In this issue of the BJO (p 1380), Ebner and colleagues present data from their pilot study of orbital steroids in Graves’ orbitopathy. Even though the patient population is small, and the treatment groups not entirely comparable, the study does provide some evidence that steroid injections used to treat Graves’ orbitopathy may be safe and efficacious.

Orbital steroid injections for Graves’ orbitopathy and other inflammatory disease of the orbit have had a somewhat chequered past. During my training under Norman Shorr, MD, at the Jules Stein Eye Institute, UCLA, I observed frequent use of orbital steroid injections to treat orbital inflammatory disease including Graves, and I also learned about steroid injections from William Stewart, MD, in San Francisco. As I subsequently travelled to different institutions as a visiting speaker, I was surprised therefore to find that in many programmes orbital steroids were never used, either because of concerns about safety or concerns about efficacy. Compared to oral steroids, they were considered the ugly sister.

Certainly, corticosteroids are a potentially dangerous medicine with a long track record of proved ability to cause significant complications. In addition to the systemic complications of steroids, injection around the eye also poses the risk of local complications including globe perforation,^1–3 intractable elevated intraocular pressure,^4,5 conjunctival or corneoscleral melting,^6–8 vascular occlusion from embolisation or pressure induced optic nerve compression,^9– …