الفهرس 
Comparative study on the efficacy of periocular methotrexate versus periocular triamcinolone injections in management of thyroid-associated orbitopathy
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Abstract
Introduction: Thyroid associated orbitopathy (TAO) is an autoimmune inflammatory condition of the
orbit. Although high dose intravenous steroids are the first line for management of active TAO, about
20-30% of patients have poor response to steroids. Other immunosuppressants may be used as steroid
sparing agents or in steroid resistant patients. Long term systemic administration of steroids or
immunosuppressants has its adverse effects. To reduce systemic side effects, periocular injections may
be used as an alternative route.
Aim: To assess the efficacy and safety of periocular injections of methotrexate in the management of
active TAO in comparison to periocular injections of triamcinolone.
Methods: Prospective double-blind interventional randomized clinical trial in which 18 patients with
bilateral active, moderate to severe TAO were randomized such that an orbit received methotrexate
(7.5mg) and the contralateral orbit received triamcinolone (20mg). Each orbit received three periocular
injections at 3-weeks interval.
Results:
In the methotrexate group, the mean CAS decreased significantly from 5.2± 0.89 at baseline to 0.9 ± 1.7
six months after last injection (p-value<0.001), mean proptosis also decreased from 25.2 ± 3.4 mm at
baseline to 23.8 ± 3.7 mm at end of study (p-value=0.01). In the triamcinolone group, the mean CAS
score decreased significantly from 5.1± 0.9 at baseline to 1 ± 1.7 six months after last injection (p-
value<0.001), mean proptosis also decreased from 24.27 ± 3.06 mm at baseline to 23.27 ± 3.3 mm at
end of study (p-value=0.049).
Statistically significant decline in lid aperture and soft tissue inflammatory score in each group was
observed in all visits compared to baseline. BCVA in both groups remained stationary throughout the
study. A statistically significant reduction in IOP was noted in the methotrexate but not in the
triamcinolone group.
About 89% of patients in both groups had improvement in CAS at week 30, 33-50% of patients showed
improvement in proptosis or lid aperture measurements and only 5.6% of patients had improvement in
EOM function. No statistically significant difference was detected between both methotrexate and
triamcinolone groups at any follow up visit. Both drugs were safe with minimal local complications and
systemic adverse effects.
Conclusion: Periocular methotrexate injection is as effective as periocular triamcinolone injection and
represents an effective and safe modality for management of active TAO