Sir,
We are grateful to Drs Litwin and Malhotra1 for their interest in our paper,2 and for outlining a useful adjunctive therapy for upper eyelid retraction during the acute phase of thyroid eye disease. We note with interest that double the normal dose of BoNTA is required, this suggesting an attenuated effect likely to be due to hypervascularity of the inflamed tissues. This higher dose confers a risk of reduced superior rectus action and Bell’s response, with the studies by Morgenstern et al3 (transconjunctival route, active disease), and Shih et al4 (transcutaneous route, inactive disease) both noting increased diplopia in a small number of patients. It is this risk—and consequently that of corneal exposure in patients whose ocular elevation may already be compromised—that is of concern, but the authors (RM and AL) are to be congratulated for not having had this complication to date in their own series, and we are grateful for their insights on the management of these patients.
References
Litwin AS, Malhotra R . Comment on ‘Acute thyroid eye disease (TED): Principles of medical and surgical management’. Eye 2014; 28 (5): 632.
Verity DH, Rose GE . Acute thyroid eye disease (TED): Principles of medical and surgical management. Eye 2013; 27 (3): 308–319.
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.
Shih MJ, Liao SL, Lu HY . A single transcutaneous injection with botox for dysthyroid lid retraction. Eye 2004; 18 (5): 466–469.
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Verity, D., Rose, G. Response to Drs Litwin and Malhotra. Eye 28, 632–633 (2014). https://doi.org/10.1038/eye.2013.293
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DOI: https://doi.org/10.1038/eye.2013.293