub-Tenon space or orbital floor injection is well established in the treatment of intraocular inflammation. Similarly, intralesional injection of corticosteroids has been used to treat periorbital conditions such as capillary hemangioma, 9 chalazia, 10 cutaneous sarcoidosis, 11 and vernal keratoconjunctivitis.
Local control was obtained in all patients; however, 4 patients required repeated injections 22 injections in 1 patient. Mohammad 8 described a series of 5 patients with acute dacryoadenitis who were treated with intralesional betamethasone injection dose range, mg. All patients had complete resolution of disease after a single injection, and no recurrence was noted over a minimum follow-up of 8 months.
The use of intraorbital corticosteroid injections in thyroid ophthalmopathy has a long history but does not seem to be widely used.
In that study, a series of 4 weekly injections of 20 mg of triamcinolone acetonide were given in the inferolateral quadrant of each orbit. No complications were observed. Harris 17 has suggested that intraoperative local injection with triamcinolone is useful, especially in sclerosing inflammation. In our series, 2 of the 3 patients with sclerosing inflammation showed a response to triamcinolone injection. Triamcinolone acetonide has been most commonly used for periocular injections, though betamethasone and methylprednisolone have also been used.
However, inasmuch as the injections are not given daily, the total systemic dose is substantially smaller with periocular corticosteroids. Although the injection of orbital corticosteroids is usually safe, potential risks include skin depigmentation, 7 methyl cellulose—initiated granuloma, 7 intractable elevated intraocular pressure, 20 ptosis, 21 globe perforation, 22 corneoscleral or conjunctival melting, 23 retinal artery occlusion from embolization or pressure-induced optic nerve compression, 24 , 25 proptosis, 26 and fat atrophy.
The most dreaded complication of periorbital corticosteroid injection is central retinal artery occlusion 26 ; however, this seems to be a rare complication and is primarily associated with injections into capillary hemangiomas. Imaging studies should be used to localize the quadrant of injection, and injection away from the globe into the anterior orbit may minimize complications.
At least a gauge needle and preferably a gauge needle should be used because smaller needles offer greater resistance to corticosteroid flow and increase injection pressure. The corticosteroid should then be injected slowly with the patient's eyes open to detect any blurring of vision during the treatment.
The fundus may be monitored during the injection with indirect ophthalmoscopy or with an immediate postinjection fundus examination.
As with systemic corticosteroid therapy, some patients are resistant to periocular corticosteroid treatment. In our opinion, it is unlikely that patients with a localized disease process who do not respond to corticosteroid injection will respond to systemic corticosteroid therapy. However, because the dose equivalent between corticosteroid injections and systemic corticosteroid therapy is unknown, a trial of high-dose systemic corticosteroid therapy may be considered before other therapies such as immunosuppressive agents or radiotherapy.
Our findings demonstrate that intraorbital corticosteroid injections may be at least as efficacious as systemic corticosteroid therapy in the treatment of anterior IOI, with minimal systemic adverse effects. Larger studies will be required to further assess the local safety issues with the use of corticosteroid injections in the context of IOI. The risk of local adverse effects perhaps may be minimized by giving close attention to the technique, placing the corticosteroid bolus in the anterior orbit, using a gauge needle, and using the smallest volume necessary of corticosteroid.
Biopsy is recommended in all cases to confirm the diagnosis and to exclude malignant neoplasm. A substantial number of patients may require repeated injections to achieve a therapeutic response.
Although further investigation is required to delineate the safety profile, intraorbital corticosteroid injections may have a role as first-line therapy in the treatment of anteriorly located IOI and in patients with IOI who are corticosteroid responsive but corticosteroid intolerant.
April 29, ; final revision received July 4, ; accepted July 15, Drs Leibovitch, Prabhakaran, and Selva had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Analysis and interpretation of data: Drafting of the manuscript: Critical revision of the manuscript for important intellectual content: Administrative, technical, and material support: Leibovitch, Davis, and Selva.
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