Therapeutic Intra-arterial Hyaluronidase Infusion for Ophthalmic Artery Occlusion Following Cosmetic Facial Filler (Hyaluronic Acid) Injection

Although dermal/subcutaneous injection of filler into the face is a popular aesthetic surgery, severe complications related to arterial occlusion, including skin necrosis and visual loss, have been reported. Herein, we report a case of intra-arterial hyaluronidase infusion in the ophthalmic artery and other arteries supplying the facial skin following hyaluronic acid injection at the glabella and nasal ala. Despite direct hyaluronidase infusion into the ophthalmic artery, retinal arterial perfusion was not restored, but branches of the ophthalmic and facial arteries were recanalised. Skin discoloration was normalised, and partial recovery of retinal and choroidal perfusion and complete recovery of ocular movement were achieved.     

Tear trough rejuvenation: A safety evaluation of the treatment by a semi-cross-linked hyaluronic acid filler

The aim of this study is to describe the experience of 33 physicians, dermatologists and surgeons, with the use of a semi-cross-linked hyaluronic acid (HA) gel as a tear trough deformity filler within one month following injection, and to assess patient satisfaction with the procedure. This study is a case series conducted between February 2012 and December 2012 with the use of semi-cross-linked HA to correct tear trough deformity. The filler was administered in the preperiosteal tissues. The study involved case note review and a patient satisfaction survey. A total of 302 eyes of 151 patients were treated by 33 physicians, with a mean follow-up of 3 weeks. Patients were mainly female (86%), and middle-aged (mean age 48 years old). The gel was placed preperiosteally, deep to the orbicularis, anterior to the inferior orbital rim, with a mean volume of 0.48 ml per eye to achieve correction. The injection procedure was performed without local anesthetic for 79% of the patients. No serious adverse event was recorded. Side effects reported by investigators immediately after injection included bruising (11%), swelling (12%), and redness (inflammation 12%). Very few transitional blue discolorations (2.6%) were observed. No patient required dissolution with hyaluronidase. According to our satisfaction survey, all patients had cosmetic improvement. Most patients (97%) described marked or moderate satisfaction with the treatment. At one month, 18% requested additional hyaluronic acid gel for a touch-up injection. This case series confirms the effective use of a semi-cross-linked HA gel in tear trough rejuvenation. It has excellent patient tolerability, minimal complications, and excellent patient satisfaction.     

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.     

Chronic Invasive Fungal Sinusitis Presenting as Inferior Altitudinal Visual Field Defect

A young male with acute blurring of vision (6/9) complained of an inferior altitudinal field defect in right eye. Clinical ophthalmological examination was normal. Magnetic resonance imaging (MRI) of the brain revealed the expansion and mucosal thickening of right posterior ethmoid and sphenoid sinuses and opacified right maxillary sinus. Surgical intervention (transethmoidal sphenoidotomy) and histopathological examination revealed chronic invasive granulomatous fungal sinusitis. Anti-fungal therapy led to resolution of visual complaints and restoration of visual field defects.     

Oclusión de la arteria central de la retina tras inyección facial de ácido hialurónico

A 57-year-old woman with no premorbidities presented with symptoms of sudden painless vision loss in the right eye (RE). Best-corrected visual acuity in the RE was counting fingers to 10 cm. A relative afferent pupillary defect was observed in the RE. Ocular fundus examination of RE was suggestive of central retinal artery occlusion. Systemic evaluation was normal. The most interesting fact in this case is that a hemorrhagic edema in the right glabellar region was the basis for the diagnostic suspicion. The patient recognized the loss of vision 24 hours after hyaluronic acid injection as a facial rejuvenation treatment.     

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.     

精神病患者巨大眶内异物1例

患者,男,39岁,以右眼红、痛入院。他受到一个老者暗示将自己的右眼用木棒击伤。临床表现为右眼中度突出,完全性眼肌麻痹和严重眶周皮肤肿胀。眼科影像学表现为右眼眼窝蜂窝组织炎及眼下静脉血栓形成,两侧海绵窦综合征和海绵窦血栓。报告中无眼内及眶内异物。积极使用静脉抗生素,患者的病情并没有得到改善。在麻醉下检查发现在穹窿下有一个巨大的木质异物。异物去除及强力抗生素治疗下患者病情明显恢复。诊断中发现受伤原因可能是由这个精神病患者自我伤害引起。详细的病史、检查及合理的调查揭示其潜在的病因。敏锐的察觉及相关的临床发现与影像学研究在眶内异物及眶蜂窝组织炎处理中显得尤为有效的。及时诊断和治疗可能进一步减少患者的发病率或死亡率。     

Ischaemic Optic Neuropathy in Lyme Disease

A 57-year-old man was referred for a painful acute inferior visual field defect in his right eye. Fundus examination of the right eye revealed diffuse optic disc oedema compatible with a papillitis. Cerebrospinal fluid (CSF) findings were consistent with lymphocytic meningitis, and serologic tests for Lyme disease were positive in both serum and CSF. After treatment with ceftriaxone and bolus of methylprednisolone, right eye inferior altitudinal visual field defect persisted despite resolution of papillitis, and fundus examination disclosed a superior optic atrophy in the right eye. To our knowledge, it is the first reported case of a unilateral Lyme optic neuritis occurring simultaneously to neuroborreliosis and further complicated by non-arteritic anterior ischaemic optic neuropathy.     

Ocular and cerebral infarction from periocular filler injection

A 20-year-old woman presented with loss of vision in her right eye and a “black nose” after receiving hyaluronic acid filler injections in her right glabella 1 month prior. Her vision was no light perception, and external examination revealed resolving skin necrosis at the nasal tip. A dilated fundus exam showed a fibrotic membrane emanating from a pale optic nerve and a diffusely atrophic retina with sclerotic vessels. An MRI demonstrated scattered right-sided parietal lobe infarcts. These findings were consistent with inadvertent cannulation of the supraorbital artery, followed by injection of filler into the internal carotid circulation. The product traveled in a retrograde fashion, occluding the right ophthalmic artery, right dorsal nasal artery, and arterial segments to the Circle of Willis. This case highlights the importance of understanding the complex vascular architecture of the periorbita and the mechanism by which such occlusions occur.     

Paradoxical reaction in tubercular meningitis resulting in involvement of optic radiation

A 25-year-old woman was diagnosed to have tubercular meningitis (TBM) with a right parietal infarct. She responded well to four-drug anti-tubercular treatment (ATT), systemic steroids and pyridoxine. Steroids were tapered off in one and a half months; she was put on two-drug ATT after two months. Six months after initial diagnosis she presented with sudden, bilateral visual loss. Vision was 3/200 with afferent pupillary defect and un-recordable field in the right eye; vision was 20/60 in the left eye, pupillary reaction was sluggish and the field showed a temporal hemianopia. On reintroduction of systemic corticosteroids vision improved (20/120 in right eye and 20/30 in left eye) within three days; the field defects improved sequentially to a left homonymous hemianopia, then a left homonymous inferior quadrantonopia. A diagnosis of TBM, on treatment, with bilateral optic neuritis, and right optic radiation involvement was made. Since the patient had been off ethambutol for four months, the optic neuritis and optic radiation lesion were attributed to a paradoxical reaction to tubercular allergen, corroborated by prompt recovery in response to corticosteroids. This is the first report of optic radiation involvement in a paradoxical reaction in neuro-tuberculosis in a young adult.     

Visual impairment by multiple vascular embolization with hydroxyapatite particles

We demonstrate a case of ocular impairment caused by a hydroxyapatite filler injection and review the prior literature on clinical presentations. A healthy woman, who received a hydroxyapatite filler injection into the glabella for nose augmentation suddenly had symptoms of nausea, diplopia, visual loss in the left eye, and impaired consciousness. Her left eye showed paresis of the inferior branch of the oculomotor nerve, conjunctival injection, cell infiltration in the anterior chamber, and multiple white spots in the nasal fundus. Purpura was detected in the area from the glabella to the left forehead. An orbital computed tomography (CT) scan demonstrated high-density deposits along vessels in the left medial orbit and forehead. Although her consciousness stabilized after a few days, the vision in her left eye deteriorated due to corneal edema and both hypopyon and hyphema in the anterior chamber, and the skin from the glabella to the left forehead developed necrosis. Multiple plaques were observed within the conjunctival and scleral vessels. After 2 months, diplopia and visual loss issues were mostly resolved. A histological examination of the conjunctiva specimen showed multiple foreign bodies plugged vessels that could be dissolved by decalcification. Recently, the number of complications by cosmetic filler injections has increased. The migrated hydroxyapatite particles in vessels cause multiple vascular emboli that can lead to various symptoms.     

Transient impaired vision,external ophthalmoplegia,and internal ophthalmoplegia after blepharoplasty under local anesthesia

PURPOSE: To report a case of transient bilateral vision impairment with external ophthalmoplegia and internal ophthalmoplegia after blepharoplasty under local anesthesia. DESIGN: Interventional case report. METHODS: A 70-year-old man underwent bilateral upper blepharoplasty under local anesthesia. During orbital fat removal additional anesthetic was injected into both medial fat pads for pain control. RESULTS: Immediate postoperative examination revealed bilateral decreased visual acuity and internal ophthalmoplegia in the right eye. An exotropia was present with marked limitation of right eye adduction. These findings resolved completely 3 hours postoperatively. CONCLUSIONS: Local anesthesia during blepharoplasty can enervate the optic nerve, ciliary ganglion, and extraocular muscle nerves. Local anesthesia should be injected judiciously during orbital fat removal to avoid this reversible but alarming event.     

Optic atrophy in acute intermittent porphyria.

A 24-year-old woman developed bilateral blindness after recovery from coma secondary to acute intermittent porphyria. Gradual return of vision in the right eye with a permanent unilateral visual field defect and optic atrophy followed. We believe the pathophysiologic mechanism was spasm of the vessels supplying the optic disk leading to ischemia and infarction of the optic nerve.     

复方樟柳碱治疗AION的微视野研究

目的:探讨复方樟柳碱(compound anisodine hydrobromide injection)治疗前部缺血性神经病变(anterior ischemic optic neuropathy,AION)的微视野的临床疗效。方法:AION患者66例107眼,采用患侧颞浅动脉旁皮下注射2mL,1次/d,10d一个疗程,基础疗程为四个,依照病情可增加1~2个疗程,观察眼底视盘形态与视功能改变,以反映其疗效的临床价值。结果:采用患侧颞浅动脉旁皮下注射四个疗程后,视力恢复有显著疗效者约55%,治疗第三、四疗程与第一、二疗程比较,视野缺损度改善有显著性差异(P<0.05),且患侧颞浅动脉旁皮下注射第四疗程视功能恢复最佳。结论:复方樟柳碱可以有效改善AION患者的视力和视野缺损度,是一种治疗AION方便、快捷、安全的方法。     

The central retinal artery occlusion in the right eye followed by a branch retinal artery occlusion in the left eye four days later

A 65-year-old woman was admitted to our clinic with complaints of sudden, painless, decrease in vision, and sectoral visual field defect in the left eye and later presented to our clinic again with a history of sudden loss of vision in her right eye. In this case study we reported that the patient had branch retinal artery occlusion (BRAO) in the left eye and at the same time progressing central retinal artery occlusion (CRAO) in the right eye.     

Anterior Ischemic Optic Neuropathy Associated with Pegylated Interferon Therapy for Chronic Hepatitis C

Purpose: To report a case of anterior ischemic optic neuropathy (AION) associated with the combined therapy of pegylated interferon alpha (PEG-IFNα) and ribavirin. Methods: Case report. Results: A 57-year-old male with chronic hepatitis C, treated with PEG-IFNα -2b and ribavirin for 6 months, noted sudden onset of painless blurred vision in his right eye. The initial visual acuity decreased to 20/60 in the right eye. Fundoscopy of right eye revealed optic disc edema with disc hemorrhage. Visual field examination disclosed inferior altitudinal defect. Relative afferent pupillary defect with poor color vision function was also noted in the right eye. Visual evoked potential demonstrated decreased amplitude in the right eye. A marked resolution of disc edema and improvement of visual acuity to 20/20 were noted at 6 weeks follow-up. Conclusions: AION may occur in combined treatment of PEG-IFNα -2b and ribavirin for chronic hepatitis C. Patients who are candidates for this treatment should be informed about its possible occurrence.     

Acute visual loss after spinal surgery

Purpose: To report visual loss after prone spinal surgery. Methods: Computed tomography scan, fundus photography, optical coherence tomography (OCT). Results: A 56‐year‐old man demonstrated loss of vision in the left eye after cervical spinal surgery. Clinical examination revealed loss of vision to finger counting, severe visual field defect and blurred neural rim area around the optic disc in the left eye. Six weeks later, visual acuity in the left eye was 6/9 and there was inferior visual field defect. Six months after the surgery, significant reduction of retinal nerve fibre layer thickness around the optic nerve head was measured with OCT, consistent with the visual field defect. Conclusion: Ischemic optic neuropathy is the most common cause of visual loss after spine surgery and special emphasis should be given to protect the eye against possible pressure during the surgery.     

Bilateral Optic Disc Swelling Following Anastrozole Therapy

A 56-year-old female with early-stage breast cancer, stage IA grade 1 endometrial cancer, and stage IC grade 1 ovarian cancer developed sudden-onset visual changes and right inferior visual field defect following anastrozole therapy. Examination revealed severe bilateral optic disc swelling and impaired visual acuity. Laboratory work-up was otherwise unremarkable. Anastrozole was discontinued and over the next month, patient had near-complete resolution of swelling in the right eye and improvement in the left eye. This is the only reported case of optic disc swelling following anastrozole therapy.     

Diabetic papillopathy and type 2 diabetes

CASE REPORT: We report a case of a 62-year-old man with type II diabetes mellitus and mild impairment of visual acuity with bilateral optic disc edema. Visual field examination showed enlargement of right blind spot and an inferior arcuate defect in the left eye. Blood pressure, neuroimaging evaluation and cerebrospinal fluid analysis were normal. Spontaneous resolution was observed six weeks later. DISCUSSION: Although the diabetic papillopathy was initially described in juvenile diabetics, recently an afflicted older subpopulation with type II diabetes has been reported to develop this condition. We discuss the clinical characteristics, pathogenesis and differential diagnosis of this clinical entity.