Diplopia after Hyaluronic Acid Gel Injection for Correction of Facial Tear Trough Deformity

A 38 Year-old-female presented with diplopia and bilateral lower eyelid swelling 1.5 months after hyaluronic acid filler injection of tear trough deformity. Comprehensive eye examination showed an inferior oblique muscle restriction on the right eye. Diplopia and bilateral lower eyelid puffiness were treated by injection of hyaluronidase which resulted in disappearance of both diplopia and bilateral lower eyelid puffiness.     

Diplopia after hyaluronic Acid gel injection for correction of facial tear trough deformity

A 38 Year-old-female presented with diplopia and bilateral lower eyelid swelling 1.5 months after hyaluronic acid filler injection of tear trough deformity. Comprehensive eye examination showed an inferior oblique muscle restriction on the right eye. Diplopia and bilateral lower eyelid puffiness were treated by injection of hyaluronidase which resulted in disappearance of both diplopia and bilateral lower eyelid puffiness.     

Complete recovery of filler-induced visual loss following subcutaneous hyaluronidase injection

The rise in popularity of hyaluronic acid (HA) dermal filler injection has caused an exceptional increase in the number of cases of reported irreversible blindness. Here, we reported a case of ischemic optic neuropathy and ophthalmoplegia following subcutaneous HA filler injection with complete visual recovery. A 31-year-old Chinese woman presented with sudden onset of right monocular visual impairment associated with diplopia. Patient had received a hyaluronic acid-containing ?ller injection for nasal dorsum augmentation twelve hours prior to presentation. Visual acuity of the right eye was counting finger. A right relative afferent pupillary defect was demonstrated with ophthalmoplegia. Humphrey visual field test disclosed a right inferior altitudinal field defect with impairment of colour vision. Computed tomography of the orbit revealed mild enlargement of the right medial and inferior recti muscles. Our patient showed a tremendous improvement of vision after a subcutaneous hyaluronidase injection with complete visual recovery within 2 weeks.     

Filling the periorbital hollows with hyaluronic acid gel: initial experience with 244 injections

PURPOSE: To review our initial experience using hyaluronic acid gel (Restylane) as a filler to treat the periorbital hollows. METHODS: This is a retrospective, anecdotal case review of 244 cosmetic hyaluronic acid gel injections in 155 patients. An average volume of 0.9 ml per injection session was used in an individualized pattern that variably included the orbital rim hollow, zygomatic hollow, septal confluence hollow, and eyebrow and cheek fat pad. To achieve smooth contours, a layered, feathered threading technique was used, placing the filler deep to the orbicularis. Hyaluronidase injections were used in 11% of patients at follow-up visits to "dissolve" some of the filler to reduce contour irregularities. RESULTS: One hundred eight of 121 (89%) patients with follow-up visits were satisfied with the cosmetic improvement after hyaluronic acid gel injections. For maintenance, the interval to second injection averaged 6.5 months. Side effects included lumps or contour irregularities (11%), bruising (10%), color change (7%), and fluid (15%). Twelve patients were unsatisfied and were not interested in additional injections: 5 with malar fluid, 3 with lumpy irregularity, and 3 with color change. CONCLUSIONS: Complex 3-dimensional contours and thin skin over bone render periorbital filling difficult. However, with individualized planning and with care taken to create smooth, feathered contours, it is possible to achieve acceptable improvement. We found that most patients considered themselves improved cosmetically, despite occasional side effects including contour irregularity or lumps, bruising, color change, and fluid accumulation. Patients with very thin skin, preexisting color problems, or preexisting eyelid fluid may not be good candidates for periorbital filling with hyaluronic acid gel. The effect of the filler is temporary, of course, and we counsel patients to anticipate maintenance injections at 6- to 12-month intervals.     

Deep-fill hyaluronic acid for the temporary treatment of the naso-jugal groove: a report of 303 consecutive treatments

PURPOSE: To report a 2-year experience of treating the naso-jugal groove with injectable hyaluronic acid gel, using a deep-fill method. METHODS: This was a consecutive, retrospective, nonrandomized case series of patients presenting with concerns involving dark circles, lower eyelid hollows, or other contour irregularities that make up the naso-jugal groove. One author performed all treatments, consisting of transcutaneous injection of hyaluronic acid gel filler, to address the naso-jugal groove. The filler was placed deep on the anterior lip of the orbital rim and molded to the desired shape. RESULTS: Between December 2003 and December 2005, 164 patients (34 male and 130 female) received hyaluronic acid gel filler in the face. Ninety-eight patients were treated just once and 66 had multiple treatment sessions. The mean dose of filler per session was 1.53 +/- 0.8 ml, with 0.84 +/- 0.38 ml divided between the two lower eyelids. The most common complication was localized swelling, followed by bruising, asymmetry, cellulitis (2 cases), and migraine (1 case). There were no cases of visual loss. CONCLUSIONS: Hyaluronic acid gel fillers have had an enormous impact on the practice of cosmetic surgery, and this series demonstrates the usefulness of these fillers for treatment of the lower eyelid and midface. The authors recommend the deep-fill method described as a reliable means of addressing the hollow created by the naso-jugal groove.     

Retinal branch artery occlusion following injection of hyaluronic acid (Restylane)

The authors report a retinal branch artery occlusion occurring after facial injection of a dermal filler. The superior temporal artery showed occlusion due to a clearly visible long and fragmented embolus suggestive of gel and clearly distinguishable from calcific or cholesterol emboli. The authors suppose that hyaluronic acid gel was embolized in the patient. The embolized material is supposed to enter the ocular circulation through retrograde arteriolar flow after intra-arterial injection into one of the peripheral branches of the ophthalmic artery. If there is any evidence of a visual problem after facial injection of a dermal filler, prompt consultation of an ophthalmologist is recommended.     

Periorbital aesthetic concerns in patients seeking corneal refractive surgery

Purpose:To report the frequency of periorbital aesthetic abnormalities in patients undergoing refractive surgery and to report the ability of the patient and the refractive surgeon in picking up these findings compared to the oculoplastic surgeon.Methods:Single-center, prospective observational case series. All patients underwent standard pre-operative work-up for refractive surgery, answered a study questionnaire, and underwent face photographs (with and without glasses). The patient, the refractive, and the oculoplastic surgeons evaluated the photographs to categorize the concerns as none, presence of ptosis, tear trough deformity, scleral show, and others. The findings of the oculoplastic surgeon were taken as the standard of reference.Results:The photographs of 121 patients were analyzed. The mean age was 25.76 ± 3.75 years and 72% were males. The main indication for surgery was to eliminate dependency on glasses in a majority (76%) followed by cosmesis in 23%. The oculoplastic surgeon noted tear trough deformity in 14 (11.5%) cases, scleral show in 51 (42.1%), ptosis in 35 (28.9%), and other findings in 45 (37.1%). When the symmetrical scleral show was excluded, the patient picked up aesthetic concerns in only 8.26%, the refractive surgeon in 14% as compared to 39% by the oculoplastic surgeon (P < 0.01).Conclusion:Periorbital aesthetic significant findings were noted in 39% of the patients undergoing corneal refractive surgery when assessed by an oculoplastic surgeon. The refractive surgeon was able to pick up less than 50% of these. We recommend a basic aesthetic initial evaluation prior to refractive surgery and photographic documentation, especially in cosmetically aware patients.     

Dermal filler-associated malar edema: Treatment of a persistent adverse effect

A 72-year-old Caucasian female presented for evaluation of bilateral lower eyelid “fluid filled” bags that had been present and slowly worsening for 7 years. She reported a history of lower eyelid blepharoplasty in her 40s, as well as hyaluronic acid tear trough fillers 8 years prior to presentation. Her malar edema completely resolved following injection of hyaluronidase. To our knowledge, this is the longest reported interval for presentation and treatment of hyaluronic acid associated malar edema.     

Eficacia de la hialuronidasa retrobulbar en el tratamiento de la ceguera provocada por rellenos cosméticos. Revisión sistemática

IntroductionBlindness after periocular cosmetic filler injection is a rare but devastating complication. Complication management protocols recommend injecting retrobulbar hyaluronidase if visual loss related to accidental intravascular injection of hyaluronic acid occurs. Given the dramatic increase in cosmetic filler injections and the variety of professionals that can deliver them, it is reasonable to assume that the incidence of complications will rise significantly.ObjectiveTo evaluate if there is evidence-based efficacy of retrobulbar hyaluronidase injection in visual loss secondary to periocular cosmetic filler injection.Material and methodsThe authors performed a search of English and Spanish language articles following the PRISMA statement published on the use of retrobulbar hyaluronidase to reverse vision loss precipitated by hyaluronic acid gel fillers. Articles reviewed included case reports/series and experimental investigations. We identified a total of 13 patients in this review following defined inclusion and exclusion criteria.Finally, we included 15 articles in the study, 12 of them were cases / case series. The 2 remaining articles are experimental studies in animals with a control group, in which after causing selective occlusion of the ophthalmic artery, serial injections of retroocular hyaluronidase are administered with control of visual function.ResultsOf the 15 articles included in the study, we studied 17 patients treated with retrobulbar hyaluronidase for hyaluronic acid-induced blindness. Improvement was demonstrated in 3 cases. Animal studies demonstrate variable data are provided regarding the recovery of visual acuity.ConclusionsThere is no confirmed evidence of retrobulbar hyaluronidase injection effectiveness in treating visual loss due to accidental intravascular injection of hyaluronic acid. More studies are needed to show the efficacy of hyaluronidase as a treatment for blindness caused by hyaluronic acid.     

Treatment of lower eyelid retraction by expansion of the lower eyelid with hyaluronic Acid gel

PURPOSE: To report our preliminary experience utilizing a nonsurgical alternative in the treatment of lower eyelid retraction: expansion and reinforcement of the lower eyelid with hyaluronic acid gel. METHODS: Retrospective review of patients with lower eyelid retraction treated with hyaluronic acid gel. Pretreatment, post-treatment, and follow-up photographs were digitized and overall outcomes assessed. Measurements of inferior scleral show were standardized and compared. RESULTS: Sixty-five procedures (31 patients; 14 male; mean age 58 years, range, 33-78 years) with lower eyelid retraction of various etiologies were treated with hyaluronic acid gel. A mean change in scleral show of 1.04 mm was found when pre- and post-treatment measurements were compared. The overall mean follow-up period was 6.2 months (range, 1-12 months). During the interval from initial treatment to follow-up visit (mean 4.6 months, range, 1-12 months), the effect of the hyaluronic acid gel diminished, with a mean increase in inferior scleral show of 0.52 mm. Twelve patients underwent a second, and 6 patients underwent a third, maintenance treatment with an improvement in scleral show of 0.87 mm and 1.13 mm, respectively. Complications were minor and included swelling, redness, bruising, and tenderness at the sites of injection. CONCLUSIONS: Based on our preliminary results, hyaluronic acid gel shows promise as a treatment modality for the management of lower eyelid retraction. Long-term follow-up will better clarify the required frequency of maintenance injections, the degree of hyaluronic acid gel retention, and the position of the lower eyelid over time.     

Relationship of the eye to the bony orbit, with clinical correlations

PURPOSE: To examine normal anatomic relationship of the globe to the bony orbit, and relate variations in this relationship to clinical parameters. METHODS: Seventy-nine axial and sagittal magnetic resonance imaging (MRI) scans of the globe and orbit were studied. Any patients with pathology, as reported by the radiologists' findings, were excluded. Measurements were made on the images to determine the position of the globe relative to the bony orbit and to describe the configuration of the anterior face of the maxillary sinus. Clinical measurements were performed on photographs of 36 patients who underwent MRI scans. An independent observer rated these photographs for two clinical findings: inferior scleral show and tear trough deformity. RESULTS: Correlations were found in the following sets of variables. (i) Corneal projection from infraorbital rim and corneal projection from lateral rim; (ii) corneal projection from supraorbital rim and corneal projection from lateral rim; (iii) scleral show and corneal projection from lateral orbital rim; and (iv) tear trough deformity rating and angle of anterior face of maxillary sinus.There were no significant correlations found in the other data variables. CONCLUSIONS: The data show that abnormal relationships between the globe and the bony orbit can have clinical consequences. Inferior scleral show is shown to be related to relative globe prominence, measured from either the lateral or the inferior orbital rims. The tear trough deformity is correlated with a sloping maxillary face. The results provide a rational basis for surgeries designed to normalize these relationships.     

Crosslinked hyaluronic acid with liposomes and crocin for management symptoms of dry eye disease caused by moderate meibomian gland dysfunction

AIM: To investigate whether inhibition of acetylcholinesterase (AChE) by donepezil ameliorate aberrant retinal neovascularization (RNV) and abnormal glial activation in oxygen-induced retinopathy. METHODS: A mouse model of RNV was induced in postnatal day 7 (P7) mice by exposure to 75% oxygen. Donepezil were administrated to P12 mice by intraperitoneal injection. Expression and localization of AChE in mouse retinas were determined by immunofluorescence. RNV was evaluated by paraffin sectioning and hematoxylin and eosin (HE) staining. Activation of retinal muller glial cells were examined by immunoblot of glial fibrillary acidic protein (GFAP). rMC-1, a retinal muller cell line, was used for in vitro study. Expression of hypoxia-induced factor 1α (HIF-1α) and vascular endothelial growth factor (VEGF) were determined by Western-blot analysis, enzyme-linked immunosorbent assay (ELISA) or immunostaining. RESULTS: Aberrant RNV and glial activation was observed after OIR. Of note, retinal AChE was mainly expressed by retinal muller glial cells and markedly increased in OIR mice. Systemic administration of donepezil significantly reduced RNV and abnormal glial activation in mice with OIR. Moreover, ischemia-induced HIF-1α accumulation and VEGF upregulation in OIR mouse retinas and cultured rMC-1 were significantly inhibited by donepezil intervention. CONCLUSION: AchE is implicated in RNV with OIR. Inhibition of AChE by donepeizl is likely to be a potential therapeutic approach for retinal neovascular diseases.     

Increased vitreal levels of interleukin-10 in diabetic retinopathy: a Meta-analysis

AIM: To study the effect of uncrosslinked and crosslinked hyaluronic acid combined with other artificial tear components in patients with dry eye caused by moderate meibomian gland dysfunction. METHODS: Prospective, single-blind, contralateral eye study. Fifty eyes (25 patients) were analyzed. Eye selection for each tear type was random, and the eye drop formulations, 0.4% uncrosslinked hyaluronic acid and 0.2% galactoxyloglucan (tear A) and 0.15% crosslinked hyaluronic acid, crocin, and liposomes (tear B) were used. The determined dosing schedule was three times a day for six weeks, and the study participants underwent a clinical examination before and 45d after lubricant treatment. The Schirmer test, tear breakup time (TBUT) test, and Ocular Surface Disease Index (OSDI) questionnaire were applied before and after instillation period with both types of artificial tears. RESULTS: On the Schirmer test, a significant improvement was obtained with both tear A (P<0.01) and tear B (P<0.01). On the TBUT test, a significant improvement was obtained with tear A (P<0.01) and tear B (P<0.01). The OSDI score significantly decreased after instillation period with both artificial tear types (P<0.01). CONCLUSION: Uncrosslinked hyaluronic acid combined with other components, such as tamarind seed polysaccharide, and crosslinked hyaluronic acid combined with liposomes and crocin are effective for management symptoms of dry eye disease.     

The surface activity of purified ocular mucin at the air-liquid interface and interactions with meibomian lipids

PURPOSE: Ocular mucins are thought to contribute to the stability of the tear film by reducing surface tension. The purpose of this study was to compare the effect of different mucins and hyaluronic acid (HA) alone and mixed with meibomian lipids on the surface pressure at an air-liquid interface. METHODS: A Langmuir trough and Wilhelmy balance were used to measure and compare the surface activity of bovine submaxillary gland mucin (BSM), purified BSM, purified bovine ocular mucin and HA, and mixtures of these with meibomian lipids, phosphatidylcholine, and phosphatidylglycerol. Their appearance at the surface of an air-buffer interface was examined using epifluorescence microscopy. RESULTS: Purified ocular mucin had no surface activity even at concentrations that were 100 times more than normally occur in tears. By contrast, commercial BSM caused changes to surface pressure that were concentration dependent. The surface pressure-area profiles showed surface activity with maximum surface pressures of 12.3-22.5 mN/m depending on the concentration. Purified BSM showed no surface activity at low concentrations, whereas higher concentrations reached a maximum surface pressure of 25 mN/m. HA showed no surface activity, at low or high concentrations. Epifluorescence showed that the mucins were located at the air-buffer interface and changed the appearance of lipid films. CONCLUSION: Purified bovine ocular mucin and HA have no surface activity. However, despite having no surface activity in their own right, ocular mucins are likely to be present at the surface of the tear film, where they cause an increase in surface pressure by causing a compression of the lipids (a reorganization of the lipids) and alter the viscoelastic properties at the surface.     

Efficacy of the Mineral Oil and Hyaluronic Acid Mixture Eye Drops in Murine Dry Eye

Purpose

To investigate the therapeutic effects of mineral oil (MO) and hyaluronic acid (HA) mixture eye drops on the tear film and ocular surface in a mouse model of experimental dry eye (EDE).

Methods

Eye drops consisting of 0.1% HA alone or mixed with 0.1%, 0.5%, or 5.0% MO were applied to desiccating stress-induced murine dry eyes. Tear volume, corneal irregularity score, tear film break-up time (TBUT), and corneal fluorescein staining scores were measured at 5 and 10 days after treatment. Ten days after treatment, goblet cells in the conjunctiva were counted after Periodic acid-Schiff staining.

Results

There was no significant difference in the tear volume between desiccating stress-induced groups. The corneal irregularity score was lower in the 0.5% MO group compared with the EDE and HA groups. The 0.5% and 5.0% MO groups showed a significant improvement in TBUT compared with the EDE group. Mice treated with 0.1% and 0.5% MO mixture eye drops showed a significant improvement in fluorescein staining scores compared with the EDE group and the HA group. The conjunctival goblet cell count was higher in the 0.5% MO group compared with the EDE group and HA group.

Conclusions

The MO and HA mixture eye drops had a beneficial effect on the tear films and ocular surface of murine dry eye. The application of 0.5% MO and 0.1% HA mixture eye drops could improve corneal irregularity, the corneal fluorescein staining score, and conjunctival goblet cell count compared with 0.1% HA eye drops in the treatment of EDE.     

Ocular ischemia with hypotony after injection of hyaluronic acid gel

The authors experienced a case with ocular ischemia with hypotony following injection of a dermal filler for augmentation rhinoplasty. Immediately after injection, the patient demonstrated a permanent visual loss with typical fundus features of central retinal artery occlusion. Multiple crusted ulcerative patches around the nose and left periorbit developed, and the left eye became severely inflamed, ophthalmoplegic, and hypotonic. Signs of anterior and posterior segment ischemia were observed including severe cornea edema, iris atrophy, and chorioretinal swelling. The retrograde arterial embolization of hyaluronic acid gel from vascular branches of nasal tip to central retinal artery and long posterior ciliary artery was highly suspicious. After 6 months of follow up, skin lesions and eyeball movement became normalized, but progressive exudative and tractional retinal detachment was causing phthisis bulbi.     

The fat pearl graft in ophthalmic plastic surgery: everyone wants to be a donor!

Autogenous fat pearl grafting offers a solution to several difficult problems in ophthalmic plastic surgery. These include lower eyelid contour and tear trough deformities, depressed scars, and upper eyelid crease asymmetries and hollow superior sulci. The grafting technique is easily learned and patient satisfaction is high.     

Intravitreal bevacizumab treatment of choroidal neovascularization secondary to age-related macular degeneration

PURPOSE: To describe the short-term anatomical and visual acuity responses after intravitreal injection of bevacizumab (Avastin, Genentech) in patients with choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). METHODS: We conducted a retrospective study of patients with CNV secondary to AMD who were treated with intravitreal injection of bevacizumab (1.25 mg) during a 3-month period. Patients underwent best-corrected Snellen visual acuity testing, optical coherence tomography, and ophthalmoscopic examination at baseline and follow-up visits. RESULTS: There were 266 consecutive eyes of 266 patients who received injections, and follow-up information was available for 251 (94.4%). The mean age of the patients was 80.3 years, the mean baseline visual acuity was 20/184, and 175 (69.7%) had inadequate response to alternate methods of treatment. At the 1-month follow-up (data available for 244 patients), the mean visual acuity was 20/137 (P < 0.001 as compared with baseline), and 74 (30.3%) of patients had improvement in visual acuity as defined by a halving of the visual angle. At the 2-month follow-up (data available for 222 patients), the mean visual acuity was 20/122 (P < 0.001), and 78 (31.1%) of patients had visual improvement. At the 3-month follow-up (data available for 141 patients), the mean visual acuity was 20/109 (P < 0.001), and 54 (38.3%) of patients had visual acuity improvement. The mean central macular thickness at baseline was 340 mum and decreased to a mean of 247 microm at month 1 (P < 0.001) and 213 microm at month 3 (P < 0.001). At 1 month, two patients had mild vitritis, as did one patient at 2 months, who had a history of recurrent uveitis. No endophthalmitis, increased intraocular pressure, retinal tear, or retinal detachment occurred. The risk for thromboembolic disorders did not seem to be different than reported previously in studies concerning macular degeneration. CONCLUSION: There were no apparent short-term safety concerns for intravitreal bevacizumab injection for CNV. Treated eyes had a significant decrease in macular thickness and improvement in visual acuity. The follow-up was too short to make any specific treatment recommendations, but the favorable short-term results suggest further study is needed.     

Retinal pigment epithelial tears after intravitreal bevacizumab injection for exudative age-related macular degeneration

Purpose: To determine the incidence of and the risk factors for the development of retinal pigment epithelial (RPE) tears after intravitreal bevacizumab (Avastin) injection for the treatment of exudative age‐related macular degeneration (AMD). Methods: A retrospective, multicentre, consecutive interventional case series of all patients with subfoveal exudative AMD treated with intravitreal bevacizumab between August 2005 and April 2007. The main outcome measures were pre‐ and post‐RPE tear visual acuity and choroidal neovascular membrane lesion types, incidence of tears and time from first injection until development of the tear. Results: A total of 920 eyes with exudative AMD were treated with intravitreal bevacizumab. Fifteen eyes from 15 patients developed a RPE tear for an incidence of 1.6%. The average patient age was 79 years. Fourteen of the fifteen eyes (93%) had an occult subfoveal choroidal neovascular membrane. Forty‐seven per cent (7/15) of the RPE tears occurred within the first 6 weeks of treatment, and all tears occurred within the first 18 weeks of treatment initiation. The mean pre‐injection visual acuity was 20/100 with a mean post‐tear visual acuity of 20/200. In all 10 eyes in which the tear involved the fovea, the final visual acuity was poor. Six of the 15 eyes continued with bevacizumab/ranibizumab (Lucentis) injections after tear development, and four of these six eyes continued to have visual improvement. Conclusion: RPE tears occur after intravitreal bevacizumab injections for exudative AMD in approximately 1.6% of eyes and can cause severe vision loss. Maintenance of therapy may help preserve vision after RPE tear development.