Ophthalmoplegia with skin necrosis after a hyaluronic acid filler injection.

Hyaluronic acid filler injection is commonly used for aesthetic purposes. However, many clinicians neglect the possibility of developing vascular occlusion and its devastating sequelae. Besides visual loss after iatrogenic ophthalmic artery occlusion, ophthalmoplegia without blindness is rare but may occur. Here, we report a 23-year-old woman with ptosis, lateral deviation of the right eye, and skin necrosis after hyaluronic acid filler injection. After hyaluronidase injection and steroid pulse therapy, ptosis and eye movement were completely restored. Skin necrosis was treated with a human epithelial growth factor ointment, followed by Nd:YAG laser. Complete healing with minimal scar was achieved.

Reduction of oculocardiac reflex with Tetracaine eye drop in strabismus surgery.

INTRODUCTION: Recently, to reduce the incidence of oculocardiac reflex (OCR) in strabismus surgery, retrobulbar block and anticholinergic drugs or local anesthesia are also used. The present study evaluated the effects of Tetracaine eye drop as a topical nerve blocker on OCR during strabismus surgery. METHODS AND MATERIALS: In this randomized trial, 70 strabismus surgery candidates were randomly divided into placebo or synthetic teardrop (E) and Tetracaine eye drop (T) groups, so 3 drops of each solution were dropped in four directions of patients' eye immediately after applying anesthesia and before surgery. The incidence and severity of OCR during the stages of muscle release and incision (cutting), hemodynamic changes, the required time for OCR recovery and atropine dose were assessed. RESULTS: OCR was more seen in release phase compared to cutting phase. There were no significant differences between two group regarding the incidence and severity of OCR in the release phase (p > 0.05), but the incidence and severity of OCR in the cutting phase was more in group E than group T (p = 0.02, for both). The duration of OCR improvement (p-value = 0.74) and Atropine consumption (p-value = 0.92) did not differ between the groups. CONCLUSION: Tetracaine eye drop only reduces the incidence and severity of OCR during the incision stage of strabismus surgery.

Treatment Effects of Botulinum Toxin Injection and Acupuncture on Blepharospasm Assessed by the Change in Lower Eyelid Tension.

Objective: To investigate the treatment effects of botulinum toxin-A (BTA) injection and acupuncture on blepharospasm (BP) evaluated by the change in lower eyelid tension (LET). Methods: A series of 30 patients (male: 8, female: 22) aged between 37 and 83 years (63.80 ± 10.96 yrs) who met the eligibility criteria of BP were recruited in this study, who were randomly assigned to BTA injection group (BTA group, n = 15) and acupuncture treatment group (Acupuncture group, n = 15). BTA injections were administered to the patients in BTA group while patients in acupuncture group received the acupuncture treatment. The LET was measured by a tensiometer in both groups at baseline and at post-treatment. Results: A significant decrease in LETs over 8 weeks was found in acupuncture group (812.76 ± 193.95 Pa at baseline, 549.69 ± 150.04 Pa at 4 weeks, and 510.96 ± 150.66 Pa at 8weeks, respectively; F = 31.127, p << 0.001). There was a significant decrease in LET from 858.61 ± 190.54 Pa at baseline to 414.45 ± 63.38 Pa at 2 weeks after treatment (Z = -4.542, p << 0.01) in BTA group. At the endpoint of the study, a significant difference in LET was found between the acupuncture group (301.80 ± 181.77 Pa) and the BTA group (444.16 ± 193.44 Pa) (t = -2.077, p = 0.047). Conclusions: BP patients have an increased LET. Both BTA and acupuncture are effective in decreasing the LET. Close monitoring of LET holds promise in planning the treatment strategy for Blepharospasm.

Large exotropia after retrobulbar anesthesia.

A 67-year-old woman complained of horizontal diplopia shortly following bilateral cataract surgery with intraocular lens implantation performed under retrobulbar anesthesia. Retrobulbar anesthesia was administered at an inferotemporal injection site using 1 cc lidocaine hydrochloride 2% mixed with bupivacaine hydrochloride 0.5%. The initial ophthalmologic evaluation showed a 12-prism diopter (PD) exotropia, and ocular motility evaluation revealed marked limitation of adduction without vertical limitation. One year after cataract surgery, the exodeviation increased up to 60 PD. The patient underwent an 8.0-mm recession of the right lateral rectus and a 6.0-mm recession of the left lateral rectus. Both lateral rectus muscles were biopsied, and biopsy revealed dense fibrous connective tissue without viable muscular cells. The lateral rectus muscle might be injured by retrobulbar anesthesia, and it could induce large exotropia.

Inferior Rectus Muscle Restriction after Sub-Tenon's Anesthesia

No abstract available.

Anatomical position of hyaluronic Acid gel following injection to the infraorbital hollows.

PURPOSE: To examine with histology the anatomical location of hyaluronic acid gel injected to the infraorbital hollows of cadaver specimens. METHODS: The authors dissected 5 fresh hemifacial cadaver specimens following preperiosteal injection of hyaluronic acid gel to the infraorbital hollows. Following tissue fixation, full-thickness soft tissue sections were obtained along the medial, central, and lateral lower eyelid/midface of each specimen. Histologic examination of the anatomical location of hyaluronic acid gel was performed using hematoxylin and eosin and Hale colloidal iron stains. RESULTS: Histologic examination of the central and lateral lower eyelid/midface sections revealed a significant portion of hyaluronic acid gel in either a postorbicularis or a subcutaneous plane in 8 of 10 sections. Only 2 sections displayed hyaluronic acid gel solely within a preperiosteal plane. The medial sections revealed hyaluronic acid gel resting in either a preperiosteal or an intraorbicularis plane. Soft tissue structures such as deep fat compartment septa and the orbicularis oculi muscle appeared to play a significant role in influencing the resting position of hyaluronic acid gel. CONCLUSIONS: In most specimens, the location of a significant portion of hyaluronic acid gel following injection to the infraorbital hollows differed from the intended injection plane. Soft tissue structures including fat compartment septa and the orbicularis oculi muscle appear to influence the resting position of hyaluronic acid gel. Careful attention should be used to avoid overfilling the thin soft tissue layers of the medial infraorbital hollows or tear trough.

Electrical activation of the orbicularis oculi muscle does not increase the effectiveness of botulinum toxin type A in patients with blepharospasm.

BACKGROUND: Our primary aim in this study was to determine whether electrically induced activation of the injected muscle increases effectiveness of botulinum type A toxin (BonT-A) in patients with blepharospasm (BPS). The second aim was to assess the safety of BonT-A by investigating whether BonT-A injection alters the excitability of blink reflex circuits in the brainstem. METHODS: Twenty-three patients with BPS received BonT-A (Botox) injected bilaterally into the orbicularis oculi muscle at a standard dose. In 18 patients, electrically induced muscle activation of the orbicularis oculi muscle on one side was performed for 60 min (4 Hz frequency) in a single session, immediately after BonT-A injection and in five patients for 60 min once a day for five consecutive days. The severity of BPS was assessed clinically with the BPS score. Compound muscle action potential (cMAPs) from the orbicularis oculi muscles were measured bilaterally. The blink reflex recovery cycle was studied at interstimulus intervals of 250 and 500 ms. Participants underwent clinical and neurophysiological assessment before BonT-A injection (T0) and 2 weeks thereafter (T1). RESULTS: Compound muscle action potential amplitude significantly decreased at T1 but did not differ between stimulated and non-stimulated orbicularis oculi in the two groups. BonT-A injection left the blink reflex recovery cycle tested on the stimulated and non-stimulated sides unchanged. CONCLUSIONS: In patients with BPS, the electrically induced muscle activation neither increases the effectiveness of BonT-A nor produces larger electrophysiological peripheral effects. The lack of BonT-A-induced changes in the blink reflex recovery cycle provides evidence that BonT-A therapy is safe in patients with BPS.

Imaging of the superior rectus in superior rectus overaction after retrobulbar anesthesia.

OBJECTIVE: Vertical diplopia after cataract surgery caused by an overaction of an extraocular muscle is more common when the superior rectus muscle is involved, whereas contracture is more common when the inferior rectus muscle is involved. However, no documented imaging has been presented. The aim of this report was to study the superior rectus in such a patient with magnetic resonance imaging (MRI). DESIGN: Observational case report. METHODS: Ophthalmologic examination and thin-sectioned MRI across the superior rectus muscle were performed in a patient with superior rectus overaction after cataract surgery. MAIN OUTCOME MEASURES: Ocular alignment, ocular movement, and the superior rectus muscle on MRI. RESULTS: Magnetic resonance imaging disclosed focal thickening of the superior rectus muscle near the orbital apex in a patient who showed superior rectus overaction after retrobulbar anesthesia for cataract extraction. CONCLUSIONS: The focal thickening of the superior rectus muscle in this patient is consistent with the theory that segmental contracture leads to overactive muscles after retrobulbar anesthesia.

Peribulbar and retrobulbar combined anesthesia for vitreoretinal surgery using ropivacaine.

PURPOSE: To evaluate the efficacy and clinical effects of local retrobulbar anesthesia using ropivacaine in vitreoretinal surgery. METHODS: Prospective study. A total of 919 vitreoretinal operations were followed. The operations were divided into three groups, depending on the degree of anesthesia needed. Group A: Vitrectomies with episcleral procedures (208 vitrectomies for detached retina or perforating trauma). Group B: Episcleral procedures only (410 operations for detached retina without vitrectomy). Group C: Vitrectomies without episcleral surgery (301 operations for macular pucker or hole, proliferative diabetic retinopathy, or silicone oil removal). Anesthesia was administered using a 23-gauge Atkinson-type retrobulbar needle, after topical anesthesia. Six mL of the solution containing 7.5 mg ropivacaine/mL were injected into the peribulbar space, and the other 4 mL deeper, into the retrobulbar space. The degree of infiltration of the palpebral region, the motor block in the extrinsic ocular muscles, and pain felt were checked and rated. RESULTS: Swelling of lids was seen in 885 patients (96%); in 21 (2%) swelling was partial. In 13 patients (1%) there were no signs of infiltration. The motor block was total in 801 (87%) eyes, while 118 (12%) had reduced ocular movements. The degree of anesthesia was as follows, considering the three groups together: no pain = 855 (93%) patients; moderate pain = 44 (4%) patients; very strong pain = 20 (2%) patients. No adverse events or side effects were observed. CONCLUSIONS: Ropivacaine used for retrobulbar-peribulbar combined anesthesia in vitreoretinal surgery showed excellent clinical efficacy as regards analgesia and muscle akinesia.

Transient diplopia following maxillary local anesthetic injection.

A 36-year-old female patient developed diplopia and an ipsilateral lateral rectus paresis following local anesthetic administration to remove a left maxillary second molar. Complete resolution occurred within 3 hours. The clinical examination and management plan are reviewed for this uncommon occurrence. The relevant anatomical pathways are discussed and illustrated with photographs.

[Contralateral amaurosis and extraocular muscle palsies after retrobulbar injection]. / Ceguera y parálisis de la musculatura extraocular contralateral tras inyección retrobulbar.

CASE REPORT: We report a rare complication of retrobulbar anesthesia in ophthalmic surgery-amarurosis and extraocular muscle palsies in the contralateral eye. Our patient did not suffer permanent sequelae from the injection. DISCUSSION: Numerous complications resulting from retrobulbar injections in the eye and orbit have been reported. One possible explanation of this case is the inadvertent penetration of the subdural or subarachnoid space surrounding the optic nerve and the injection of anesthetic into that space. The drug then tracks along the ipsilateral optic nerve to the chiasm and then to the contralateral optic nerve. Several methods of decreasing the probability of such a complication are discussed.

Effect of hyaluronidase on ocular motility and eyelid function in sub-Tenon's anaesthesia: randomised controlled trial.

PURPOSE: To assess the effect of hyaluronidase on eye and eyelid movements when used as an adjunct in sub-Tenon's anaesthesia. METHODS: A total of 60 patients who had sub-Tenon's anaesthesia prior to phacoemulsification surgery were divided into two equal groups in a double-masked randomised controlled fashion. Of these, Group A had 4 ml lignocaine 2%, while Group B had 4 ml lignocaine 2% with the addition of sodium hyaluronidase 75 IU/ml. Ocular motility, levator, and orbicularis oculi function were measured in all patients at 5 and 8 min. Levator function was scored from 0 (no function) to 3 (complete function) while orbicularis function was scored from 0 to 2. The score for ocular motility was the sum in four positions of gaze, each position scoring from 0 to 2. Results were compared using a nonparametric test. RESULTS: Group B achieved significantly better ocular and lid akinesia than Group A both at 5 and 8 min with P<0.01. The median scores for levator function at 5 and 8 min were 2 for Group A and 0 for Group B. For orbicularis function, the median scores at both time intervals were 2 for Group A and 1 for Group B. For ocular motility, the median score for Group A at 5 min was 3 and at 8 min was 2.5; for Group B at 5 min was 0.5 and at 8 min was 0. CONCLUSIONS: The addition of hyaluronidase in sub-Tenon's anaesthesia has a significant effect in improving ocular and lid (levator and orbicularis) akinesia.

Inferior oblique overaction/contracture following retrobulbar anesthesia for cataract extraction with a positive Bielschowsky Head Tilt test to the contralateral shoulder. A report of one case.

BACKGROUND AND PURPOSE: This is a report of a patient with diplopia, hypertropia, extorsion and a positive Bielschowsky Head Tilt Test following retrobulbar anesthesia, due to an inferior oblique muscle overaction-contracture. CASE REPORT: Oculomotor and sensorimotor examinations and ocular motility recordings and Bielschowsky Head Tilt Test demonstrated overaction characteristics overpowering the contracture characteristics of the involved inferior oblique muscle. RESULTS: Weakening of the overacting inferior oblique eliminated the vertical and torsional deviations and the forced head tilt difference upon tilting the head to either shoulder. It also normalized ocular motility and resulted in a symptom-free patient. CONCLUSION: Oblique muscle dysfunction with vertical and torsional deviations and a positive Bielschowsky Head Tilt Test can result from retrobulbar anesthesia.

Lidocaine tape (Penles) reduces the pain of botulinum toxin injection for Meige syndrome.

PURPOSE: To evaluate the efficacy of lidocaine tape in reducing pain during botulinum toxin injection. DESIGN: Randomized double-blind study. METHOD: Six men and four women with a diagnosis of Meige syndrome undergoing botulinum toxin injection were recruited. Lidocaine tape was applied to the eyelid skin of a randomly selected eye and placebo tape to the other eye. Pain during botulinum toxin injection was evaluated subjectively by a visual analogue scale. Side effects were also monitored. RESULTS: Mean subjective pain both on puncturing skin and on injection in the lidocaine group was significantly lower than that in the placebo group. Nine of 10 patients found lidocaine tape to be more effective than placebo tape in reducing pain during injection. CONCLUSIONS: Lidocaine tape is a simple and convenient method of reducing pain during botulinum toxin injection. This method is recommended for patients reluctant to receive this treatment because of pain during injection.

Persistent diplopia after retrobulbar anesthesia.

PURPOSE: To determine the causative factors of persistent diplopia after retrobulbar anesthesia. SETTING: Strabismus Section, Department of Ophthalmology, Seoul National University, Seoul, South Korea. METHODS: Prism and alternate cover tests in the diagnostic positions of gaze and ductions/versions were performed in 28 patients with persistent diplopia 6 months after retrobulbar anesthesia. The Lancaster test, Bielshowsky head tilt test, double Maddox rod test, fundoscopic examination for torsion, forced duction test, force generation test, tensilon test, thyroid function test, and/or orbit computed tomography were performed when necessary. RESULTS: Most of the patients (26 patients, 93%) did not have diplopia before retrobulbar anesthesia. Of the 14 patients with extraocular muscles imbalance, 12 patients showed vertical rectus overaction (11 superior recti, 1 inferior rectus) and 2 patients, mild vertical rectus underaction. Nine patients were presumed to have a sensory strabismus related to the preoperative poor vision, but this went unnoticed preoperatively. Three patients showed a small vertical deviation without any specific causative factors. CONCLUSIONS: Fifty percent of the cases of diplopia were associated with either direct trauma or anesthetic myotoxicity to the extraocular muscles, in which overactions were more common than underactions. Thirty-two percent of the patients were presumed to have sensory strabismus, which suggested the importance of preoperative examination for strabismus as well as providing an explanation about the risk of postoperative diplopia before surgery.

Effect of retrobulbar injection of lidocaine on saccadic velocities.

PURPOSE: To determine whether exposing the extraocular muscles (EOMs) to lidocaine via retrobulbar injection for cataract surgery has a demonstrable negative effect on subsequent function of the muscle. SETTING: York Finch Eye Associates, Humber River Regional Hospital, and Toronto Western Hospital Research Institute, Toronto, Ontario, Canada. METHODS: This study comprised 37 eyes that had phacoemulsification and posterior chamber intraocular lens implantation; 13 eyes had retrobulbar lidocaine with hyaluronidase and 24 eyes, topical anesthesia. The postoperative saccadic velocities were compared with the preoperative velocities using a sensitive recording device. The results were compared within and between the retrobulbar lidocaine and topical anesthesia groups. RESULTS: No detectable decrement in postoperative saccadic velocities was detected in any patient, and no difference was found between the groups. CONCLUSIONS: Exposing EOMs to lidocaine for cataract surgery had no detectable negative effect on saccadic velocities 1 week after surgery.

A novel in vitro model for screening and evaluation of anti-asthenopia drugs.

Patients suffering asthenopia are steadily increasing with an expanding use of visual display terminals such as computers. An attempt was made to develop an in vitro model for asthenopia. Ciliary muscle removed from eyeballs of a rabbit was stimulated with acethylcholine, resulting in contraction of the muscle. Repeated stimulations caused decreased contraction, which may be related to fatiguing of ciliary muscle and hence asthenopia. Treatment of the repeatedly stimulated muscle with cyanocobalamin restored contraction dose-dependently. Thus, the model developed in this study can be used to screen drug candidates for treating asthenopia.