Periocular Injection Research Articles

Mitochondria and Autophagy Dysfunction in Glucocorticoid-Induced Ocular Hypertension/Glaucoma Mice Model

ABSTRACTPurpose: This study is aimed to investigate the effects of periocular steroids induction on intraocular pressure (IOP), retinal ganglion cells (RGCs) and trabecular meshwork (TM) ultrastructure in glucocorticoid-induced ocular hypertension mice model.Materials and Methods: Dexamethasone-21-acetate (Dex-Ace) was administered through periocular conjunctival fornix injection every 3 days in C57BL/6J mice. Intraocular pressure was measured weekly by rebound tonometry. RGCs were examined with immunofluorescent staining of BRN3a at week 1, 4, and 8. TM morphology was visualized with electron microscopy. Autophagy was evaluated with immunoblotting in TM tissues.Results: Dex-Ace rapidly and significantly induced IOP, which peaked at week 4. The absolute increase in IOP in the Dex-Ace-treated mice was 8.1 ± 1.4 mmHg, a 60% induction (p < .0001) compared with that in the vehicle-treated mice. The IOP sustained a higher level in the Dex-Ace group from week 4 to week 8. Dex-Ace treatment decreased the number of RGCs in a time-dependent manner, suggesting that high IOP resulted in optic neuropathy. In addition, Dex-Ace thickened trabecular beams and decreased intertrabecular spaces, with marked accumulation of fibrillar and amorphous granular extracellular material. Moreover, Dex-Ace induced swollen and elongated mitochondria in TM cells. The average mitochondria area was 0.090 ± 0.044 µm2 in the vehicle-treated mice, and increased to 0.161 ± 0.094 µm2 (p < .0001), 0.121 ± 0.029 µm2 (p = .0223) and 0.171 ± 0.076 µm2 (p < .0001) in the Dex-Ace-treated mice at weeks 1, 4 and 8, respectively. Autophagy was also increased by Dex-Ace treatment, indicating by the upregulation of LC3-I, LC3-II and beclin-1, and downregulation of p62.Conclusion: Dex-Ace administration decreased RGCs and changed TM ultrastructure, mimicking hallmarks of human glucocorticoid-induced glaucoma (GIG). In addition, mitochondria and autophagy dysfunction suggested abnormal energy metabolism in TM cells, which warranted further study to fully elucidate the pathogenesis of GIG.

This issue of ACTA

This issue of ACTA

The Role of Steroids and NSAIDs in Prevention and Treatment of Postsurgical Cystoid Macular Edema.

Pseudophakic cystoid macular edema (PCME) remains one of the most common visionthreatening complication of phacoemulsification cataract surgery (PCS). Pharmacological therapy is the current mainstay of both prophylaxis, and treatment of PCME in patients undergoing PCS. We aimed to review pharmacological treatment options for PCME, which primarily include topical steroids, topical nonsteroidal antiinflammatory drugs (NSAIDS), periocular and intravitreal steroids, as well as anti-vascular endothelial growth factor therapy. The PubMed and Web Of Science web platforms were used to find relevant studies using the following keywords: cataract surgery, phacoemulsification, cystoid macular edema, and pseudophakic cystoid macular edema. Of articles retrieved by this method, all publications in English and abstracts of non-English publications were reviewed. Other studies were also considered as a potential source of information when referenced in relevant articles. The search revealed 193 publications. Finally 82 articles dated from 1974 to 2018 were assessed as significant and analyzed. Based on the current literature, we found that corticosteroids remain the mainstay of PCME prophylaxis in uncomplicated cataract surgery, while it is still unclear if NSAID can offer additional benefits. In patients at risk for PCME development, periocular subconjunctival injection of triamcinolone acetonide may prevent PCME development. For PCME treatment the authors recommend a stepwise therapy: initial topical steroids and adjuvant NSAIDs, followed by additional posterior sub-Tenon or retrobulbar corticosteroids in moderate PCME, and intravitreal corticosteroids in recalcitrant PCME. Intravitreal anti-vascular endothelial growth factor agents may be considered in patients unresponsive to steroid therapy at risk of elevated intraocular pressure, and with comorbid macular disease. Therapy with topical corticosteroids and NSAIDs is the mainstay of PCME prophylaxis and treatment, however, periocular and intravitreal steroids should be considered in refractory cases.

A Review of Periocular Botulinum Neurotoxin on the Tear Film Homeostasis and the Ocular Surface Change.

Clinical usage of botulinum neurotoxin (BoNT) in ophthalmology has dramatically increased since the 1980s and has become one of the most widely used agents for treating facial movement disorders, autonomic dysfunction and aesthetic wrinkles. Despite its high efficacy, there are some complications with periocular BoNT injections due to its chemodenervation effect. Among these, there is still controversy over the BoNT effect on tear film homeostasis and the ocular surface. A periocular BoNT injection could dry the eye by reducing tear production of the lacrimal gland and increase tear evaporation due to potential eyelid malposition and abnormal blinks. On the contrary, the injection of BoNT in the medial eyelids could treat dry eye disease by impairing lacrimal drainage. Regarding the ocular surface change, corneal astigmatism and high-order aberrations may decrease due to less eyelid tension. In conclusion, the entire awareness of the effect of BoNT and the patients’ ocular condition is crucial for successful and safe results.

Comparative Study between the Efficacy of Fentanyl, Antihistamines, and Dexmedetomidine in Suppressing Photic Sneeze Reflex during Peribulbar Block.

Background:The photic sneeze reflex (autosomal dominant) is a condition that causes sneezing in response to numerous stimuli, such as looking at bright lights or periocular (surrounding the eyeball) injection. Unexpected or sudden sneezing during injection can be a dangerous side effect in periocular injection, in which abrupt head movement may cause globe injury.Aims:We intended to evaluate the efficacy of adding fentanyl, dexmedetomidine, and antihistamines on the incidence of the sneeze reflex associated with propofol sedation during periocular local anesthesia injections.Settings and Design:Our study was a randomized, prospective, double-blinded and controlled clinical study.Patients and Methods:This study was conducted in Ain Shams and Fayoum university hospitals at the ophthalmic surgery department. After obtaining approval from our universities ethical committee and written informed valid consents from the patients, 90 patients were included in this study. The study population included patients of both sex, ASA grade 1 and 2, in the age ranging from 18-65 years. Patients were scheduled for cataract extraction surgeries and received peribulbar block. Then patients were randomly divided into three groups (30 patients each) using a computer- generated table of random numbers. Patients were preoxygenated with supplemental oxygen by nasal cannula, all 90 patients received intravenous propofol 1mg.kg- 1 bolus for sedation and were randomized to receive adjunctive drug 2 to 4 minutes prior to propofol injection: 30 patients received intravenous fentanyl 1 μmg.kg-1 (Group F), 30 patients received dexmedetomidine 1μmg.kg-1 (Group D), and 30 patients received antihistamine (pheniramine 22.75 mg) (Group H). The same local anesthetic admixture, consisting of 5 mL 2% lidocaine with 90 IU hyaluronidase, combined with 5 mL 0.5% plain bupivacaine in a 10-mL syringe at room temperature was administered to all patients using peribulbar block technique. A masked observer (surgeon or anesthesia assistant) recorded whether the patient had a sneezing event. Continuous cardiorespiratory monitoring was performed intraoperatively. Intraoperative and postoperative medication side effects were recorded including bradycardia (HR <55 beats/min), hypotension (MAP <50 mmHg sustained for >10 min), oxygen desaturation (SpO2<90%), nausea, vomiting and prolonged sedation using Ramsay Sedation Score (RSS).Statistical Analysis Used:Student's t-test and Chi-square test were used for analysis.Results:The demographic data of the three study groups revealed non-significant differences between the three study groups as regards age, sex distribution, and the duration of surgery. No patient was excluded after inclusion to the study. All patients were able to complete the entire study and their data were included in the final analysis. Five events of sneezing had occurred in 90 patients. Two in (D) group and three in (H) group with is no statistically significant difference between the three groups as regard sneezing. Bradycardia, hypotension and sedation had occurred significantly in group (D) compared to group (F) and group (D). No patient suffered from nausea, vomiting or oxygen desaturation in all studied groups. No statistically significant difference as regards patient satisfaction between the three studied groups.Conclusion:Fentanyl, dexmedetomidine and antihistamines with propofol sedation suppress photic sneeze reflex during peribulbar block.

Visual loss following cosmetic facial filler injection

Facial filler injection for soft-tissue augmentation, wrinkle reduction, and rejuvenation has recently become increasingly popular. This procedure is well accepted and widely performed because of its safety and excellent outcomes. However, complications may occur even in the most skilled hands. A 36-year-old female presented with immediate loss of vision in her right eye following the periocular injection of cosmetic hyaluronic acid facial filler into the glabellar region. The visual loss was accompanied by weakness of her left arm. Blindness may complicate cosmetic facial filler injection. The treating physician should have a firm knowledge of the facial vascular anatomy, and the patient should be aware of the potential blinding complications associated with facial filler injection.

Observation on the efficacy of periocular triamcinolone acetonide injection in preventing delayed uveitis after cataract surgery in diabetic patients

Objective To observe the efficacy of periocular triamcinolone acetonide(TA) injection for preventing delayed uveitis after phacoemulsification in diabetic patients. Methods The data of 592 eyes of 592 diabetic patients with cataract who received phacoemulsification combined with intraocular lens implantation from Jan. 2016 to Jun. 2018 were analyzes retrospectively. All patients were divided into three groups randomly. Group A, 197 eyes received phacoemulsification without medicine injection. Group B, 206 eyes received subconjunctival injection of dexamethasone (2.5 mg) after phacoemulsification, while 189 eyes in group C received periocular injection of TA (20 mg) after phacoemulsification. The follow-up time was for 1-3 months after surgery. Results Twelve eyes (6.1%) in group A suffered from delayed uveitis after surgery, 4 eyes (1.9%) in group B and 1 eye (0.5%) in group C. The difference of the incidence of delayed uveitis was not statistically significant between group A and B (χ2=4.55, P=0.03>0.0167), and the difference was statistically significant between group A and C(χ2=9.17, P=0.00 0.0167). Conclusion Periocular injection of TA and subconjunctival injection of dexamethasone are effective in controlling delayed uveitis in diabetic patients following phacoemulsification. Key words: Diabetes mellitus; Cataract; Phacoemulsification; Uveitis, delayed; Triamcinolone acetonide; Periocular injection

Periocular injection of candesartan-PLGA microparticles inhibits laser-induced experimental choroidal neovascularization.

PurposeMicroparticle technology enables local administration of medication. The purpose of this study was to examine the inhibitory effect of locally administered candesartan (CAN)-encapsulated microparticles on experimental choroidal neovascularization (CNV).MethodsLaser photocoagulation was used to induce CNV in Brown Norway rats. The rats were pretreated with subconjunctival injections of CAN (5.0 mg/eye) or phosphate buffer saline for 3 days before photocoagulation. The volume of CNV was evaluated 7 days after laser injury using the lectin staining technique. The infiltration of macrophages within the CNV lesion was determined using immunofluorescent staining with an anti-CD68 antibody. mRNA levels of MCP-1, IL1-β and VEGF in the retinal pigment epithelium/choroid complex were determined using quantitative PCR (q-PCR).ResultsCNV volume was significantly suppressed by the treatment with CAN compared with that in vehicle-treated eyes (P<0.05, two-tailed Student’s t-test). Subconjunctival injections of CAN decreased the numbers of CD68+ cells in the CNV lesion. The increased mRNA levels of MCP-1, IL1-β, and VEGF induced by photocoagulation was significantly suppressed following the local administration of CAN (P<0.05, two-tailed Student’s t-test).ConclusionLocal administration of CAN inhibited experimentally induced CNV possibly through anti-inflammatory effects.

Periocular and Intravitreal Steroid Use in Treatment of Behcet’s Disease-Related Uveitis

Behcet’s disease has an intractable chronic recurrent course and ocular involvement is one of the most important morbidity reasons. Systemic steroids and immunosuppressive constitute the basis of the treatment in ocular involvement. However, both the side effects and the necessity of high dosages for ocular penetration of the medications favors the local treatment options. Periocular injections (orbital floor and subtenon) in this manner are found to be effective as an adjuvant in the treatment of intractable disease, reducing the systemic dosage and preventing the recurrences. In the intravitreal route, the most commonly used is triamcinolone acetonide (IVTA) injection. With this route, local depot effect, rapid impact on the posterior segment, and retinal vasculitis, better outcomes in vitreous haze and macular edema can be achieved. However, complications like cataract and intraocular pressure (IOP) rise are commonly seen. Other options in the intravitreal route are Fluocinolone acetonide (Retisert®) and dexamethasone (Ozurdex®) implants. Ozurdex® becomes a suitable treatment option with its long-lasting effect and low side effect profile compared to IVTA. Although Retisert® seems effective with its action that might extend to 3 years, the necessity of surgery for implantation, and the high rate of cataract and glaucoma complications, it is not preferred frequently.

Periocular triamcinolone acetonide injection for treating polypoidal choroidal vasculopathy concurrent with hemorrhagic retinal detachment.

To investigate the clinical efficiency of periocular triamcinolone acetonide (TA) injection for treating polypoidal choroidal vasculopathy (PCV) concurrent with hemorrhagic retinal detachment (HRD).Twenty-two cases confirmed with PCV concurrent with HRD characterized by massive subretinal hemorrhage and exudation presented to our department from January 2015 to May 2017 were included in this study. The initial vision varied from counting finger to 0.2. All cases were randomly divided into TA group (n = 12), which received periocular TA injection per month, and anti-VEGF group (n = 10), which were treated by anti-VEGF intravitreous injection per month. The patients were followed up for 6 months, in which fundus examination and visual acuity along with optical coherence tomography (OCT) were carried out.The treatment effect is divided into the following categories. Cure was defined as the elimination of subretinal hemorrhage and exudation accompanied by retinal edema and choroidal neovascularization (CNV) extinction and rise of visual acuity. Improvement was characterized by alleviation of subretinal hemorrhage and exudation accompanied by retinal edema and CNV reduction and rise of visual acuity. Ineffective means remained subretinal hemorrhage and exudation in fundus and no improvement of visual acuity, and polypoid lesions in OCT images. Among the 12 cases in TA group, 1 case was treated by periocular injection of TA twice, and 11 cases were treated by 3 times injection. After that, 3 cases (25%) were cured, 8 cases (66.7%) got improvement, and only 1 case (8.3%) showed no response. Although among 10 cases in the anti-VEGF group, 3 cases were treated by anti-VEGF intravitreous injection twice. Seven cases were treated by 3 times injection. After that, 4 cases (40%) got improvement, and the other 6 case (60%) showed no response. All patients showed no recurrence in the 6-month follow-up. No complications were noticed under periocular injection or intravitreous injection.Periocular TA injection is effective for treating PCV concurrent with HRD.

Glucocorticoid Receptor Transactivation is Required for Glucocorticoid-Induced Ocular Hypertension and Glaucoma: A Deleterious Effect of Chronic Glucocorticoid Therapy

Glucocorticoid (GC)-induced ocular hypertension (OHT) is a serious side-effect of prolonged GC therapy that can lead to glaucoma and permanent vision loss. GCs cause a plethora of changes in the trabecular meshwork (TM), an ocular tissue that regulates intraocular pressure (IOP). GCs act through the glucocorticoid receptor (GR), and the GR regulates transcription both through transactivation and transrepression. Many of the anti-inflammatory properties of GCs are mediated by GR transrepression, while GR transactivation largely accounts for GC metabolic effects and side effects of GC therapy. There is no evidence showing which of the two mechanisms play role in GC- OHT. Methods: GRdim transgenic mice (which have active transrepression and impaired transactivation) and wild type (WT) C57BL/6J mice received weekly periocular DEX-Ac injections. IOP, outflow facilities, and biochemical changes to the TM were determined. Results: GRdim mice did not develop GC-OHT DEX treatment, while WT mice had significantly increased IOP and decreased outflow facilities. Both TM tissue in eyes of DEX-treated GRdim mice and cultured TM cells isolated from GRdim mice had reduced or no change in the expression of fibronectin, myocilin, collagen type I, and α-SMA. GRdim MTM cells also had a significant reduction in DEX-induced cytoskeletal changes, which was clearly seen in WT MTM cells. Conclusion: We provide the first evidence for the role of GR transactivation in regulating GC-mediated gene expression in the TM and in the development of GC- OHT. This discovery suggests a novel therapeutic approach for treating ocular inflammation that will not cause the serious side effect of GC-OHT and glaucoma. Funding: NIH/NEI EY016242. Declaration of Interest: AFC is a consultant for Goodmans LLP, LayerBio, Kala Pharmacuticals and has received research support from Unity Biotechnology and Lung Therapeutics. However, none of these are related to the study presented. The other authors declare that they have no competing interests. Ethical Approval: All experimental protocols were approved by University of North Texas Health Science Center Institutional Animal Care and Use Committee regulations.

The Effectiveness Analysis of Joint Use of Different Groups Anti-Inflammatory Drugs Treatment and Prevention of Cystoid Macular Edema in Patients after Phacoemulsification

Purpose: to analyze the results of the joint eye drops application of 0.09 % solution of bromfenac and 0.1 % solution of dexamethasone and subtenons triamcinolone injection for treatment and prevention of cystoid macular edema (CME) in patients after phacoemulsification.Patients and methods: The study included 914 patients (1147 eyes) which held phacoemulsification with IOL implantation. Depending on the postoperative treatment patients randomized into two groups. Patients of the first group received instillation of eye drops of antibiotics-fluoroquinolones and 0.1 % dexamethasone. Patients of the second group were prescribed instillation of eye drops of 0.09 % solution of bromfenac in addition to the treatment. In each group the patients diagnosed CME after phacoemulsification were divided into subgroups depending on the presence or absence of concomitant involution of retinal pathology. In cases of diagnosis of macular edema after phacoemulsification (2nd group of patients) periocular triamcinolone injections were made.Results. The efficacy of bromfenac was estimated by the number of cases of postoperative CME in the compared groups. In patients of the first group, complications occurred in 3.1 % of cases. In patients of the second group the number of complications was significantly lower (1.5 %), including a significant reduction in the incidence of CME observed in patients without concomitant of macular pathology (AMD and epiretinal fibrosis). A combination of steroid and NSAID in the treatment of CME provides the regression of macular edema in all patients, regardless of the presence of involution macular pathology. The positive effect of periocular triamcinolone injections in the treatment of anti-inflammatory eye drops was noted in 8 of 9 cases a month after the first injection.

Difluprednate for the Treatment of Uveitic Cystoid Macular Edema

To describe clinical outcomes associated with the use of topical difluprednate in treating uveitic cystoid macular edema. Retrospective, interventional case series. Setting: Medical record review in a tertiary care uveitis center. Fifty-eight patients (72 eyes) with uveitic cystoid macular edema (CME) treated with difluprednate 0.05% ophthalmic solution between June 2012 and May 2016. Macular central subfield thickness (CST) determined by optical coherence tomography, improvement of CME (≥20% reduction in CST or resolution), and resolution of CME (CST ≤ 320μm with no cysts) at 30days after starting treatment. Outcomes were assessed up to 90days. CST on average decreased by 17% (95% CI:-33%,-7%) for eyes using only difluprednate (n= 43) and by 6% (95% CI:-17%,-2%) for eyes in patients using concomitant systemic immunosuppressive therapy (n= 29) at 30days, a 12% difference between groups (95% CI: 2%, 21%, P= .02). Of eyes on difluprednate alone, 76% had improvement and 48% had resolution of CME. In patients using systemic therapy, 37% of eyes had improvement and 17% had resolution. Eight eyes (11%) had an intraocular pressure (IOP) > 24mm Hg within the first 30days. By 90days, CME had improved in 69% of all eyes and resolved in 43% of eyes, with only 9 patients starting or increasing systemic immunosuppressive medications and 2 patients receiving periocular corticosteroid injections. Difluprednate was associated with an improvement in uveitic CME and could be a reasonable first-line therapy. IOP should be closely monitored.

Multifocal choroiditis - an unusual finding in Crohns disease.

To report a patient with Crohns disease and acute decreased vision in one eye secondary to multifocal choroiditis and serous retinal detachment. A complete ocular examination, including fluorescein angiography, was performed. Fundus biomicroscopy disclosed multifocal, deep, discretely elevated yellowish lesions at the posterior pole of the affected eye. Fluorescein angiographic study of these lesions revealed early hypofluorescence followed by late yperfluorescence. Subtenonian injection of corticosteroids rapidly induced remission of the choroidal lesions. Chorioretinal involvement in patients with Crohns disease may or may not be related to reactivation of this disorder. Therefore, even patients without gastrointestinal symptoms who present with posterior segment inflammation must be informed of this. The chorioretinal inflammatory lesions do seem to respond promptly to periocular injection of corticosteroids. (Eur J Ophthalmol 2004; 14: 345-9).

Blau-Jabs Syndrome in a Tertiary Ophthalmologic Center

In a prospective case series of patients with Blau-Jabs syndrome (BJS) conducted in the Ophthalmology Department/Federal University of Sao Paulo, seven patients with clinical and ophthalmologic manifestations of the disease and a positive genetic test result for the presence of a mutation in the CARD15/NOD2 gene were followed for a minimal period of 1 year. All patients had uveitis, five had nummular corneal subepithelial opacities, and four had multifocal choroiditis. Oral prednisolone was administered to all patients; inflammation was controlled in six patients with at least one immunosuppressive drug. Infliximab (Remicade; Janssen Pharmaceuticals, Beerse, Belgium) and etanercept (Enbrel; Amgen, Thousand Oaks, CA) were used to treat two cases refractory to the anti-inflammatory drugs. A subconjunctival dexamethasone implant (Ozurdex; Allergan, Irvine, CA) and a periocular injection of triamcinolone were used in one case to achieve inflammation control. Six patients achieved a visual acuity of 20/25 or better. The authors conclude that periocular treatment with steroid injections might be effective adjuvant therapy to control ocular inflammation. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:70-75.].

Pioglitazone ameliorates retinal ischemia/reperfusion injury via suppressing NLRP3 inflammasome activities.

To explore the role of Pioglitazone (Pio) on a mouse model of retinal ischemia/reperfusion (I/R) injury and to elucidate the potential mechanism. Retinal ischemia was induced in mice by increasing the intraocular pressure, and Pio was administered 4h though periocular injection before I/R. The number of cells in the ganglion cell layer (GCL) was counted 7d after retinal I/R injury. Glial fibrillary acidic protein (GFAP), nuclear factor-kappa B (NF-κB), p38, phosphorylated-p38, PPAR-γ, interleukin-1β (IL-1β), Toll-like receptor 4 (TLR4), NLRP3, cleaved caspase-1, caspase-1 were determined by real-time polymerase chain reaction and Western blotting. Pio promoted the survival of retinal cells in GCL following retinal I/R injury (P<0.05). Besides, retinal I/R injury stimulated the expression of GFAP and TLR4, which were partially reversed by Pio treatment (P<0.05). Retinal I/R injury-upregulated expression of NLRP3, cleaved caspase-1, IL-1β was attenuated after Pio treatment (P<0.05). Moreover, I/R injury induced activation of NF-κB and p38 were inhibited by Pio treatment (P<0.05). Pio promotes retinal ganglion cells survival by suppressing I/R-induced activation of TLR4/NLRP3 inflammasomes via inhibiting NF-κB and p38 phosphorylation.

Topical nepafenac for prevention of post-cataract surgery macular edema in diabetic patients: patient selection and perspectives.

Since its first description, the prevention of pseudophakic cystoid macular edema (PCME) continues to pose challenges for ophthalmologists. Recent evidence suggests that prophylaxis is unnecessary in patients without risk factors. Diabetes mellitus is generally considered as a risk factor for the development of PCME after cataract surgery since it causes breakdown of the blood–retinal barrier. Diabetic retinopathy (DR) increases the risk even further. Therefore, prophylactic nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered in diabetic patients, especially if they have DR. NSAIDs block the cyclooxygenase enzymes responsible for prostaglandin production and reduce the incidence of PCME after cataract surgery. Nepafenac seems superior to other NSAIDs in terms of ocular penetration allowing higher and sustained therapeutic levels in retina and choroid. Topical steroids are less effective and may cause intraocular pressure increase limiting their long-term use. Nepafenac is cost effective, when the burden of PCME prevention is compared with the burden of treatment. Prevention is much cheaper and less harmful than invasive treatments like periocular or intravitreal injections. Overall, both nepafenac 0.1% and nepafenac 0.3% are well tolerated. They should be used carefully in patients with compromised corneas such as those with severe dry eye or penetrating grafts. If otherwise healthy cataract patients have ≥2 risk factors, like PCME in the other eye or posterior capsule rupture during surgery, treatment should be considered. Once-daily nepafenac 0.3% dosing may improve postoperative outcomes through increased patient compliance and may reduce treatment burden further. Every patient should be assessed in terms of risks/benefits of the treatment, in individual basis, before cataract surgery.

Filling the periorbital hollows with hyaluronic acid gel: Long-term review of outcomes and complications.

Hyaluronic acid gel has been used for rejuvenation of the periorbital tissues since 2004. The in-office, nonsurgical procedural nature has resulted in the growing popularity of the use of fillers. The periorbital region poses unique challenges to the cosmetic surgeon. Malar edema, blue-gray dyschromia, and contour irregularities are well reported short-term complications. We present a long-term follow-up review of complications associated with periocular injection of hyaluronic acid gel fillers. Retrospective review of 147 patients with at least a 5-year follow-up period since the first injection. Five senior masked reviewers were asked to grade photographs of patients in comparison with preinjection photographs. Grading was based on a reference photographic key looking specifically at the presence and severity of malar edema, blue-gray dyschromia, and contour irregularity. Malar edema (11%), blue-gray dyschromia (31.3%), and contour irregularities (30.5%) continue to be problems in longer term follow-up of patients. The vast majority (90%) of these complications were mild and required no intervention. There is no statistically significant difference in the mean volumes injected by severity grading of each measured complication. Hyaluronic acid gel fillers of the periorbital region are well tolerated in our long-term follow-up experience. The vast majority of cases of malar edema, blue-gray dyschromia, and contour irregularities are mild and do not require intervention. Conservative treatment and tailored treatment approaches, in terms of volume and frequency of injections, may decrease the tendency of these adverse effects to occur.

Botulinum toxin therapy in patients with oral anticoagulation: is it safe?

When used therapeutically, botulinum toxin (BT) has to be injected into its target tissues. All manufacturers warn not to do so in patients with oral anticoagulation to avoid haematoma. We wanted to study the haematoma frequency (HF) in patients with anticoagulation receiving BT therapy. 32 patients (16 females, 16 males, age 69.3±10.0years) with blepharospasm (n=6), hemifacial spasm (n=8), post-stroke spasticity (n=16), and cervical dystonia (n=2) received BT therapy (needle size 27G, post-injection tissue compression) whilst on anticoagulation (anticoagulation group, AG). 32 patients matched for disease, target muscles, age, and gender received identical BT therapy without anticoagulation (control group, CG). Anticoagulation was performed with phenprocoumon. International normalised ratio (INR) at the time of BT injection was in all patients within the recommended margins of 2.0 and 3.0 (mean 2.6±0.27). Overall HF was 3.0% in AG and 1.8% in CG (not significant). All hematomas occurred in blepharospasm patients (AG 5.2%, CG 2.6%, not significant) and hemifacial spasm patients (AG 3.9%, CG 2.9%, not significant). In cervical dystonia and spasticity there were no haematomas. Throughout an observation period of 4years, none of the haematomas was surgically relevant. Haematomas are a rare complication of BT therapy, mainly occurring in periocular injections. Anticoagulation only marginally increases HF, provided INR is controlled and appropriate injection techniques are used. Surgically relevant haematomas do not occur. Interruption of oral anticoagulation to perform BT therapy is not justified.

Acute Anterior Uveitis

A 36-year old female presents with acute (recurrent) anterior uveitis in the right eye, HLA-B27 positive. She has ahistory of bilateral recurrent non-granulomatous uveitis attacks since 2011, but she has no extraocular manifestation ofautoimmune disease. She has typical signs of acute anterior uveitis (the ciliary conjunctival injection, hypopyon leveland fibrin reaction at pupillary area as in Fig. A.). Fig. B shows signs of previous uveitic attack in the same eye as Fig.A (residual fibrin on the anterior lens surface is visible on slit lamp examination after pupillary dilatation). This case requirestreatment of combined periocular steroids injection and topical steroids plus cycloplegics to control the inflammation.