Janetos, Timothy M.; Thyparampil, Preeti
Purpose: This perspective explores the safety profile of ocular cosmetics and explores the role ophthalmologists can play in mitigating potential ocular harm from unsafe products.
Results: Cosmetics and personal care products represent a large industry that is currently unregulated in any meaningful way. Products intended for use around the eyes carry a risk of serious side effects including contact dermatitis and bacterial infection. Currently, legislation has been proposed to change regulation to provide more meaningful oversight of cosmetics.
Conclusions: Ophthalmologists are often the first to recognize patterns in harmful products intended for use around the eye and can help mitigate potential future ocular harm by reporting adverse events to the Food and Drug Administration and by advocating for cosmetic regulation change.
Huang, Peijie; Liu, Ailin; Ren, Hui; Xue, Kang
Purpose: This study aimed to evaluate the effects of retinal artery occlusions caused by cosmetic facial filler injections on the retrobulbar blood flow parameters.
Methods: This was a retrospective, noncomparative case series. Ten consecutive patients with fundus artery occlusions caused by facial filler injections were evaluated using color Doppler flow imaging (CDFI). The peak systolic velocity and end diastolic velocity of the ophthalmic artery, central retinal artery, and posterior ciliary arteries were determined. The clinical features, including the filler material, injection site, best-corrected visual acuity, fundus fluorescein angiography, and associated ocular and systemic manifestations were also collected.
Results: Injected materials included autologous fat (7 cases) and hyaluronic acid (3 cases). In 6 of the patients with ophthalmic artery occlusions, the CDFI showed no or drastic declines in the retrobulbar blood flow in the ophthalmic artery, central retinal artery, and posterior ciliary arteries. In 3 of the patients with central retinal artery occlusions, the CDFI showed no or a grossly decreased retrobulbar blood flow in the central retinal artery. In one patient with anterior ischemic optic neuropathy, the CDFI showed decreased end diastolic velocities and increased pulsatility and resistance indices in the central retinal artery, posterior ciliary arteries, and ophthalmic artery. During the follow-up period, the retrobulbar blood flow recovered to some degree. Overall, ophthalmic artery occlusion patients receiving autologous fat may have neurologic complications.
Conclusions: The results suggest that the retrobulbar ocular blood flows measured with CDFI were distinctly different in the different types of ophthalmic artery occlusion. Color Doppler flow imaging could provide a practicable and convenient method for the diagnosis and follow up of retinal artery occlusions caused by cosmetic facial filler injections.
Scofield-Kaplan, Stacy M.; Patel, Sagar Y.; Mueller, Andrew; Ford, W. Cameron; Evers, Bret M.; Hogan, R. Nick; Mancini, Ronald
Foreign-body granuloma formation following filler injections is most commonly seen with permanent fillers; these reactions can occur years following the injections and often require either an intralesional steroid injection or surgical excision. The authors present a case of a 75-year-old woman with a history of systemic sarcoidosis previously treated with numerous immunosuppressive medications who was examined for bilateral infraorbital nodules and swelling that were unresponsive to treatment. She underwent a bilateral anterior orbitotomy through a transconjunctival approach with mass excision. The histologic analysis was consistent with foreign-body granulomata juxtaposed to implantable material, specifically ArteFill, which was injected many years prior. There were no separate noncaseating granulomas to suggest sarcoidosis as the underlying etiology. It is important to consider prior filler injections in patients with sarcoidosis who present with subcutaneous nodules as this changes management and may prevent the need for more aggressive immunosuppressive treatment.
Hans Olav Ueland, Roy M. Nilsen, Eyvind Rødahl, Svein Arthur Jensen
To compare injections of hyaluronic acid (HA) and autologous fat (AF) for the treatment of unsightly temporal hollowing after lateral orbital wall decompression in thyroid eye disease.
In this nonblinded prospective comparative interventional study, patients received injections of HA in the right temple and AF in the left temple. Additional injections were given when needed at follow-up after 6, 12, 18, and 24 months. Follow-up included an interview; clinical examination with an evaluation of symmetry, contour, and skin surface; and ultrasound measurements. From photographs, the temporal hollowing was graded 1–3. The main endpoints were grading of temporal hollowing and temporal soft tissue thickness.
Seventeen patients were treated bilaterally and 12 unilaterally (five received HA and seven AF). Injection(s) of HA and AF administered at each site were a median (range) of 1 (1–4) and 2 (1–5), respectively. The total combined volume of HA injected per site was 0.9 (0.2–2.0) ml and that of AF was 3.1 (0.5–9.6) ml. At the final examination, a statistically significant difference in mean (SD) grading scores of temporal hollowing due to HA (1.18 (0.26)) compared to those of AF (1.85 (0.44)) was observed (p < 0.001). Six months after administering an injection of HA, the temporal soft tissue thickness was 2.35 (0.24) cm compared to 2.19 (0.28) cm obtained with an injection of AF (p < 0.001). By using a linear mixed-effect model and adjusting for baseline values, age, sex, and refill, the difference in favor of HA persisted at all later follow-ups. Increased fibrosis of the subcutaneous tissue developed at 5/24 sites that received AF.
Injection of HA is superior to that of AF for treating temporal hollowing after lateral orbital wall decompression.
I-Hsin Ma, Bo-I Kuo, Yu-Chih Hou
To present recurrent corneal erosion (RCE) caused by late suture exposure after blepharoplasty.
Four patients who have unilateral RCE were found to have previous blepharoplasty. The RCE was associated with late suture exposure. The clinical courses, characteristics, methods to identify the suture exposure and treatment were presented.
The clinical presentations including local erosion of upper bulbar conjunctiva, corneal abrasion lines, local corneal epithelial defects with rough border, and subepithelial opacity were noticed in all four patients. RCE symptoms exaggerated in eye blinking and did not respond to artificial tears treatment. Erosion recurred soon after the removal of therapeutic contact lenses. They underwent blepharoplasty 1–10 years before RCE emerged, and the RCE lasted 1–8 months before suture exposure was found. RCE healed within 1 week after suture removal.
Suture exposure may occur several years after blepharoplasty and could cause RCE. Thorough exploration of the fornix by double eyelid eversion can identify the hidden sutures in such patients.
Mariel Angelou A. Parulan, Gangadhara Sundar, Jeffrey Hy Lum & Umashankar Ramachandran
We report a case of a 49-year old East-Asian female who presented with delayed onset granuloma formation at the right medial lower eyelid area. The clinical and radiologic presentation with pathologic correlation following synthetic hyaluronic acid filler injection and its management are described along with a review of literature following dermal-filler injections types. Dermal-filler-related granuloma formation should be included in the differential diagnoses of periorbital inflammatory and mass lesions. It is recommended that clinicians who perform this procedure should discuss these risks and possible late complications with patients and provide them with the relevant product information of the injected filler for appropriate management should such early or late complications occur.
Kalin-Hajdu, Evan; Kersten, Robert C.
Although generally safe, hyaluronic acid rejuvenation of periorbital tissue has been reported to cause minor and major adverse events. The authors document a case of nasolacrimal duct obstruction due to hyaluronic acid rejuvenation of the tear trough. Nasolacrimal duct obstruction immediately resolved following irrigation of hyaluronidase into the affected lacrimal system. To the authors’ knowledge, this is the first reported case of nasolacrimal duct obstruction due to filler injection.
Hwang, Catherine J.; Mustak, Hamzah; Gupta, Adit A.; Ramos, Regina M.; Goldberg, Robert A.; Duckwiler, Gary R.
Purpose: Hyaluronic acid gel filler-associated blindness is an uncommon but devastating complication. Hyaluronidase can potentially dissolve intravascular filler and improve perfusion; however, its role in filler-associated blindness has yet to be determined. The purpose of this study is to determine the effect of retrobulbar hyaluronidase on hyaluronic acid gel-induced ophthalmic artery occlusion in a rabbit model.
Methods: New Zealand red rabbits were used to simulate hyaluronic acid gel filler-associated vascular occlusive blindness. Ophthalmic artery occlusion and subsequent ischemia were confirmed by both retinal fundus photography and electroretinogram changes. Retrobulbar hyaluronidase 1,000 IU was injected 30 minutes after occlusion. Fundus photography and electroretinogram changes were recorded at 30, 60, 90, and 120 after administration of retrobulbar hyaluronidase.
Results: A total of 6 rabbits were used, for a total of 12 eyes. Four eyes were used as controls. Of the 8 experimental eyes, 2 eyes had recorded partial occlusion and 6 eyes had fully occluded ophthalmic arteries by angiographic evaluation. One of the partially occluded eyes demonstrated some improvement in perfusion 60 minutes after injection of retrobulbar hyaluronidase; however, electroretinogram readings remained flat over the 120-minute period of observation. Six eyes with completely occluded ophthalmic arteries showed no improvement in retinal perfusion with corresponding flat electroretinogram readings at 120 minutes following retrobulbar hyaluronidase injection.
Conclusions: In this rabbit model, 1,000 IU of retrobulbar hyaluronidase administered 30 minutes after occlusion failed to reverse obstruction or restore function following hyaluronic acid gel occlusion of the ophthalmic artery.
Mohammed Alghoul, MD, FACS
Blepharoplasty is one of the most commonly performed cosmetic surgical procedures. To date it remains the most powerful method of periorbital rejuvenation when compared to other nonsurgical modalities, especially in the aging face. Despite that, the procedure has its shortcomings that include a steep learning curve, prolonged recovery, and potential for appearance and life-changing complications. Attaining successful outcomes relies on a solid understanding of facial topography, patient and technique selection, and, when appropriate, following a conservative approach. Modern blepharoplasty relies on tissue conservation and volume enhancement rather than aggressive removal. This concept was conceived after the realization that older techniques resulted in a hollowed appearance, which accentuated the aging process. It was further reinforced by advances in knowledge of periorbital anatomy and aging changes. This Continuing Medical Education article will detail periorbital surgical anatomy, preoperative planning, and varied blepharoplasty approaches and techniques, with an emphasis on safety and tailoring the procedure to the patient’s anatomy.