Periocular Complications

16 Nov 2016

Mr Daniel Ezra advises how to successfully avoid and manage complications associated with treatment around the eyes

Recent years have seen an explosion in the number and range of aesthetic facial treatments. Whilst there is good safety data to support most of these treatment modalities, very few have had any form of safety evaluation with regard to potential periocular complications and their management. Management of complications in medical aesthetics is a major unmet educational need for practitioners and most recognised training programmes rarely address the best way to deal with complications. This is especially true of the eyes, around which many cosmetic interventions are targeted, but often with very little knowledge of recognising potential complications and how to manage them.

Whilst there are numerous potential problems that can arise from different treatments, this article will summarise the relevant aspects of the common treatments with a focus on some simple take-home messages.

Botulinum toxin therapy

The periocular areas are the most common sites for botulinum toxin therapy, with the corrugator muscles and orbital orbicularis oculi muscles targeted to soften the glabellar lines and crow’s feet respectively. Some of the most common side effects of toxin injections into this area are ptosis (droopy eyelid) and double vision. This occurs because of diffusion of the toxin to the extraocular muscles, which are the muscles deep within the eye socket that are attached to the eye and mostly control movement. Anatomically, the contents of the orbit are separated from the anterior eyelid tissues and protected by a tough connective tissue layer called the orbital septum. The orbital septum forms a diaphragm across the eye socket taking origin from all of the bony rim and inserting into the canthal tendons and tarsal plates of the eyelids. The orbital septum is pierced by the levator palpebrae superioris, which is the muscle responsible for most of the upper eyelid opening. The inferior part of the muscle and its aponeurosis lie anterior to the protective septum, making it susceptible to toxin seepage, which can result in ptosis.1

Ptosis

Risk factors for the development of ptosis include anatomical considerations related to the injection site, dose and dilution. The needle should never approach the insertions of the orbital septum and beginners should always point the needle away from the eye. Care should also be taken by more advanced practitioners who may be treating more delicate areas such as the pretarsal orbicularis in order to treat small degrees of ptosis or the lower lid pretarsal roll. Injections within the orbital aperture should always be directed subcutaneously to protect deeper structures, and patients should also be monitored for symptoms of dry eye, which results from impaired eyelid closure. Injections at higher doses have some advantages, such as longevity of effect and also more profound muscle weakening, which may be desirable for some patients. However, higher doses injected close to the orbital septum carry a higher risk of ptosis. If higher doses are required, the risk can be minimised by reducing the volume of drug injected for a given dose.

Ptotis can occur in up to 5% of patients,2 and it can usually be treated effectively with apraclonidine eye drops. These a-adrenergic agonists stimulate the contraction of the Muller’s muscle, which raises the eyelid and is sympathetically innervated for fight-or-flight response.1 However, care should be taken to avoid using this medication for long periods of time as it is known to cause significant skin irritation in the form of chronic or acute allergic dermatitis, pupillomotor changes, watering, discomfort, dry mouth and altered taste.3 Apraclonidine is not a treatment for other forms of ptosis and should never be used in this way.

Diplopia

Double vision after toxin therapy is much less common and is almost always due to the administration of higher doses of toxin too close to or beyond the orbital septum.4 If you are finding that patients regularly have problems with diplopia, you should revisit your training and technique. Diplopia is one of the most debilitating ophthalmic symptoms and can severely limit work and other activities of daily living. Temporary supportive measures for patients with transient post-treatment diplopia are possible in the form of prisms and, sometimes, occlusive contact lenses, so patients with this complication should be referred to an ophthalmologist for further treatment.

Filler therapy

Hyaluronic acid (HA) fillers have now become the treatment of choice for non-surgical soft tissue augmentation. These are generally safe treatments with minimal immunogenicity, long lasting duration and excellent patient satisfaction (Figure 1). However, they are associated with quite significant complications, especially if the filler is applied incorrectly. HA filler complications are the most common problems I tend to see in my revision practice, often presenting with a variety of issues. Although the range of complications that arise is similar to those encountered in other anatomical locations, the thin and delicate tissues around the eyes make complications more common in the periocular areas.

Swelling

Swelling is the most common problem and is associated with all fillers, and this is especially true of the tear trough area. Swelling is due to the hydrophilic nature of the gels and also the inherent disruption of normal vascular and lymphatic dynamics.5 The risk of persistent swelling can be minimised in a variety of ways. Firstly, careful thought must be applied in considering the type of filler material to be used around the eyes. There is a range to choose from, and the choice of filler should match the location being injected. If you are using the same filler for all parts of the face, you are likely to be doing something wrong. Highly cross-linked HA gels are excellent for larger volume and deeper fills such as the nasolabial folds or lateral cheeks. However, these are more prone to swelling and should be avoided around the eyes in favour of less cross-linked preparations or blends.3 In addition, remember that when treating the tear troughs, small volumes are key. If you are used to treating areas where large injection volumes are used, you will find the volume requirements around the tear trough very different, as often 0.2-0.3ml is more than sufficient for each tear trough deformity.

Infection

Foreign body reactions and infections can present several months or even years after the initial injections (Figure 2). Granuloma and foreign body reactions are one of the most common complications and it is important to differentiate these from lumps and bumps caused by excessive injection or poor technique. Granulomas are discrete nodules characterised by specific inflammatory responses. They are often red, tender and well defined. These reactions had previously been thought to be sterile, but are now understood to be infective in origin.6 Infective processes are thought to be due to either inoculation at the time of injection or biofilm formation around the gel.7 Infections are very difficult to treat because the organism can sequester within the filler6,7 with poor vascular penetration leading to common recurrence after antibiotic use. Preventing organism inoculation at the time of injection is a critical precaution when administering fillers. It is therefore essential to ensure that procedures are conducted under aseptic conditions. This means using sterile gloves and conducting skin prep with either chlorhexidine or povidone iodine. Established infection requires specialist treatment consisting of combinations of antibiotics, steroids, surgical drainage and hyaluronidase therapy.8

Vascular occlusion

Vascular occlusions are the most serious complications associated with HA filler use. Filler injections in the tear trough area induce significant perfusion changes with engorgement of the veins evident immediately after the injections, most likely resulting from changes to the delicate relationship between drainage of the lymphatics and venous pressure.9 There have been many reports of blindness or loss of vision resulting from periocular HA injection use.10 This phenomenon is due to vascular occlusion of the central retinal artery caused by passage of filler through the external carotid arterial system into the internal carotid tree (Figure 3). This is most likely to occur through the numerous external/internal carotid artery terminal branch anastomoses around the orbit, many of which are branches of the ophthalmic artery, which perfuse the eyelids and periocular tissues. Vision loss is sudden and often associated with ptosis, ophthalmoplegia and pain.11

Other forms of vascular occlusion can cause local areas of necrosis which tend to occur around medial structures of the face, particularly in the distribution of the supraorbital or labial end-arteries. This leads to necrosis of the skin in these distributions, which is sometimes mistaken for infection. The characteristic signs of vascular skin occlusion are sudden blanching and discolouration of the skin associated with pain and paraesthesia.12 The injecting should stop immediately and warm compresses should be applied to promote vasodilatation. I would recommend applying hyaluronidase, at a dose of approximately 300u in total over the area and repeated daily if necessary. Higher doses of hylauronidase should be avoided as this can induce very significant adverse soft tissues changes as outlined below. Patients should also be treated with oral antibiotics.

In the event of symptoms of vision loss, patients should be sent as an emergency to their local accident and emergency department or eye department. Acute management is highly specialised and would include decreasing intraocular pressure with either intravenous acetazolamide or direct anterior chamber puncture and decompression, although the prognosis for visual recovery is very poor.13 Vascular complications must be avoided and by ensuring that the injection technique is appropriate, these risks can be minimised. This critically means that it is essential to ensure that the injector has a thorough understanding of the anatomy of the area to be injected with an emphasis on vascular branches and their variations and to be aware of the key danger areas. Low pressure injecting with gentle pressure on the syringe plunger is also essential to avoid intravascular injection. Wider bore needles or cannulas are also helpful and can reduce hydrostatic pressure of the filler during the injection phase. The risk can be further minimised by aspirating the syringe to exclude intravascular positioning. Using cold compresses prior to injection may be helpful by encouraging vasoconstriction.14

Essential kit

  • Eye wash station
  • Normal saline
  • Access to apraclonidine, antibiotics, steroid injections
  • Hyaluronidase
  • Warm compresses
  • Cold compresses
  • Emergency ophthalmic referral details
  • Cannulas
  • Universal pH paper
  • Sterile gloves
  • Chlorhexidine or povidone Iodine

Management

Therapy with hyaluronidase is an essential technique for managing the complications of filler injections. Hyaluronidase is a powerful enzyme used for a variety of medical purposes to break down natural connective tissues. Whilst deeper injections to other areas of the face are often more forgiving, the thinness of the tear trough areas allows for much less tolerance of adverse results from hyaluronidase use. Higher doses can lead to damage of native extracellular matrix glycosaminoclycans, leaving a gaunt appearance with poor skin texture (Figure 4). Patients are increasingly presenting with hyaluronidase-related damage, which is often untreatable. Hyaluronidase therapy to the periocular area can have devastating results and should only be provided by experienced practitioners with caution. The view that fillers are a ‘natural substance’ and can be simply dissolved without complications is outdated. Given that we are now understanding more about how fillers interact with the body we need to move away from the simplistic view of fillers as an easily reversible therapy and any periocular hyaluronidase therapy must be delivered with extreme caution.

Chemical injuries

The sheer range of aesthetic techniques means that many different types of chemicals and drugs are often used in close proximity to the eyes. Eyelash tinting, acid peels and retinoid therapies can all cause chemical injuries and corneal damage. Although caution should be undertaken when using chemicals around the eyes, inadvertent inoculation of the ocular surface can be a common presenting scenario to the ophthalmologist. Acid injuries are less severe than alkali injuries, but can cause quite significant corneal epithelial damage and denudement. Corneal protection is predominantly a form of barrier immunity and any compromise of the epithelium can lead to infections and pain. In the event of ocular inoculation, an eyebath should be available on the premises for immediate washing, or running a sterile saline bag gently onto the eye with the patient leaned over the sink. Rapid washing is essential and the pH of the tear film should be measured to ensure a neutral pH is achieved and this can be confirmed with universal indicator paper. Patients should then be referred to the local accident and emergency department if they remain in pain as they will often require a bandage contact lens and antibiotic therapy, as well as close review.15

Conclusion

Optimal complication management for aesthetic treatments is a major unmet training need, and this is particularly true for periocular complications. If safe and effective treatments are to be provided for patients, a basic understanding of the relevant anatomy and physiology underlying these treatments is required to allow them to choose the correct product and administer it in a safe fashion.

References

  1. Ezra DG, Beaconsfield M, Collin R., ‘Surgical anatomy of the upper eyelid: old controversies, new concepts’, Ex Rev Op, 4(1) (2009), pp.47-57.
  2. Scheinfeld N., ‘The use of apraclonidine eyedrops to treat ptosis after the administration of botulinum toxin to the upper face’, Dermatol Online J,11(1) (2005), pp.9.
  3. Yuksel, NE; Karabas, L; Altintas, O; et al., ‘A comparison of the short-term hypotensive effects and side effects of unilateral brimonidine and apraclonidine in patients with elevated intraocular pressure’, Opthalmologica, 216 1 (2002), pp.45-49.
  4. Wollina, U; Konrad, H., ‘Managing adverse events associated with botulinum toxin type A - A focus on cosmetic procedures’, American Journal of Clincial Dermatology, 6 3 (2005), pp.141-150.
  5. Sundaram H, Cassuto D., ‘Biophysical characteristics of hyaluronic acid soft-tissue fillers and their relevance to aesthetic applications’, Plastic and Reconstructive Surgery, 132 (4 Suppl 2) (2013) 5S–21S.
  6. Beer K, Avelar R., ‘Relationship between delayed reactions to dermal fillers and biofilms: facts and considerations’, Dermatol Surg,40 (11) (2014), pp.1175-1179.
  7. Wagner, Ryan D.; Fakhro, Abdulla; Cox, Joshua A.; et al., ‘Etiology, Prevention, and Management of Infectious Complications of Dermal Fillers’, Seminars in Plastic Surgery, 30 2 (2016), pp.83-85.
  8. Rzany B, DeLorenzi C., ‘Understanding, avoiding, and managing severe filler complications’, Plast Reconstr Surg, 136 (5, Suppl) (2015), pp.196S-203S.
  9. Pimentel de Miranda A, Nassiri N, Goldberg RA., ‘Engorgement of the Angular and Temporal Veins Following Periorbital Hyaluronic Acid Gel Injection’, Ophthalmic Plastic and Reconstructive Surgery, 32(2) (2016), pp.123-6.
  10. Beleznay, Katie; Carruthers, Jean D. A.; Humphrey, Shannon; et al., ‘Avoiding and Treating Blindness From Fillers: A Review of the World Literature’, Dermatologic Surgery, 41 10 (2015), pp. 1097-1117.
  11. Hwang CJ., ‘Periorbital Injectables: Understanding and Avoiding Complications’, J Cutan Aesthet Surg, Medknow Publications, 9(2) (2016), pp.73-9.
  12. Signorini, Massimo; Liew, Steven; Sundaram, Hema; et al., ‘Global Aesthetics Consensus: Avoidance and Management of Complications from Hyaluronic Acid Fillers-Evidence- and Opinion-Based Review and Consensus Recommendations’, Plastic and Reconstructive Surgery, 137 6.
  13. Beatty S, Au Eong KG., ‘Acute occlusion of the retinal arteries: current concepts and recent advances in diagnosis and management’, J Accid Emerg Med, 2000 17 (5), pp.324-9.
  14. Signorini M, Liew S, Sundaram H, De Boulle KL, Goodman GJ, Monheit G, et al., ‘Global Aesthetics Consensus: Avoidance and Management of Complications from Hyaluronic Acid Fillers-Evidence-and Opinion-Based Review and Consensus Recommendations’, Plastic and Reconstructive Surgery, 137(6) (2016), 961e–71e.
  15. Duffy B., ‘Managing chemical eye injuries’, Emerg Nurse, 16(1) (2008), pp.25-9. 

Comments

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  • Dr Amane Abdul-Razzak 19 Dec 2018 / 11:54 PM

    Where is figure 4?