Comment on ‘acute thyroid eye disease (ted): principles of medical and surgical management’

SIR, We congratulate Drs Verity and Rose on their excellent update and review of the management of acute thyroid eye disease.1 They state that use of Botulinum toxin (BoNTA) for eyelid

retraction in this disease state is inadvisable. Certainly, through a transcutaneous approach we agree that the correct placement of BoNTA without affecting the superior rectus or

orbicularis oculi is variable in both its efficacy and effectiveness.2 However in our experience, we find transconjunctival administration to be a much safer and predictable approach.

Injection of BoNTA through a transconjunctival approach is ideally suited for patients with active thyroid orbitopathy and moderate or severe eyelid retraction. It can be used as an adjunct

to other supportive therapies.3 Rather than using the standard 2.5 units of BoNTA that would achieve complete ptosis in patients without thyroid orbitopathy, we have found 5 units in 0.1 ml

to be safe and effective in patients with thyroid eyelid retraction. This very rarely gives rise to severe or prolonged ptosis, and we have not encountered BoNTA-induced hypotropia or

superior rectus underaction; a finding consistent with studies that have utilised even larger subconjunctival doses.4, 5 Topical local anaesthetic is instilled and the upper eyelid is

everted. A minimum dose of 2.5 units and maximum of 7.5 units (usual dose 5 units for scleral show 1–2 mm) BoNTA (Botox diluted 5 units/0.1 ml, Allergan Limited, UK) is administered via a

single injection into the subconjunctival space at the superior margin of the central tarsal plate. Within 48 h, eyelid retraction and lagophthalmos improves and a better aesthetic

appearance is achieved, particularly during active disease when patients may be unsuitable for surgical lowering. REFERENCES * Verity DH, Rose GE . Acute thyroid eye disease (TED):

Principles of medical and surgical management. _Eye_ 2013; 27 (3): 308–319. Article  CAS  Google Scholar  * Shih MJ, Liao SL, Lu HY . A single transcutaneous injection with botox for

dysthyroid lid retraction. _Eye_ 2004; 18 (5): 466–469. Article  CAS  Google Scholar  * The management of thyroid-related eyelid retraction. In: Leatherbarrow B . _Oculoplastic Surgery_ 2nd

edn. Informa Healthcare: London, 2011 pp 177–191. Google Scholar  * Uddin JM, Davies PD . Treatment of upper eyelid retraction associated with thyroid eye disease with subconjunctival

botulinum toxin injection. _Ophthalmology_ 2002; 109 (6): 1183–1187. Article  Google Scholar  * Morgenstern KE, Evanchan J, Foster JA, Cahill KV, Burns JA, Holck DE _et al_. Botulinum toxin

type A for dysthyroid upper eyelid retraction. _Ophthal Plast Reconstr Surg_ 2004; 20 (3): 181–185. Article  CAS  Google Scholar  Download references AUTHOR INFORMATION AUTHORS AND

AFFILIATIONS * Corneoplastic Unit, Queen Victoria Hospital NHS Trust, East Grinstead, West Sussex, UK A S Litwin & R Malhotra Authors * A S Litwin View author publications You can also

search for this author inPubMed Google Scholar * R Malhotra View author publications You can also search for this author inPubMed Google Scholar CORRESPONDING AUTHOR Correspondence to R

Malhotra. ETHICS DECLARATIONS COMPETING INTERESTS The authors declare no conflict of interest. RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Litwin,

A., Malhotra, R. Comment on ‘Acute thyroid eye disease (TED): Principles of medical and surgical management’. _Eye_ 28, 632 (2014). https://doi.org/10.1038/eye.2013.292 Download citation *

Published: 07 March 2014 * Issue Date: May 2014 * DOI: https://doi.org/10.1038/eye.2013.292 SHARE THIS ARTICLE Anyone you share the following link with will be able to read this content: Get

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