Orbital decompression with intraorbital corticosteroid injection during the active phase of thyroid eye disease: outcomes in a real-world cohort.

Background: Orbital decompression is an effective surgery for reducing orbital congestion and proptosis for patients with thyroid eye disease (TED). However, it is commonly stated that elective orbital decompression, i.e., for reasons other than compressive optic neuropathy, should await the quiescent phase of the disease. The reason is to avoid inducing a flare-up of the orbitopathy secondary to surgical inflammation. Still, this means that patients with moderate to severe TED who are suffering from symptoms associated with TED must wait months to years before initiating surgical treatment. The purpose of this study is to evaluate the effectiveness of orbital apex decompression combined with intraorbital corticosteroid injection in patients with active TED, defined as Clinical Activity Score (CAS) ≥3. Methods: This retrospective, single-center cohort study included patients with active TED (pre-operative CAS ≥ 3) who underwent single or staged orbital decompression between February 2023 and September 2025. All lateral wall decompressions included an intraorbital injection of a combination triamcinolone and dexamethasone as part of the operative technique. Primary outcomes included change in CAS, change in proptosis, and postoperative disease progression (≥ 2-point increase in CAS at ≥ 8 weeks). Secondary analysis compared outcomes in patients with and without perioperative treatment using disease-modifying therapy (DMT). Results: Thirty-six patients met inclusion criteria; 14 had preoperative dysthyroid optic neuropathy. Mean CAS decreased from 4.7 to 1.6 (Δ -3.1; 95% CI -3.92 to -2.36), and mean proptosis decreased from 22.7 mm to 19.7 mm (Δ -3.0 mm; 95% CI -3.28 to -2.23). One patient with severe TED met criteria for postoperative disease progression. Outcomes were consistent across subgroups regardless of perioperative DMT exposure. No patients developed new-onset diplopia. Conclusions: Orbital decompression combined with intraorbital corticosteroid injection during active TED was associated with clinically meaningful reductions in CAS and proptosis, with infrequent postoperative deterioration and no major surgical complications. These findings provide real-world evidence supporting use of this combined approach during active disease, including in patients without dysthyroid optic neuropathy. These results are specific to a particular surgical technique and to the perioperative management of underlying thyroid status and risk factors associated with TED exacerbation.