[Effectiveness and interest of retrobulbar hyaluronidase injections in the treatment of blindness complicating facial hyaluronic acid injections: A literature review]. / Efficacité et intérêt des injections rétrobulbaires de hyaluronidase dans le traitement des cécités compliquant une injection faciale d'acide hyaluronique : revue de la littérature.

INTRODUCTION: Hyaluronic acid injections are becoming increasingly common among both the general public and the medical community, but they are not without risks. The occurrence of blindness, although rare, is a tragic event for both the patient and the practitioner. One of the treatments proposed in the literature is to inject hyaluronidase as close as possible to the site of ischemia, retrobulbarly. The aim of our study is to evaluate the effectiveness and potential benefits of retrobulbar hyaluronidase injections. MATERIALS AND METHODS: A literature review was conducted using the PubMed database. Only articles addressing retrobulbar hyaluronidase injections for the treatment of blindness following hyaluronic acid injections were included. RESULTS: We identified 12 case reports or series, comprising a total of 16 patients. Among these 16 patients, 3 regained their vision. Hyaluronidase was injected between 20minutes and 7days after the onset of the complication, with injected doses ranging from 3×150IU to 3×1500IU. DISCUSSION: Literature reveals only 3 cases of successful treatment out of the 16 reported injections. The time interval before retrobulbar injection, as well as the dose and the experience of the injecting practitioner, may influence the success rate of this treatment. Other treatments, such as intravascular hyaluronidase injections, remain to be explored.

Effect of retrobulbar prostaglandin analog injection on orbital fat in rats.

PURPOSE: Periorbital fat atrophy is a known side effect of topical prostaglandin analogs (PA). This side effect may have implications in the treatment of diseases like thyroid orbitopathy. In this in vivo study we aimed to evaluate the effects of retrobulbar injection of three different PAs on orbital fat. METHODS: Eighteen adult male Wistar-albino rats were divided into three groups of six animals. 0.1 ml of 0.03% bimatoprost, 0.005% latanoprost, or 0.005% travoprost was injected into the right orbits and saline was injected into the left orbits, as controls. Both orbits were exenterated after 3 weeks. Histological cross-sections were analyzed using ImageJ image analysis software. Intraconal adipocyte density was calculated. RESULTS: There was no significant difference in the adipocyte density between the PA injected orbits and the control side in each of the three groups. When calculations from all three groups were analyzed together, again the difference in the adipocyte density between the PA injected orbits and the control side was not significant. CONCLUSION: No significant fat atrophy was noted in this rat model three weeks after retrobulbar injection of PAs. To evaluate retrobulbar injection of PA as a potential therapy for orbital diseases with fat proliferation, in vivo studies in different animal models, higher concentrations of PA, or longer follow-up duration are required.

Retrobulbar Filling for Enophthalmos Treatment in Dogs: Technique, Description and Computed-Tomographic Evaluation. Preliminary Cadaveric Study.

A new therapeutic approach for enophthalmos may be retrobulbar lipofilling. This study aims to standardize the intraconal filling technique and to evaluate the degree of eyeball displacement by computed tomography (CT). Skull CT was performed on six dog cadavers before and after intraconal injection of two 5% iodinated, viscoelastic solutions, one per eye, using an ultrasound-guided supratemporal approach. The volume to be injected was calculated using formulas for retrobulbar cone anesthesia. After CT, the dogs underwent necropsy and histopathology to evaluate damages that eventually occurred to retrobulbar structures. Eyeball displacement was estimated using two CT-based methods, named M1 and M2. The Wilcoxon signed-rank test revealed no significant difference between the two injected materials in both M1 (p > 0.99), and M2 (lateral p = 0.84 and rostral p = 0.84 displacement). A statistically significant difference was found between the pre- and post-injection group M1 (p = 0.002), M2 (p = 0.004) for the lateral and (p = 0.003) for rostral displacement. Although the slight eyeball displacement, the retrobulbar filling can lead to enophthalmos resolution. Compared to M1, the M2 method has better-defined anatomical landmarks. Further, preclinical in vivo studies are necessary to assess retrobulbar filling efficacy and safety.

Retrobulbar Amphotericin B Injection in Curbing the Progression of COVID Associated Rhino-orbital Cerebral Mucormycosis: A Retrospective Case Series.

Purpose To assess whether transcutaneous retrobulbar Amphotericin B (TRAMB) injection can halt disease progression and reduce the requirement of exenteration in post-COVID 19 Rhino-orbital cerebral Mucormycosis (ROCM)) with limited orbital disease. Methods Retrospective series from a single center included 22 patients with KOH proved post-COVID 19 ROCM with radiographic evidence of limited orbital involvement were evaluated from May 2021 to October 2021. TRAMB was given along with systemic intravenous Amphotericin B injection and sinus debridement. Demographic profile, clinical data, operative notes, blood and radiological investigations were evaluated. The primary outcome was to assess the halt in the progression of orbital disease. The primary outcome measure was to assess the halt of the disease progression and the secondary outcome was improvement in the clinical signs and symptoms. Results The mean age was 50.36 ± 9.72 years and 77.3% were men. The Stagewise distribution was twelve (54.5%) patients in stage 3a, four (18.2%) patients in stage 3b, four (18.2%) in stage 3c, one (4.5%) patient in stage 3d and one (4.5%) had stage 4 disease. Improvement in lid edema and conjunctival chemosis were noticed and it was statistically significant (p value < 0.01), similarly visual acuity and ocular motility showed significant improvements (p value 0.04 and < 0.01 respectively). 1 patient died and 1 patient required exenteration later. Twenty patients showed halting of orbital disease after TRAMB injection. Conclusion TRAMB can be an alternative adjuvant therapeutic option to preserve the globe in patients with limited orbital disease but not at all replacement for exenteration.

Outcomes of Transcutaneous Retrobulbar Amphotericin B in Rhino-Orbital-Cerebral Mucormycosis Among Patients Recovering From COVID-19: A Preliminary Experience.

Background In this study, we aimed to assess the outcomes of transcutaneous retrobulbar injection of amphotericin B (TRAMB) in rhino-orbital-cerebral mucormycosis (ROCM) among patients recovering from coronavirus disease 2019 (COVID-19). Methodology This retrospective study was conducted at a tertiary care center in eastern India from May 29th to July 31st, 2021, and included post-COVID-19 patients admitted with stage 3 and 4a ROCM who underwent TRAMB. The details of the ophthalmic examination, laboratory investigations, and radiological examination were retrieved from patients records. Patients were given TRAMB (3.5 mg/mL) on alternate days till they underwent debulking surgery and resumed from the second postoperative day alternatively till the patients showed clinical stabilization or improvement. Results In total, 45 eyes of 41 patients were included in the study. The median number of injections given was six (minimum = 3; maximum = 10). Following was the distribution of number of injection needed in each eye: eight eyes (three injections), six eyes (four injections), seven eyes (five injections), three eyes (six injections), eight eyes (seven injections), 11 eyes (eight injections), and one eye had received nine and ten injections each. Overall, 21/32 (65.62%) eyes had improvement in proptosis whereas 9/32 (28.12%) had improvement in ptosis. Six patients had improvement in extraocular movement. In total, 25 eyes had no improvement whereas seven eyes had improvement in vision. Four eyes underwent exenteration. All nine patients with limited orbital disease had good improvement with fewer injections (median = 4). None of the patients undergoing TRAMB had an intracranial extension of disease. Moreover, 8.88% (4/45) of the eyes had post-TRAMB transient inflammation which resolved without any intervention. Finally, 3/41 of the patients died. Conclusions TRAMB can be considered as an useful therapeutic adjunct in managing ROCM. Further, it can halt the progression of the disease while awaiting definitive surgical intervention.

Chronic invasive fungal sinusitis with orbital and olfactory cleft involvement secondary to indolent mucormycosis.

PURPOSE: Chronic invasive fungal sinusitis secondary to indolent mucormycosis is a rare clinical entity, and the ideal management is controversial. A case of indolent mucormycosis successfully managed with conservative debridement and retrobulbar amphotericin B is herein reported. OBSERVATIONS: A 42-year-old man with diabetes mellitus and kidney transplant presented with chronic invasive fungal sinusitis with left orbital involvement from indolent mucormycosis. The patient was treated with aggressive systemic antifungal therapy, left retrobulbar injection of liposomal amphotericin B, reduction in immunosuppression, and conservative surgical debridement. Although the left olfactory cleft was involved, the cribriform plate was not resected due to risk of seeding the intracranial space. Given mild orbital involvement, no orbital debridement was performed and the patient had resolution of his orbital findings with systemic and retrobulbar amphotericin B. The patient had clinical and radiographic stability at 6-month follow-up. CONCLUSIONS: Conservative resection with subsequent long-term antifungal treatment can be a successful regimen in indolent mucormycosis. Retrobulbar amphotericin B may be a prudent orbit-sparing adjuvant therapy in indolent mucormycosis.

Retrobulbarly injecting nerve growth factor attenuates visual impairment in streptozotocin-induced diabetes rats.

PURPOSE: To explore whether retrobulbar administration of nerve growth factor (NGF) can restore visual function of streptozotocin-induced diabetes rats. METHODS: A high-sucrose/high-fat diet and single injection of streptozotocin (STZ) were used in modeling diabetes. During week 13-15 after STZ injection, diabetic rats were received retrobulbar ßNGF injection. On week 17 after STZ injection, the rats were tested with flash visual evoked potential (FVEP) to reflect visual function and with both optical coherence tomography (OCT) and hematoxylin and eosin (H&E) staining to show retinal morphological changes. Furthermore, periodic acid-Schiff (PAS) staining for retinal vascular digest preparations was performed to investigate retinal microvascular alterations, and immunofluorescences for slides of the optic nerve or retina were checked to assess astrocyte activation, autophagy level, and the unfolded protein response (UPR). RESULTS: Retrobulbar ßNGF injection significantly improved FVEP of diabetic rats. It also significantly alleviated retinal ganglion cell (RGC) loss and scarcely elicited other retinal/microvascular morphological changes, in OCT, H&E staining, and microvascular preparation. Moreover when diabetes rats treated with NGF, immunostaining of the optic nerve showed downregulation of complement 3d (C3d) and upregulations of glial fibrillary acidic protein (GFAP), S100-A10, microtubule-associated proteins 1A/1B light chain 3b (LC3b), and activating transcription factor 4 (ATF-4), while immunostaining of the retina showed upregulation of LC3b and no expression of ATF-4. CONCLUSION: Our findings demonstrate that retrobulbar administration of ßNGF reduces visual impairment with RGC-loss attenuation and without retinal-microvascular morphological alteration in diabetic rats. Furthermore, enhancements of A2 astrocyte activation, autophagy-protein expression, and ATF-4-mediated UPR may play crucial roles in the protective mechanism of NGF in diabetic visual-pathway neurodegeneration.

Suspected systemic uptake of chlorpromazine after retrobulbar injection.

PURPOSE: To present a case of suspected systemic uptake of chlorpromazine after a patient underwent retrobulbar injection for a blind painful eye. OBSERVATIONS: The patient is a 63-year-old Hispanic female who presented to the surgery center with neovascular glaucoma and uncontrolled intraocular pressure of her right eye. Immediately following retrobulbar injection of chlorpromazine, the patient became very sedate and difficult to arouse and blood pressure recordings fell. After 4.5 hours, her symptoms improved, and the patient was discharged. There were no further systemic symptoms reported on follow up. CONCLUSION AND IMPORTANCE: Systemic uptake of chlorpromazine following retrobulbar injection is a risk that should be considered when managing blind painful eyes. Ophthalmologists should practice caution with this technique and educate patients and staff on potential risks.

Retrobulbar Injection for Hyaluronic Acid Gel Filler-Induced Blindness: A Review of Efficacy and Technique.

While blindness after hyaluronic acid gel filler injection occurs only very rarely, it represents a devastating complication for the patient and the surgeon. Retrobulbar injection with hyaluronidase is the only known potential means of reversing this adverse event. However, positive outcomes remain anecdotal. We have attempted to review the current literature regarding possible efficacy and detail the indications and technique to be utilized, if hyaluronidase retrobulbar injection is to be attempted. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical Observations and the Anatomical Basis of Blindness After Facial Hyaluronic Acid Injection.

BACKGROUND: Blindness or visual loss is the most serious complication resulting from facial hyaluronic acid (HA) injection. In this study, three recent clinical cases were analyzed, and the relevant anatomy of cadavers was evaluated to investigate the mechanism behind visual impairment due to HA injection. METHODS: Three patients with different extents of visual loss after HA injection were studied. Ophthalmic testing and corresponding treatments were performed, and the clinical progress was observed. In addition, thirty-six fresh Asian cadaver hemifaces were anatomized to investigate the morphology of the ophthalmic artery and its branches. The minimum dose of HA for central retinal artery embolism was calculated based on the ophthalmic arterial volumes of cadavers. RESULTS: Visual impairment was more severe in central retinal artery occlusion and combined intraocular branch occlusion than in posterior ciliary artery occlusion. During follow-up, no improvement was observed in terms of visual impairment. Cadaver study reconfirmed that the ophthalmic artery included facial and intraocular branches. The ophthalmic arterial volumes running from the supraorbital artery and supratrochlear artery to the central retinal artery were 0.083 cm3 and 0.089 cm3, respectively. CONCLUSIONS: The severity of blindness caused by HA injection may be associated with the occlusion site. Our clinical observations indicate that conventional treatments, such as retrobulbar hyaluronidase injection, are insufficient to relieve visual impairment. Injecting as little as 0.08 ml of HA into the facial branch is enough to cause central retinal artery embolism. Limiting the volume per injection could represent a simple prophylactic strategy. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Management of inadvertent needle penetration resulting in subretinal triamcinolone acetonide and retinal detachment.

PURPOSE: To report management of inadvertent needle penetration during subtenons triamcinolone acetonide administration resulting in retinal detachment. OBSERVATIONS: A 71-year-old female with history of diabetes, hypothyroidism, and mild myopia underwent subtenons triamcinolone acetonide (TA) injection in the right eye for nodular scleritis. There was unexpected patient movement concurrent with the injection resulting in needle penetration, subretinal and intravitreal injection of TA, superotemporal retinal break, and macula-involving retinal detachment. The patient underwent partial subretinal TA removal, successful retinal detachment repair, and recovered 20/25 visual acuity. CONCLUSIONS AND IMPORTANCE: In spite of prominent subretinal TA and retinal detachment, successful repair of retinal detachment and recovery of good visual acuity is possible.

Effects of retrobulbar or intravitreal injection of triamcinolone acetonide combined with laser photocoagulation for diabetic macular edema / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM:To investigate the clinical efficacy of retrobulbar or intravitreal injection of triamcinolone acetonide combined with 532nm laser photocoagulation in the treatment of diabetic macular edema(DME). <p>METHODS: Sixty-two eyes in 40 DME patients were divided into two groups(Group A and Group B)randomly. Thirty-one eyes in Group A were treated with retrobulbar injection of triamcinolone acetonide(RBTA)and 31 eyes in Group B were treated with intravitreous injection of triamcinolone acetonide(IVTA). Eyes with limited macular edema were treated by local direct retinal laser, those with diffuse and cystic macular edema were treated by grid retinal laser using Vitra 532nm fundus lasers at 1mo after injection. Visual acuity, intraocular pressure, fundus, macular edema and complications were recorded after 1wk, 1, 3 and 6mo in the follow-up study. <p>RESULTS: The mean best corrected visual acuity was improved and macular edema subsided after treatment in the two groups in the follow-up study at 1wk, 1, 3 and 6mo(<i>P</i><0.05), while there had no significant difference between groups(<i>P</i>>0.05). In Group A, significant efficiency rate was 39%(12/31), total effective rate was 90%(28/31). In Group B, significant efficiency rate was 39%(12/31), total effective rate was 94%(29/31). The follow-up study showed no retinal detachment, endophthalmitis, intraocular hemorrhage and other complications. <p>CONCLUSION: Triamcinolone acetonide injection combined with laser photocoagulation is an effective method for treatment of DME with significant effect, less adverse reactions, patient's vision improved effectively and macular edema reduced. No significant difference was noted in the treatment of DME between RBTA and IVTA.

Vertical diplopia after cataract surgery, overacting, and/or underacting extraocular muscle.

The purpose of this study was to demonstrate two cases of vertical diplopia after cataract surgery and to discuss the mechanism and types of strabismus caused by the local anesthesia with retrobulbar injection. Two cases of vertical diplopia after cataract surgeries were reported. They were operated by the same surgeon and both happened to the left eye and both presented with marked left hypotropia. The clinical findings consisted of overacting left inferior rectus (LIR) in case 1 and mixed overacting and restrictive LIR in case 2. The diplopia and left hypotropia were eliminated after muscle operation. Retrobulbar injection is a basic technique in ophthalmic practice. Although it is generally safe, complications do happen in certain cases including diplopia and strabismus. Ophthalmologists should know about the orbital anatomy and learn to prevent any accidental insult to extraocular muscles.

Retinal Vascular Occlusion Secondary to Retrobulbar Injection: Case Report and Literature Review.

Retrobulbar injection has been widely practiced as a technique of ocular anesthesia for many decades. Nevertheless, the technique is not free from complications. Vascular occlusion secondary to retrobulbar injection is rare but can be vision threatening. We report a case series of two such patients who presented with poor vision following retrobulbar injection. Fundus showed pale retina with cherry red spot suggestive of central retinal artery occlusion in case 1 and pale disc with sclerosed vessels and multiple superficial hemorrhages suggestive of a combined occlusion of retinal artery and vein in case 2. Optical coherence tomography (OCT) showed thickened inner retinal layers with intact outer retinal layers in case 1 and thinning in case 2. We conclude that retrobulbar injections can rarely be associated with dreadful vision-threatening complications like in our patients. We also report the role of OCT in assessing the prognosis following vascular occlusion.

Gasserian Ganglion and Retrobulbar Nerve Block in the Treatment of Ophthalmic Postherpetic Neuralgia: A Case Report.

OBJECTIVES: Varicella zoster virus reactivation can cause permanent histological changes in the central and peripheral nervous system. Neural inflammatory changes or damage to the dorsal root ganglia sensory nerve fibers during reactivation can lead to postherpetic neuralgia (PHN). For PHN of the first division of the fifth cranial nerve (ophthalmic division of the trigeminal ganglion), there is evidence of inflammatory change in the ganglion and adjacent ocular neural structures. First division trigeminal nerve PHN can prove to be difficult and sometimes even impossible to manage despite the use of a wide range of conservative measures, including anticonvulsant and antidepressant medication. Steroids have been shown to play an important role by suppressing neural inflammatory processes. We therefore chose the trigeminal ganglion as an interventional target for an 88-year-old woman with severe ophthalmic division PHN after she failed to respond to conservative treatment. METHODS: Under fluoroscopic guidance, a trigeminal ganglion nerve block was performed with lidocaine combined with dexamethasone. A retrobulbar block with lidocaine and triamcinolone settled residual oculodynia. RESULTS: At 1-year follow-up, the patient remained pain free and did not require analgesic medication. CONCLUSION: To our knowledge, this is the first reported case of ophthalmic division PHN successfully treated with a combination of trigeminal ganglion and retrobulbar nerve block using a local anesthetic agent and steroid for central and peripheral neural inflammatory processes.

Intravitreal Injection-Induced Migraine Headaches.

A case of migraine headache triggered by intravitreal injection, and aborted by retrobulbar injection, is reported. To date, migraine and related cephalgia have not been reported after intravitreal injection. Ophthalmologists and neurologists should be aware of this potential sequela of a very common procedure.

Comparison of two bupivacaine delivery methods to control postoperative pain after enucleation in dogs.

OBJECTIVE: To compare the efficacy of a preoperative retrobulbar injection of bupivacaine to an intraoperative splash block of bupivacaine in controlling postoperative pain following enucleation in dogs. ANIMALS STUDIED: Prospective, randomized, double-masked clinical study of 31 client owned dogs with end-stage ophthalmic disease requiring enucleation. PROCEDURES: Dogs admitted for unilateral enucleation were randomly assigned to receive bupivacaine 0.5% (1 mL/kg) into the retrobulbar space either via an inferior-temporal palpebral (ITP) injection preoperatively or an intraoperative splash block. Pain was assessed prior to pre-anesthetic sedation and at 0, 0.25, 0.5, 1, 2, 4 6, 8, and 24 hours (H) after extubation by masked observers using a previously described subjective pain scoring system. Rescue analgesia was initiated if overall pain score was >9 or if the score in any category at any time point was >3. RESULTS: There were no adverse reactions. One of 15 dogs that received bupivacaine via a preoperative retrobulbar ITP injection required rescue analgesia. There was no significant difference between groups with regard to the need for rescue analgesia or pain scores at any time point or overall. CONCLUSIONS AND CLINICAL RELEVANCE: Pain control using an intraoperative orbital splash administration of bupivacaine is not significantly different to a preoperative retrobulbar injection of bupivacaine.

Clinical observation of retrobulbar injection of triamcinolone acetonide combined 577 nm laser macular grid photocoagulation for the treatment of cystoid macular edema / 国际眼科杂志(Guoji Yanke Zazhi)

AlM:To evaluate the efficacy of retrobulbar injection of triamcinolone acetonide ( TA ) combined with 577nm laser macular grid photocoagulation for the treatment of cystoid macular edema. METHODS: Fifty-eight cases ( 66 eyes ) with cystoid macular edema caused by different diseases were recruited in this study. The included patients were treated with both retrobulbar injection of triamcinolone acetonide and 577nm laser macular grid photocoagulation. The best corrected visual acuity, macular thickness, fundus and intraocular pressure were observed in the 1wk, 1 and 3mo after the treatment in all of the included cases. RESULTS: After treatment, all of the 66 eyes showed cystoid macular edema partially or completely subsided according to optical coherence tomography and fluorescence fundus angiography; 54 eyes ( 82%) visual acuity improved, 12 vision remained the same. CONCLUSlON: Retrobulbar injection of triamcinolone acetonide combined with 577nm laser macular grid photocoagulation has good curative effect, simple operation procedure and rare complications in the management of cystoid macular edema.

The curative effect analysis on central retinal artery occlusion treated by compound anisodine / 中国基层医药

Objective Compare the difference on vision,vision field between treating on central retinal artery with compound anisodine retrobulbar injection associate with emporat artery side injection and emporal artery side injection simply.Estimate the curative effect of the two ways on the disease.Methods Observe the patients'vision,vison field and cross-check,analyze the results who have central retinal artery and there are 20 who treated by compound anisodine retrobulbar injection associate with emporal artery side injection together with 20 who treated by emporal artery side injection purely.Results The therapeutics that is compound anisodine retrobulbar injection associate with emporal artery side injection is excellence to 10,effective to 6 and ineffective to 4;the therapeutics that is arter3,side injection purely is excellence to 5,effective to 5 and ineffective to 10.The two therapeuticses has significant difference on improving vision and ameliorating vision field.Conclusion It's quite effective to treat central retinal artery occlusion by compound anisodine retrobulbar injection associate with emporal artery side injection.

The Effects of EMLA on Pain Associated with Retrobulbar Injection

A prospective study was undertaken to assess the efficacy of the anesthetic cream EMLA (Eutectic Mixture of Local Anesthetics)in alleviating the pain of retrobulbar injection in patients undergoing cataract surgery.One-hundred forty-three patients who had undergone cataract surgery under local anesthesia in Korea Veterans Hospital from July 1999 to February 2000 were selected randomly into three groups and each of them had no significant difference in their age, sex and underlying conditions.Fifty-seven patients received the EMLA cream, 43 patients received the placebo and the remaining 43 patients received nothing.Among three groups, the EMLA group and the placebo group were double masked.The pain assessed subjectively by the patient was expressed in 11 scales (0-10).And the reactions of the patients to needle insertion, which had been objectively assessed by the one operator, were graded into 4 scales (0-3).No patient experienced serious side effects in each treatment group.In subjective grading, the EMLA group which had been graded as 2.91 +/-1.93 was proven to be more effective in reducing pain than the placebo group (6.2 +/-2.02)and the not-treated group (6.56 +/-1.64).In objective grading, the EMLA group (0.44 +/-0.63)was superior to the placebo group (0.98+/-0.99)and the no treated group (1.4 +/-0.13).In conclusion, local pretreatment using the EMLA cream to alleviate the pain on retrobulbar injection is one of good methods for enhancing the patient cooperation in cataract surgery with reduced anxiety.