Use of 5-Fluorouracil Injections in Traumatic Cicatricial Malposition of Eyelids.

Abstract

Scarring in the eyelid and periocular regions has both cosmetic and functional implications. Free and unrestricted movement of the eyelids is imperative for opening and closing of the eye and for protection of the ocular surface. Among the nonsurgical modalities of scar treatment, the antineoplastic drug 5-fluorouracil has been used widely.1 We share our experience with its use in posttraumatic cicatrizing eyelid malposition. All the patients had undergone primary treatment for eyelid trauma elsewhere. The patients presented with lagophthalmos (Fig. 1), ptosis, or cicatricial ectropion. [See Figure, Supplemental Digital Content 1, which shows a patient with ptosis caused by cicatricial tethering of eyelid at the lateral orbital rim. Photograph taken 4 weeks after the injury. Lateral view shows the scar (above) and the resolution of ptosis 4 weeks after the last injection. A total of 105 mg of 5-fluorouracil was injected in three sittings. The patient did not desire surgery. Lateral view after 5-fluorouracil injection shows improvement in the scar (below), https://links.lww.com/PRS/F327.] Twelve patients (mean age, 38.3 years; SD, 12.6 years; nine male and three female) received injections before any surgical intervention at our clinic.Fig. 1.: (Above) Clinical photograph showing cicatricial lagophthalmos 4 weeks after trauma. (Below) Clinical photograph of the patient at 12 months follow-up after injection of 5-fluorouracil (total 140 mg in four sittings).Measurements and clinical photographs were taken before and after injection. We continued the injections every 3 to 4 weeks or until improvement plateaued. The earliest injections were at 4 weeks, with a mean delay of 3.08 months. All cases were performed under topical anesthesia with a mixture of lignocaine 2.5% W/W and prilocaine 2.5% W/W (Prilox cream; Neon Laboratories, Bangalore, India). We injected 5-fluorouracil 50 mg/ml (Fluracil; Zydus Cadila, Ahmedabad, India) with a 26-gauge or 30-gauge needle in 0.1-ml aliquots injected at intervals of 5 mm into and around the scar. Traction sutures were applied to facilitate lengthening of the scar. The mean interval from injury to first presentation at our clinic was 3.08 months (range, 1 to 14 months). The mean dose of injections required was 54.3 mg (range, 15 to 105 mg) in one to four sittings. Objective improvement was seen in 11 of 12 patients (91.6 percent) (Fig. 1). [See Figure, Supplemental Digital Content 1, https://links.lww.com/PRS/F327.] Reconstructive surgery could be avoided in six of 12 patients (50 percent). Patients with anterior lamellar skin deficiency required surgery. Pain and burning sensation were reported after the first injections in the first two patients. Oral paracetamol 650 mg immediately after injection kept the patients comfortable. No patient experienced 5-fluorouracil toxicity on the ocular surface. No patient showed wound dehiscence or skin ulceration, known adverse events.2 5-Fluorouracil, an antimetabolite, acts both on the phase of proliferation and the phase of maturation in the healing wound. It inhibits DNA synthesis and repair.2 It also interferes with RNA function, reduces proliferation of dermal fibroblasts, and affects transforming growth factor–β signaling and formation of type 1 collagen.2,3 Reports also show that the inhibitory effects of 5-fluorouracil on fibroblast proliferation and fibroblast action last for more than 6 weeks after a single application.4 There are few original reports of periocular use of 5-fluorouracil.5 Conventional use has been to inject weekly or biweekly, starting soon after surgery.5 For our series, the drug was injected during the phase of wound maturation, with less frequent dosing. The injections were still effective, with few adverse events. We propose that injection of 5-fluorouracil is a safe and effective modality for wound modulation in eyelid scarring and can reduce the need for surgical intervention. PATIENT CONSENT Patients provided written informed consent for the use of their images. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.