Hyaluronidase allergy mimicking orbital cellulitis.

PURPOSE: Hyaluronidase enzyme is a common additive with local anesthetic agent to facilitate faster permeation of the anesthetic in periocular tissues during ophthalmic surgery. We report a series of five subjects presenting with clinical features mimicking orbital cellulitis following peribulbar anesthesia and consequently diagnosed with hyaluronidase hypersensitivity. SETTING: The study was conducted at a tertiary eye care center in Southern India. DESIGN: It was a retrospective interventional case series. METHODS: We retrospectively reviewed the case records of patients diagnosed as and treated for hyaluronidase allergy from 2011 to 2015. The presenting features included periocular edema, proptosis, and restriction of ocular movements. The symptoms appeared immediately after the injection to as late as 6 days after the surgery. All patients underwent comprehensive ophthalmic evaluation, relevant investigations, and dermal allergy tests. All five patients tested positive for hyaluronidase. Patients were treated with antihistaminics, systemic steroids, and emergency orbital decompression, when required. In majority of the patients, symptoms resolved in 3-5 days. Clinically, hyaluronidase allergy may mimic orbital cellulitis, which in the context of a recent intraocular surgery may be alarming for both the patient and the surgeon. However, with prompt intervention, the prognosis is extremely favorable in cases of hyaluronidase allergy. It is important for ophthalmic surgeons and anesthetists to recognize and differentiate this entity from the more serious vision threatening conditions.

Orbital inflammation secondary to a delayed hypersensitivity reaction to sub-Tenon's hyaluronidase.

We report a rare case of a delayed orbital inflammation with raised intraocular pressure as a result of hyluronidase allergy following sub-Tenon's anaesthesia. Here, we have shown evidence to prove the orbital inflammation to be an allergic response to hyluronidase with a skin patch test. This is the first case to our knowledge of a delayed hypersensitivity reaction to sub-Tenon's hyluronidase comprising of an initial exposure to hyluronidase in the fellow eye with no subsequent allergic response, but with a subsequent delayed reaction to hyluronidase during a second eye cataract surgery. This case demonstrates hyaluronidase allergy should be considered as a differential diagnosis among patients presenting with acute post-operative orbital inflammation, even if there is a history of previous exposure to hyaluronidase in the fellow eye with no subsequent allergic response.

Histologic features of mesotherapy-induced orbital fat inflammation.

A 67-year-old man developed acute orbital inflammation after receiving cosmetic mesotherapy (Lipo-Dissolve) to the inferior orbital fat compartments. The injection was intended to cause lipolysis and shrinkage of fat lobules with subsequent cosmetic improvement. Injections of a mixture of bile salts, phospholipid, and alcohol preservative bilaterally in inferior orbital fat lobules led to an acute inflammatory reaction characterized histologically 12 days later by mild lymphocytic infiltration, fat necrosis, and fibrosis in the target areas. Benign proliferation of peripheral nerve trunks consistent with a traumatic neuroma was also noted histologically on one side. Inflammation including fat necrosis and traumatic neuroma are all possible consequences of mesotherapy.