Botulinum toxin type A treatment of upper eyelid retraction in active inflammatory Graves' ophthalmopathy

Abstract

Abstract: : Purpose: In Graves disease, upper eyelid retraction management is usually deferred until the acute inflammation subsides and the eyelid is stable. Treatment with botulinum toxin A injections has been used for these patients, after stabilization of the ophthalmopathy. This study evaluates management of Graves eyelid retraction with botulinum toxin injections early during its active phase to reduce discomfort and, potentially, the permanent structural changes that occur in the lid musculature. This could diminish the need for delayed surgery. Methods: Prospective interventional series of 12 patients (17 eyelids) followed for a maximum of 13 months. After a neuro–ophthalmic examination and grading of inflammation based on chemosis, conjunctiva and lid hyperemia, lid edema and resting and movement pain, patients were injected with botulinum toxin subconjunctivally superior to tarsus. Dose was dependent on the amount of retraction. Eyelid position, inflammatory index and complications were compared photographically and clinically with baseline at each follow–up. Results: Inflammation indexes varied from 1 to 6 (over 8). 77% of eyelids returned to a normal position, 1–2 mm below the limbus. Only 2 eyelids (12%) were not improved. These were from the 2 patients with the longest standing retraction (≥ 2 years). 53% of eyelids continue to receive injections every 3 months to maintain the effect; 18% are maintaining a normal position without further injection; the rest (29%) exited the study. Lagophthalmos and 1mm ptoses were the only complications. An injection dosing scale dependent on the degree of retraction in mm was also developed. Conclusion: Botulinum toxin type A used during the active inflammatory phase of Graves ophthalmopathy is an effective and lasting treatment for eyelid retraction.

Keywords: clinical (human) or epidemiologic studies: treatment/prevention assessment/controlled clinical trials • eyelid • injection