The functional and histopathologic change in the levator palpebrae superioris and Müller muscle after subconjunctival injection of triamcinolone acetonide

Morphological and Histological Changes Following Triamcinolone Injection Alone or Mixed Injection of Triamcinolone and Botulinum Toxin in Upper Eyelid

OBJECTIVE

The purpose of this experiment was to evaluate the functional and histologic changes in the upper eyelid muscles after injection of triamcinolone acetonide (TA) alone or TA combined with botulinum toxin A (Botox or BTXA) in the cynomolgus monkey model.

METHODS

Twenty eyes of 10 cynomolgus monkeys were divided into 4 groups: 3 experimental groups (1, 2, and 3) and the control group (group 4) based on the injection type. In group 1, 0.5 mL of TA (Kenalog 40 mg/mL) was administered subconjunctivally (between the conjunctiva and the Müller muscle) with a 26 G needle to the inverted upper eyelid of one eye. In group 2, the same procedure was done with 0.5 mL TA injected into the other upper eyelid. After that, 5 UI/0.1 mL Botox was injected transcutaneously into the suborbicularis oculi space in the middle third of the upper eyelid 3 mm above the center of the superior tarsal border. In group 3, a subconjunctival of 0.5 mL TA was administered to the inverted upper eyelid of one eye 3 times: the injection day, 2 weeks, and 6 weeks after the first injection, whereas a normal saline injection of the same volume was administered one time to the other eye at the injection day in group 4 (control group). Follow-up was done to evaluate the clinical changes in eyelid position at 2, 6, and 12 weeks after injection. Hematoxylin-eosin and Masson trichrome were used to assess the levator or Muller muscle histology and measure the fiber diameter.

RESULTS

During the clinical follow-up, there were no major complications observed in any monkeys. The macroscopic appearance of the upper lid on the biopsy day did not differ among groups 1, 2, and 4. There were no cases in these groups that had subconjunctival TA deposit 3 months after injection. Conversely, in group 3, there were 3/5 eyes showing the subconjunctival TA deposit at the last examination.No specific changes in the marginal reflex distance 1, marginal reflex distance 2 (MRD2), and lid crease were noted in either TA alone injection groups 1, 3, and 4. In contrast, there was a significant decrease in marginal reflex distance 1 at 2 weeks (P = 0.003) and 6 weeks (P = 0.005) after TA injection in group 2 in comparison to the baseline.In terms of MRD2, while in group 2, there were significant differences between the pre-MRD2 and the post-MRD2 till the 2 weeks after injection (P = 0.006), then it became insignificant from the sixth week afterward. In contrast, at 2 weeks after injection, MRD2 was reduced in both TA-injected groups 1 and 3, but the observed difference was not significant in both groups. At 6 and 12 weeks, MRD2 fluctuation was not remarkable in these 2 groups and there were no significant differences in comparison to the baseline (P > 0.05).Histological evaluation showed that Müller muscle does not attach directly to the superior border of the tarsus, but it changes to the tendon before attaching to the tarsal plate. In addition, there were no statistical differences in levator muscle fiber diameter and Müller muscle fiber diameter between the 4 groups, with P = 0. 621 and P = 0.695, respectively.

CONCLUSION

Triamcinolone acetonide combined with BTXA showed better results in decreasing upper eyelid height than TA alone in normal monkey eyelids due to its predictable effect. In addition, there were no differences between the side effects and the histology results between the 4 groups. Therefore, TA combined with BTXA may become a promising treatment for selective thyroid eyelid retraction and could offer an alternative to surgery and its complications.

Synergistic Therapy for Graves' Ophthalmopathy-Associated Eyelid Retraction: Steroid, 5-FU, and Botulinum Neurotoxin a Combination

Background: Graves' ophthalmopathy (GO) is characterized by upper eyelid retraction (UER), the most prevalent clinical sign. We aimed to assess the clinical efficacy of a multimodal combination of steroids, 5-fluorouracil (5-FU), and botulinum neurotoxin A (BoNT-A) injections in managing UER with GO and analyze the clinical factors in relation to the injection response. Methods: A total of 37 eyes from 23 patients were enrolled for UER with GO. At the endocrinology clinic, the patients were referred to the ophthalmology clinic after taking antithyroid medication for an average of 5.76 months (13 patients), while 10 patients were initially diagnosed with GO and referred to the endocrinology clinic for management of the thyroid hormone function. They performed an orbital computed tomography (CT) scan and measured the cross-sectional area of the orbit, orbital fat, and each extra ocular muscle (EOM) except for the inferior oblique muscle 4 mm behind the eyeball. Each of the EOMs and orbital fat were calculated as a ratio to the total orbit area. A total of 0.1 cc of triamcinolone (40 mg/mL), dexamethasone (5 mg/mL), 5-FU, and BoNT-A (2.5 units) was injected transconjunctivally. Medical records were examined and photographs were utilized to assess MRD1, inferior palpebral fissure (IPF), and lid lag during down gaze before and after the injection. The patients were divided into two groups: responders (more than 1 mm decrease in MRD1 after injection) and non-responders. During the follow-up period (11.0 ± 11.6 months), any potential adverse effects were monitored. Results: CAS decreased from 3.0 ± 0.8 to 1.4 ± 0.5 after the injection, and MRD1 decreased from 5.0 ± 0.9 mm to 4.5 ± 1.3 mm. Sixty percent of the patients were responders. Before and after the injection, the difference between IPF and MRD1 in responders was 0.60 ± 1.10 mm and 0.90 ± 0.90 mm, respectively, whereas, in non-responders, it was -0.57 ± 0.88 mm and -0.15 ± 0.75 mm, respectively. In the responders, pre-injection IPF and FT4 were significantly higher (p < 0.05). Responders had a larger EOM cross-sectional area (153.5 ± 18.0 mm2), including a larger lateral rectus muscle cross-sectional area (37.6 ± 9.7 mm2) than non-responders (132.0 ± 27.9 mm2; 29.1 ± 8.1 mm2). In responders, the treatment effect on IPF and MRD1 remained consistent at 1.2 ± 3.4 mm and 1.2 ± 1.6 mm, respectively, during the latest follow-up assessment. Conclusions: The combination injection of corticosteroids, 5-FU, and BoNT-A would be effective, especially, in patients with hyperthyroidism and an elongated IPF. Additionally, an increase in EOM cross-sectional area on CT, up to 150 mm2, may serve as an additional positive indicator for the use of multimodal injections in UER with GO.

A randomized clinical trial of triamcinolone acetonide injection for suppression of inflammation after blepharoptosis surgery

This study aimed to determine the effectiveness of triamcinolone acetonide in suppressing inflammation after blepharoptosis surgery. The study was designed as prospective, randomized, two medical centers' clinical trial. Thirty-two patients with involutional blepharoptosis of the same degree in both eyelids underwent bilateral transcutaneous levator advancement. At the end of the surgery, 4 mg/0.1 ml of triamcinolone acetonide was injected into a randomly selected upper eyelid. The fellow eyelid was not injected and was used as control. Facial photographs were taken on day 1, week 1, month 1, and month 3, and the degree of inflammation, the margin reflex distance 1 (MRD-1), and levator function (LF) between the two eyelids of each patient were compared. The primary outcome was the selection of the less inflamed eyelid decided by the majority of three individuals unrelated to the study. MRD-1 and LF were analyzed for secondary outcomes. As a result, the injected eyelid was judged to be the less inflamed eyelid in all cases. The MRD-1 in the postoperative period less than 1 month was significantly larger in the injected eyelids than the control eyelids (P<0.03). The postsurgical MRD-1 at month 3, the postsurgical LF at all postsurgical examination times were not statistically different. Adverse complications by the injection, including ptosis, levator dysfunction, increase of the intraocular pressure, and visual disturbance were not observed. In conclusion, a triamcinolone acetonide injection after ptosis surgery is both safe and effective in reducing the early postsurgical inflammation and helpful in an earlier return to a daily routine for the patients.

International Harmonization of Nomenclature and Diagnostic Criteria (INHAND): Nonproliferative and Proliferative Lesions of the Rabbit

The INHAND (International Harmonization of Nomenclature and Diagnostic Criteria for Lesions Project (www.toxpath.org/inhand.asp) is a joint initiative of the Societies of Toxicologic Pathology from Europe (ESTP), Great Britain (BSTP), Japan (JSTP) and North America (STP) to develop an internationally accepted nomenclature for proliferative and non-proliferative lesions in laboratory animals. The purpose of this publication is to provide a standardized nomenclature for classifying microscopic lesions observed in most tissues and organs from the laboratory rabbit used in nonclinical safety studies. Some of the lesions are illustrated by color photomicrographs. The standardized nomenclature presented in this document is also available electronically on the internet (http://www.goreni.org/). Sources of material included histopathology databases from government, academia, and industrial laboratories throughout the world. Content includes spontaneous lesions as well as lesions induced by exposure to test materials. Relevant infectious and parasitic lesions are included as well. A widely accepted and utilized international harmonization of nomenclature for lesions in laboratory animals will provide a common language among regulatory and scientific research organizations in different countries and increase and enrich international exchanges of information among toxicologists and pathologists.