Intraorbital Injection of Triamcinolone Acetonide in Patients With Idiopathic Orbital Inflammation
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CLINICAL SCIENCES
Intraorbital Injection of Triamcinolone Acetonide
in Patients With Idiopathic Orbital Inflammation
Igal Leibovitch, MD; Venkatesh C. Prabhakaran, MS, MRCOphth; Garry Davis, FRANZCO; Dinesh Selva, FRANZCO
Objective: To present findings of a pilot study on in- traocular pressure, blood pressure, and serum glucose
traorbital corticosteroid therapy in the management of levels were measured at each visit.
idiopathic orbital inflammation. Results: Ten patients (5 men and 5 women; mean age,
49.8 years [age range, 25-82 years]) received treatment.
Methods: This prospective, noncomparative, interven- In 4 patients, an orbital mass was noted; in 6 patients,
tional case series included patients with clinically, ra- the lacrimal gland was involved (dacryoadenitis). Sub-
diologically, and histologically confirmed idiopathic or- stantial improvement (1 patient) or complete resolu-
bital inflammation with an anterior orbital mass. Twenty tion (8 patients) was noted during a follow-up of 9.8
to 40 mg/mL of triamcinolone acetonide was injected in- months (range, 3-24 months).
traorbitally (intralesionally or perilesionally) in all pa- Conclusion: Intraorbital injection of a corticosteroid is an
tients. The injection was repeated at 4-week intervals if effective treatment for idiopathic orbital inflammation and
complete resolution was not achieved. Patients were as- may be considered first-line treatment in selected patients.
sessed for local and systemic complications of cortico-
steroid injection. Visual acuity, fundus examination, in- Arch Ophthalmol. 2007;125(12):1647-1651
I
DIOPATHIC ORBITAL INFLAMMA- treatment of biopsy-proved IOI with
tion (IOI) refers to benign non- intraorbital corticosteroid injections.
infective inflammatory condi-
tions of the orbit without
identifiable local or systemic METHODS
cause.1 Onset is generally acute or sub-
acute and may be focal (myositis, dacryo- The study group included all patients with clini-
adenitis, anterior, or apical) or diffuse. cally, radiologically, and histologically con-
Histopathologic analysis usually reveals a firmed IOI and an anterior inflammatory mass
nonspecific, chronic, polymorphic treated with intraorbital injection of 40 mg/mL
inflammatory infiltrate, but sclerosing of triamcinolone acetonide at the Royal Ad-
and nonspecific granulomatous variants elaide Hospital, Adelaide, South Australia, from
may also be seen.2,3 Though IOI is usually January 1, 2002, through October 31, 2006. Pa-
exquisitely sensitive to corticosteroid tients with a blind contralateral eye, glaucoma,
ocular hypertension, or bilateral orbital inflam-
therapy, a large percentage of patients mation were excluded from the study. Patients
with posteriorly located orbital inflammation
CME available online at were excluded because of the small number of
www.archophthalmol.com cases (⬍10% of IOI cases at our center) and be-
cause these patients were treated empirically with
corticosteroids in the first instance owing to the
may not demonstrate this rapid response possible morbidity associated with biopsy. This
Author Affiliations: or may require long-term maintenance study was approved by the institutional review
Department of Ophthalmology, therapy,1,4 exposing them to the consider- board, and all patients gave written informed con-
Tel Aviv Medical Center, sent before treatment.
able adverse effects of systemic cortico-
University of Tel Aviv, Tel Aviv, Data collected in the study group included
Israel (Dr Leibovitch); and steroid therapy. Local corticosteroid initial clinical signs and symptoms, findings at
South Australian Institute of injections are an attractive alternative, physical examination and at computed tomog-
Ophthalmology and especially because ophthalmologists are raphy or magnetic resonance imaging, and fi-
Oculoplastic & Orbital familiar with the procedure. While peri- nal outcome. Patients were assessed for local
Division, Department of ocular corticosteroid injections are an and systemic complications of corticosteroid
Ophthalmology & Visual established treatment for intraocular injection including visual acuity, fundus ex-
Sciences, Royal Adelaide amination, intraocular pressure, systemic blood
Hospital, University of
inflammation, to our knowledge, there pressure, and serum glucose levels. Fol-
Adelaide, Adelaide, South are few reports in the literature about low-up examination was performed at 1 and
Australia (Drs Prabhakaran, their use in orbital inflammatory con- 4 weeks after each orbital corticosteroid
Davis, and Selva). ditions. 5-8 We describe the successful injection.
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©2007 American Medical Association. All rights reserved.Table. Data for 10 Patients With Nonspecific Orbital Inflammatory Syndrome Treated With Intraorbital Triamcinolone Acetonide
Sex/ Intraorbital Duration
Age, y/ Duration Findings Initial Triamcinolone of
Affected of Signs and at CT Histologic Systemic Acetonide Follow-up,
Eye Symptoms Symptoms or MRI Findings Treatment Injection Response Complications mo
M/65/OS 4 mo Upper eyelid Homogeneous Nonspecific None First dose: 40 Improvement None 12
edema, superior chronic mg; repeated at 1 wk;
nonaxial orbital mass inflammation doses: 40 mg complete
proptosis, involving the at 4 and 8 wk, resolution at
inferior globe SRM 20 mg at 12 16 wk
displacement, wk
and restriction
in upgaze
F/43/OD 3 mo Upper eyelid Homogeneous Nonspecific None First dose: 40 Improvement None 9
(Figure 1) edema, ptosis, mass arising inflammation mg; repeated at 4 wk;
nonaxial from lacrimal doses: 40 mg complete
proptosis, gland, at 4 and 8 wk resolution at
inferomedial extending to 20 wk
globe SRM
displacement,
and restriction
in upgaze
M/51/OS 2 mo Upper eyelid Homogeneous Sclerosing None First dose: 40 Improvement None 18
(Figure 2) edema, mass involving inflammation mg; repeated at 4 wk;
nonaxial the LRM, dose: 20 mg at complete
proptosis, extending 4 wk resolution at
medial globe posteriorly 6 wk
displacement,
and horizontal
gaze
restriction
M/47/OS 2 wk Upper eyelid Homogeneous Sclerosing None Single 40-mg Complete None 7
edema, ptosis, mass arising inflammation dose resolution at
medial globe from lacrimal 4 wk
displacement, gland
and
superolateral
mass
F/25/OS 2 mo Upper eyelid Enlarged lacrimal Nonspecific None Single 20-mg Improvement None 7
swelling and gland chronic dose at 1 wk;
erythema, inflammation complete
inferomedial resolution at
globe 4 wk
displacement,
and mild
restriction in
supraduction
and abduction
F/58/OD 2 mo Upper and lower Inferomedial Nonspecific Oral First dose: 20 Improvement None 24
eyelid swelling orbital mass granuloma- prednisolone; mg; repeated at 8 wk;
medially, lower tous therapy doses: 40 mg mild
eyelid mass, inflammation stopped at 4 and 8 wk diplopia on
axial because of downgaze
proptosis, and cushingoid
limited ocular reaction
motility on
downgaze
M/60/OD 2 mo Upper eyelid Well-defined Sclerosing Noncompliant Single 40-mg No response Nausea and 6
swelling, mass in inflammation with oral dose vomiting
limited ocular superior prednisolone
motility on muscle
upgaze complex,
enlarged
lacrimal gland
F/31/OD 2 wk Lateral upper Enlarged lacrimal Nonspecific None; patient Single 20-mg Complete None 6
eyelid swelling gland chronic was pregnant dose resolution at
and pain inflammation 1 wk
F/82/OD 2 mo Right upper Enlarged lacrimal Nonspecific None Single 40-mg Complete None 6
eyelid ptosis gland granuloma- dose resolution at
and fullness tous 2 wk
with palpable inflammation
lacrimal gland
on right side
M/36/OD 5 mo Right upper Enlargement of Nonspecific Noncompliant Single 40-mg Complete None 3
eyelid anterior chronic with oral dose resolution at
retraction and portion of inflammation prednisolone 4 wk
diplopia on right SRM
upgaze
Abbreviations: CT, computed tomography; LRM, lateral rectus muscle; MRI, magnetic resonance imaging; SRM, superior rectus muscle.
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©2007 American Medical Association. All rights reserved.A C
B D
Figure 1. 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.
Twenty to 40 mg/mL of triamcinolone acetonide was in-
jected intraorbitally (intralesionally or perilesionally) using a A
27- or 25-gauge needle. 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 pro- 2.5
cess. If no response was noted 4 weeks after the injection, the
treatment was not repeated.
RESULTS 0
cm
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 49.8 years (age range, R L
25-82 years). In most patients, onset of IOI was sub-
acute. Eyelid edema, ptosis, mild proptosis, globe dis-
placement, and impairment of motility were common B
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 or- L
bit in 1 patient. Histologic analysis revealed nonspe- 7
cific, nongranulomatous, chronic inflammation in 5 pa- 5
tients, 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 find- R
ings, repeated injections were given in 4 patients, all of
whom demonstrated an excellent response. Five pa- Figure 2. Patient 3. Axial computed tomographic scans show left lateral
tients had complete resolution of symptoms after a single rectus myositis (A), which resolved after corticosteroid injection (B).
injection. One patient did not respond to the first injec-
tion and refused further treatment. There were no signs The only complication noted was an isolated episode
of recurrence over a mean follow-up of 9.8 months (range, of nausea and vomiting that developed a few hours fol-
3-24 months) in the 9 patients who responded to the cor- lowing the injection in 1 patient. None of the patients
ticosteroid injections. demonstrated increased intraocular pressure or any
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©2007 American Medical Association. All rights reserved.systemic complications as a result of corticosteroid treat- methyl cellulose–initiated granuloma,7 intractable el-
ment. None of the patients had diabetes mellitus. evated intraocular pressure,20 ptosis,21 globe perfora-
tion,22 corneoscleral or conjunctival melting,23 retinal ar-
tery occlusion from embolization or pressure-induced
COMMENT
optic nerve compression,24,25 proptosis,26 and fat atro-
phy. 27,28 Increased intraocular pressure is a well-
Idiopathic orbital inflammation was treated with intra- recognized adverse effect of periocular corticosteroid in-
orbital injection of triamcinolone acetonide in 10 pa- jection and in intractable cases may necessitate surgical
tients in our unit during a 5-year period. Intraorbital in- removal of the corticosteroid bolus.19 Ptosis is a compli-
jection of corticosteroids (sub-Tenon space or orbital floor cation after injection into the posterior sub-Tenon space
injection) is well established in the treatment of intra- but seems to occur exclusively after triamcinolone in-
ocular inflammation. Similarly, intralesional injection of jection and may reflect the myotoxic effect of this drug.18,29
corticosteroids has been used to treat periorbital condi- As Goldberg7 noted, however, most of these complica-
tions such as capillary hemangioma,9 chalazia,10 cutane- tions have been reported after injection into the poste-
ous sarcoidosis,11 and vernal keratoconjunctivitis.12 In- rior sub-Tenon space, and it is conceivable that anteri-
tralesional corticosteroid injections are the most commonly orly placed intraorbital injections would substantially
used treatment of periorbital capillary hemangiomas.13 The decrease the complication rate
use of intraorbital corticosteroid injections to treat orbital The most dreaded complication of periorbital corti-
diseases, however, has not been widely reported, with only costeroid injection is central retinal artery occlusion26;
isolated series documenting its use in thyroid ophthal- however, this seems to be a rare complication and is pri-
mopathy,5 orbital xanthogranuloma,6 dacryoadenitis,8 and marily associated with injections into capillary heman-
orbital capillary hemangioma.14 Elner et al6 treated 6 pa- giomas.13,30 Systemic effects are uncommon, though ad-
tients with orbital xanthogranuloma with intralesional tri- renal suppression has been reported after periocular
amcinolone acetonide injection (dose range, 20-120 mg). corticosteroid injection.31 The decreased risk of sys-
Local control was obtained in all patients; however, 4 pa- temic adverse effects with local injection compared with
tients required repeated injections (22 injections in 1 pa- systemic use makes this a good option in patients who
tient). Mohammad8 described a series of 5 patients with demonstrate a good response to corticosteroid therapy
acute dacryoadenitis who were treated with intralesional but are intolerant of the systemic adverse effects. Com-
betamethasone injection (dose range, 14-28 mg). All pa- plications may be minimized with attention to the injec-
tients had complete resolution of disease after a single in- tion technique and use of the smallest volume necessary
jection, and no recurrence was noted over a minimum fol- (ⱕ1 mL of a 40-mg/mL triamcinolone injection). Imaging
low-up of 8 months. studies should be used to localize the quadrant of injec-
The use of intraorbital corticosteroid injections in thy- tion, and injection away from the globe into the anterior
roid ophthalmopathy has a long history but does not seem orbit may minimize complications. At least a 27-gauge
to be widely used.15,16 Recently, Ebner et al5 reported the needle and preferably a 25-gauge needle should be used
beneficial effects of periocular triamcinolone injection in because smaller needles offer greater resistance to cor-
diplopia and extraocular muscle size in 20 patients. In ticosteroid flow and increase injection pressure.32 The
that study, a series of 4 weekly injections of 20 mg of tri- plunger must be withdrawn before injection as a safe-
amcinolone acetonide were given in the inferolateral quad- guard against intravascular injection. The corticoste-
rant of each orbit. No complications were observed. roid should then be injected slowly with the patient’s eyes
Harris17 has suggested that intraoperative local injec- open to detect any blurring of vision during the treat-
tion with triamcinolone is useful, especially in scleros- ment. The fundus may be monitored during the injec-
ing inflammation. In our series, 2 of the 3 patients with tion with indirect ophthalmoscopy or with an immedi-
sclerosing inflammation showed a response to triam- ate postinjection fundus examination.
cinolone injection. As with systemic corticosteroid therapy, some pa-
Triamcinolone acetonide has been most commonly tients are resistant to periocular corticosteroid treat-
used for periocular injections, though betamethasone and ment. In our opinion, it is unlikely that patients with a
methylprednisolone have also been used.8,18 The elimi- localized disease process who do not respond to corti-
nation rate of these corticosteroid boluses from the in- costeroid injection will respond to systemic corticoste-
jection site has not been well documented, but active cor- roid therapy. However, because the dose equivalent be-
ticosteroid has been found 13 months after triamcinolone tween corticosteroid injections and systemic corticosteroid
injection.19 The dose equivalent between systemic and therapy is unknown, a trial of high-dose systemic corti-
periocular corticosteroid is also unknown; though Gold- costeroid therapy may be considered before other thera-
berg7 has suggested that a 40-mg injection is equivalent pies such as immunosuppressive agents or radio-
to a 20-mg/d dose of orally administered prednisone.7 As therapy.17
with oral corticosteroids, periocular injections may also Our findings demonstrate that intraorbital corticoste-
need to be repeated several times before the desired thera- roid injections may be at least as efficacious as systemic
peutic effect is achieved. However, inasmuch as the in- corticosteroid therapy in the treatment of anterior IOI,
jections are not given daily, the total systemic dose is sub- with minimal systemic adverse effects. Larger studies will
stantially smaller with periocular corticosteroids. be required to further assess the local safety issues with
Although the injection of orbital corticosteroids is usu- the use of corticosteroid injections in the context of IOI.
ally safe, potential risks include skin depigmentation,7 The risk of local adverse effects perhaps may be mini-
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©2007 American Medical Association. All rights reserved.mized by giving close attention to the technique, plac- pathic dacryoadenitis: a preliminary result. Ophthal Plast Reconstr Surg. 2005;
21(2):138-141.
ing the corticosteroid bolus in the anterior orbit, using a
9. Kushner BJ. Intralesional corticosteroid injection for infantile adnexal hemangioma.
25-gauge needle, and using the smallest volume neces- Am J Ophthalmol. 1982;93(4):496-506.
sary of corticosteroid. Biopsy is recommended in all cases 10. Pizzarello LD, Jakobiec FA, Hofeldt AJ, Podolsky MM, Silvers DN. Intralesional
to confirm the diagnosis and to exclude malignant neo- corticosteroid therapy of chalazia. Am J Ophthalmol. 1978;85(6):818-821.
plasm. A substantial number of patients may require re- 11. Bersani TA, Nichols CW. Intralesional triamcinolone for cutaneous palpebral
sarcoidosis. Am J Ophthalmol. 1985;99(5):561-562.
peated injections to achieve a therapeutic response. Al- 12. Holsclaw DS, Whitcher JP, Wong IG, Margolis TP. Supratarsal injection of cor-
though further investigation is required to delineate the ticosteroid in the treatment of refractory vernal keratoconjunctivitis. Am J
safety profile, intraorbital corticosteroid injections may Ophthalmol. 1996;121(3):243-249.
have a role as first-line therapy in the treatment of ante- 13. Wasserman BN, Medow NB, Homa-Palladino M, Hoehn ME. Treatment of peri-
riorly located IOI and in patients with IOI who are cor- ocular capillary hemangiomas. J AAPOS. 2004;8(2):175-181.
14. Neumann D, Isenberg SJ, Rosenbaum AL, Goldberg RA, Jotterand VH. Ultraso-
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ment of Ophthalmology and Visual Sciences, Royal Ad- ment strategy: the 2005 ASOPRS Foundation Lecture. Ophthal Plast Reconstr
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and side-effects of injection of posterior sub-Tenon triamcinolone versus or-
Author Contributions: Drs Leibovitch, Prabhakaran, and
bital floor methylprednisolone in the management of posterior uveitis. Clin Ex-
Selva had full access to all of the data in the study and periment Ophthalmol. 2004;32:563-568.
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Financial Disclosure: None reported. pot corticosteroid injection. J Cataract Refract Surg. 2000;26(2):163-164.
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