Etiology of Delayed Inflammatory Reaction Induced by Hyaluronic Acid Filler.

The etiology and pathophysiology of delayed inflammatory reactions caused by hyaluronic acid fillers have not yet been elucidated. Previous studies have suggested that the etiology can be attributed to the hyaluronic acid filler itself, patient's immunological status, infection, and injection technique. Hyaluronic acid fillers are composed of high-molecular weight hyaluronic acids that are chemically cross-linked using substances such as 1,4-butanediol diglycidyl ether (BDDE). The mechanism by which BDDE cross-links the two hyaluronic acid disaccharides is still unclear and it may exist as a fully reacted cross-linker, pendant cross-linker, deactivated cross-linker, and residual cross-linker. The hyaluronic acid filler also contains impurities such as silicone oil and aluminum during the manufacturing process. Impurities can induce a foreign body reaction when the hyaluronic acid filler is injected into the body. Aseptic hyaluronic acid filler injections should be performed while considering the possibility of biofilm formation or delayed inflammatory reaction. Delayed inflammatory reactions tend to occur when patients experience flu-like illnesses; thus, the patient's immunological status plays an important role in delayed inflammatory reactions. Large-bolus hyaluronic acid filler injections can induce foreign body reactions and carry a relatively high risk of granuloma formation.

Cosmetic Filler-Induced Vascular Occlusion: A Rising Threat Presenting to Emergency Departments.

Vascular emergencies from cosmetic filler-induced vascular occlusion represent an iatrogenic etiology that poses a threat to patients, with sequelae that range from disfiguring skin necrosis to blindness and stroke. As cosmetic fillers continue to grow in popularity, the importance of early identification, triaging, and management of these rare but potentially disabling injuries has motivated efforts to educate the public and professional audiences. In this practice review article, we outline components of acute care pertaining to these injuries based on evolving practice guidelines and best evidence recommendations.

Novel technique of non-surgical rejuvenation of infraorbital dark circles.

BACKGROUND: Infraorbital dark circles are a common esthetic concern which can be challenging to treat given their multifactorial nature. Under-eye dark circles are seen in all skin types, with a strong familial component in darker skin types. Other major contributing factors include soft tissue and bony changes, skin changes, lifestyle contributions, and allergies. Involutional periorbital volumetric changes cause volume loss in the tear trough, naso-jugal and palpebro-malar grove, skin and subcutaneous tissues with tethering of the eyelid skin to the tear trough ligament, giving a sunken and hollow appearance to the lower lid. Associated prolapse of the orbital fat and thin skin can worsen the appearance of a dark circle. Hyaluronic acid fillers placed in the pre-periosteal plane in the tear trough, palpebro-malar and naso-jugal grooves, give good results in patients with thick eyelid skin and negligible fat prolapse. However, in patients with thin skin and moderate fat prolapse, authors have reported worsening outcomes with risk of Tyndall (blue-gray discoloration) and contour irregularities from visible lumps. AIMS: To describe a novel technique to improve dark circles caused by a diffuse valley-type pre-septal tear trough deformity in patients with thin eyelid skin. METHODS: Retrospective case note review of 330 eyelids treated with microdroplet subdermal placement of filler in the preseptal tear trough area by a single surgeon. CONCLUSION: This novel technique shows good esthetic outcomes in patients with dark circles, with good longevity and a low risk of complications.

Awareness of management of hyaluronic acid induced visual loss: A British National Survey.

BACKGROUND: Visual loss from aesthetic hyaluronic acid filler injections is an under-reported complication. Our study surveyed British Oculoplastic consultants and Consultant members of the British Eye Emergency Care Society, on their awareness of visual vascular complications of dermal fillers and its emergency management. METHODS: A prospective survey of the members of the British Oculoplastic Society and the British Eye Emergency Society, using the Survey Monkey platform. RESULTS: There were 53 responses. Eighty five percent of responders were aware of ophthalmic artery occlusion and visual loss as a recognised complication of hyaluronic acid based fillers. Six respondents had encountered at least one case of visual loss associated with HA fillers. Approximately 27% of the respondents had some experience of the recommended appropriate management of this complication. Majority of these practitioners did not have local management guidelines for this complication (88%) nor were they aware of guidance to manage the complication (75%). CONCLUSIONS: This survey captures the current experience of British Ophthalmologists and Oculoplastic Surgeons in the management of visual vascular complication with dermal fillers. This may relate to the rarity of this complication. Although there is an awareness of visual loss as a complication from aesthetic dermal fillers, there appears to be a lack of knowledge of current management guidelines across Eye Specialists in UK. It is important for practitioners to be able to recognise and manage vascular compromise and further study recommendations are made.

Nylon Hang Back Sutures in the Repair of Secondary Ptosis Following Overcorrected Dysthyroid Upper Eyelid Retraction.

PURPOSE: Repair of blepharoptosis secondary to surgical overcorrection of thyroid related primary upper eyelid retraction (secondary ptosis) can be unpredictable. This study describes the long-term results of "hang-back" nylon sutures, for an anterior approach surgical repair of secondary ptosis. METHODS: This was a retrospective consecutive case note review of patients referred with secondary ptosis (after prior upper eyelid lowering for thyroid eye disease), under the care of a single surgeon at Moorfields Eye Hospital & subsequently at Barking Havering Redbridge University Hospitals NHS Trust (SSD). In accordance with hospital trust policy, this audit was registered and all patient data was anonymized, ethical approval was not required. Patients with secondary ptosis underwent surgery under local anesthesia through an upper eyelid skin-crease incision. The anterior portion of the levator muscle was freed from all scar tissues and its action re-established on the superior part of the upper tarsal plate, using two 6-0 nylon hang-back sutures placed centrally and medially. The margin reflex distance 1 (MRD1), skin crease height, eyelid contour, symmetry of eyelid position (difference in margin reflex distance 1 <1 mm in both eyes) and degree of lagophthalmos were assessed from clinical notes preoperative and postoperatively at 1, 3, and 12 months. RESULTS: Surgery was undertaken in 14 eyelids in 13 patients (3 males; 23%), with 9/14 (65%) eyelids having undergone attempted repair of ptosis prior to referral; in 7 of the 8 (88%) eyelids with previous failed ptosis repair, the referring surgeon had used soluble hang-back sutures. As compared with an average preoperative margin reflex distance 1 of 0.9 mm (median 1, range: -1 to 2 mm), the average margin reflex distance 1 at 3 months was 3.0 mm (median 3, range: 2.5-4 mm; p < 0.0001) and 2.8 mm at 12-month follow up (median 3, range: 2-4mm; p < 0.0001). The upper eyelid central skin crease height changed from a preoperative mean of 9.8 mm (median 9, range: 5-15 mm) to 8.7 mm at 3 months (median 8, range: 7-12 mm; p = 0.1412) and 8.9 mm at 12-month follow up (median 9, range: 7-11 mm; p = 0.2930). Only 3 patients had postoperative lagophthalmos (one patient 3 mm and two patients 1 mm) at 3 months after surgery, this resolving by the 12-month postoperative visit. Thirteen cases (93%) had a good functional, symmetrical, and aesthetic result at 12 month follow up, with a late recurrence of ptosis in 1 patient (7%). CONCLUSION: The "hang-back" semi-permanent suture technique for repair of over-corrected upper eyelid lowering in thyroid eye disease appears to provide an excellent and predictable long-term result with a low incidence of late recurrence of ptosis.

A Skin Crease Preserving Modification of Open-Sky Mullerectomy for Blepharoptosis Correction.

PURPOSE: To report the results of skin crease preservation with a modified technique of open-sky Muller's muscle-conjunctival resection that precludes the need to reconstruct the upper eyelid skin crease with full thickness sutures. METHODS: A nonrandomized, retrospective audit of 45 eyelids of 37 consecutive patients with acquired blepharoptosis, undergoing surgical correction by a single surgeon, between November 2011 and July 2014. Surgical technique involved subtotal resection of Muller's muscle plus underlying conjunctiva, under direct visualization. The stump of Muller's muscle was then reattached to the superior tarsus with buried 7-0 Vicryl. Wound closure was achieved using interrupted buried 7-0 Vicryl, without full thickness skin crease reformation. Outcomes were evaluated according to standards recommended by the British Oculoplastic Surgery Society National Ptosis survey. These included assessment of upper margin reflex distance (MRD1), skin crease, eyelid contour and symmetry and surgical complications. RESULTS: In total, all 45 eyelids met the outcome criteria for success. The median MRD1 increased from 0 mm preoperatively (range: -2 to 2) to 3.1 mm (range: 3-5 mm) following surgery, p value < 0.01. For patients with unilateral blepharoptosis, the average postoperative eyelid height difference between right and left was 0.17 mm (range: 0-1 mm). All patients achieved good eyelid contour and symmetry and none required reoperation as assessed at final follow up following surgery (mean 77 days, range: 24-366). Skin crease was lowered and normalized in all patients with median preoperative and postoperative measurements of 12 mm and 10 mm, respectively, p value < 0.01. Two cases (4.4%) developed early asymptomatic superficial punctate keratopathy, which resolved spontaneously by 4 weeks. Nonstandardized patient experience survey achieved high scores for overall satisfaction and likelihood to recommend treatment to friends and family, with low scores for postoperative pain and swelling. CONCLUSIONS: Skin Crease Preserving modified open-sky Muller's muscle-conjunctival resection is an effective technique for correcting blepharoptosis, while normalizing the skin crease.

Sliding tarsal advancement flap for upper eyelid reconstruction.

The Sliding Tarsal Advancement Flap, a modification of Hughes procedure has been used for the repair of large upper eyelid defects in three patients. The procedure yielded both good functional and aesthetic outcomes. At presentation the defect measured 50% in two cases and >50% in one case.

Two new cases of metastatic basal cell carcinoma from the eyelids.

BACKGROUND: Basal cell carcinoma (BCC) is an extremely common malignancy. Unlike other skin cancers, it very rarely metastasises. METHODS: We present two cases of advanced BCC on the eyelids that metastasized to the parotid region after local excision. DISCUSSION: We include a review of patients with metastatic BCC originating from the eyelids. CONCLUSION: Metastatic BCC from the eyelids is rare, but appears to occur in an older age group with a shorter time before metastasis when compared to metastatic BCC as a whole.

Stability of eyelid height after graded anterior-approach lid lowering for dysthyroid upper lid retraction.

OBJECTIVE: To investigate the outcome of a modified anterior approach surgical procedure for the correction of primary upper eyelid retraction in thyroid eye disease. METHODS: A retrospective review of 52 consecutive cases (in 32 patients) of anterior-approach graded upper lid lowering for the treatment of primary eyelid retraction, carried out at Moorfields Eye Hospital between 2006-2009 was conducted. Measurements of upper margin-reflex distance (MRD), upper lid skin crease height and skin fold height were taken from clinical records and photographs. A comparison between pre-operative and both early and late post-operative measurements was conducted, with a maximal follow-up of 12 months. Surgery was considered successful when all of the following criteria were met; an upper lid margin covering 0.5-1.5 mm of the superior cornea in the 12 o'clock position, smooth eyelid contour, skin crease height within 6-10 mm or upper lid skin fold within 2-5 mm of the lid margin, symmetry of lid position (difference in MRD of < 1 mm between both eyes) and patient satisfaction. RESULTS: A successful outcome was achieved in 86.5% (45/52) of lids with a single procedure. For the whole group, the mean MRD was 7.0 mm pre-operatively and 3.6 mm at 1 month after surgery. The corresponding values from photographic estimates were 6.5 mm and 3.6 mm, respectively. These values remained stable over the maximum follow-up period of 12 months. Under-correction occurred in 6/52 (11.5%) lids, one of which had persistent lateral flare, whereas over-correction occurred in 1/52 (2%). CONCLUSIONS: The described surgical approach produces reasonably predictable and stable outcome for upper eyelid lowering in patients with thyroid eye disease.

Digital image analysis to characterize the upper lid marginal peak after levator aponeurosis repair.

PURPOSE: Lid contour is important for eyelid symmetry, but clinical quantification can be difficult. The marginal peak is a major determinant of upper eyelid contour, and its horizontal position, relative to the mid-pupillary line, may be used as a measure of symmetry after surgery. This study used digital image analysis to assess the peak position in patients who had undergone levator aponeurosis repair. METHODS: An unselected group of patients underwent anterior-approach levator aponeurosis repair, performed under local anesthesia by a single surgeon, using 3 6/0 Vicryl sutures to reattach the levator aponeurosis to the upper tarsus. Both before and 2-3 weeks after ptosis repair, digital photographs were taken in a fixed format and the images analyzed using NIH imaging software to assess the position of the upper eyelid peak. Comparisons were made between the pre- and postoperative measurements in the operated eye and between the operated eye and its fellow eye. RESULTS: Twenty people (8 male; 40%) underwent unilateral levator muscle resection (9 right eyes; 45%). In eyes before ptosis surgery, the peak was significantly more medially placed (median +0.17 mm) as compared with that of fellow eyes (median +0.80 mm) (p = 0.023). There was a significant temporal shift of the median peak after surgery, from +0.17 mm to +0.92 mm (p = 0.029). Although there was a minor nasal shift of peak in the unoperated eyes after contralateral surgery (median +0.80 mm to +0.64 mm), the peak positions for the 2 eyes were not significantly different at 2-3 weeks after aponeurosis repair (p = 0.22). CONCLUSIONS: Digital image analysis allows an objective assessment of the upper eyelid marginal contour after ptosis repair. A nasal shift in the upper eyelid marginal peak has been identified in ptotic eyes (as compared with the contralateral side) and, after successful ptosis repair, there is a significant temporal shift to match the unoperated fellow eye.

Scleral contact lens usage in patients with complex blepharoptosis.

PURPOSE: To evaluate the efficacy of scleral contact lenses (ScCLs) as an alternative or as an adjunct to surgical correction for the management of complex ptosis. METHODS: A retrospective case-note review was used to determine the subjective function and cosmetic acceptability of the lenses. Digital photographs were taken, both with and without the lens in place; analytic software was used to assess the vertical height of the palpebral aperture (PA) and the upper margin-reflex distance. Three masked observers independently graded the photographs for cosmesis as "good," "moderate," or "poor." RESULTS: Ten patients (6 male) had been wearing ScCLs in 14 treated eyes for between 1 and 40 years (mean, 10.3 years; median, 3 years). Without a lens, the mean PA was 4.9 mm (median, 5.1 mm; range, 1.7-7.1 mm), increasing to 9.5 mm (median, 8.9 mm; range, 5.8-14.8 mm) with the lens in place (p < 0.005). Likewise, the upper margin-reflex distance increased from 0.39 mm (median, 0.03 mm; range, 0-2.4 mm) without a lens in place to 3.1 mm (median, 2.7 mm; range, 1.5-5.8 mm) with lens wear (p < 0.005). In 6 patients with unilateral ScCL wear, mean PA was 10.4 mm in the treated eye and 8.4 mm in the eye without a lens (p = 0.22). All patients who were wearing ScCLs long term found them to be both comfortable and cosmetically acceptable. On subjective grading of photographs, however, the cosmesis was judged as "good" in 22%, "moderate" in 64%, and "poor" in 14%. CONCLUSION: In some patients, ScCLs provide a well-tolerated and practical long-term solution to safely elevating the upper eyelid in which complex ptosis is present. The patients in our cohort seem to be satisfied with the cosmesis, although there are some limitations to this aspect when viewed subjectively.

Long-term outcomes of surgical approaches to the treatment of floppy eyelid syndrome.

OBJECTIVE: To identify and describe the different procedures used in the treatment of floppy eyelid syndrome (FES) at Moorfields Eye Hospital and to evaluate their effectiveness. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 71 patients who had undergone surgery for FES over a 13-year period since 1995 at Moorfields Eye Hospital were recruited. Retrospective data from 7 patients were also included, providing data for 78 patients. METHODS: Patients underwent a full ocular examination. A survival analysis was determined by plotting Kaplan-Meier curves for each type of procedure encountered. Comparison of survival trends was made using a log-rank test. The possible effects of bias arising from bilaterality of the condition were investigated using a sensitivity analysis and a Cox regression analysis allowing for clusters. Tests for surgeon bias were made using the Fisher exact test. MAIN OUTCOME MEASURES: Recurrence of the condition. An assessment of recurrence was made clinically by 2 independent observers who were masked to the type of surgery the patient had undergone. RESULTS: Four different forms of surgical treatment were encountered: (1) Full-thickness wedge excision (FTWE) (26 patients, 33 procedures); (2) Upper lid lateral tarsal strip (LTS) (31 patients, 43 procedures); (3) Medial canthal (MC) and lateral canthal (LC) plication (15 patients, 19 procedures); (4) Medial tarsal strip (6 patients, 6 procedures). A total of 44 of 101 procedures had failed. Superior long-term survival outcomes of both LC/MC plication (P = 0.003) and upper lid LTS (P = 0.001) procedures over FTWE was demonstrated. However, survival comparison between the LC/MC plication and LTS groups did not achieve significance (P = 0.37). No significant difference in outcome between surgeon groups of equivalent experience was demonstrated (P = 0.18). No bias arising from bilaterality of the condition was identified. CONCLUSIONS: These data provide strong evidence of better survival outcomes in FES using the MC/LC plication and LTS procedures in comparison with the FTWE procedure. On the basis of experience from our unit, we recommend that the FTWE procedure be avoided as a form of treatment for FES in favor of the MC/LC plication, LTS, or medial tarsal strip procedure. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Lax eyelid syndrome or 'progeria' of eyelid tissues.

PURPOSE: The lax eyelid syndrome was described by Van den Bosch and Lemij as an uncommon disorder seen in non-obese elderly people and characterised by chronic ocular surface irritation symptoms and a "floppy upper eyelid". The authors present some new features of the lax eyelid syndrome. METHODS: The authors report five patients, belonging to a younger age group, who presented with premature laxity of all the eyelid tissues. This caused medial and lateral canthal dystopia and eyelid malposition including ptosis, entropion and ectropion. Initial surgical correction was often followed by recurrence after some time. CONCLUSIONS: The authors highlight the differences between lax eyelid syndrome, cutis laxa, floppy eyelid syndrome and the blepharochalasis syndrome and suggest that lax eyelid syndrome can be thought of as "progeria" or premature ageing of the eyelid tissues to distinguish it clearly from these other conditions.

Role of the lower lid retractors in involutional ectropion repair.

AIM. To outline the role of the lower lid retractors in correction of involutional ectropion. METHODS. Eight eyelids with a tarsal ectropion were included in the study. Clinical clues to help identify weakness of the lower lid retractors were documented. A transconjunctival lower lid retractor reattachment with concommitant correction of horizontal lid laxity and lamellar dissociation was performed. RESULTS. Stable eyelid position was obtained in 7 of the 8 cases. One case had a lateral ectropion due to a wound dehiscence. CONCLUSIONS. This small study helps better define the clinical presentations of retractor weakness and provides evidence of a systematic approach in correcting involutional ectropion.

Surgical correction of entropion and excess upper eyelid skin in congenital cutis laxa: a case report.

Congenital cutis laxa is a rare generalized inherited elastosis, characterized by the appearance of premature aging and skin laxity with mild to severe systemic anomalies. Ocular manifestations include excess skin in the eyelids, ptosis and lower lid ectropion. Of the hyperelasticity syndromes - Ehlers Danlos, Pseudoxanthoma elasticum and cutis laxa - only cutis laxa has normal skin wound healing. The diagnosis must therefore be established before surgical options for treatment are considered. We report an unusual case of a 5-month-old male child with cutis laxa who presented with upper lid entropion secondary to severe redundant upper eyelid skin. An anterior lamellar repositioning procedure successfully corrected the lid margin malposition with complete relief of symptoms.