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Lucaciu A, Samp PF, Hattingen E, Kestner RI, Davidova P, Kohnen T, Rudolph J, Dietz A, Steinmetz H, Strzelczyk A. Sudden vision loss and neurological deficits after facial hyaluronic acid filler injection. Neurol Res Pract 2022; 4:40. [PMID: 35850779 PMCID: PMC9290300 DOI: 10.1186/s42466-022-00203-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/12/2022] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The ongoing expansion of the cosmetic armamentarium of facial rejuvenation fails to uncover the inherent risks of cosmetic interventions. Informed consent to all risks of cosmetic filler injections and potential sequelae, including ocular and neurological complications, should be carefully ensured. We present two cases of complications following facial hyaluronic acid filler injections. CASE PRESENTATIONS Case 1: A 43-year-old woman presented with monocular vision loss of the left eye, associated ptosis, ophthalmoplegia, periocular pain and nausea, cutaneous changes of the glabella region and forehead, and sensory impairment in the left maxillary branch dermatome (V2) after receiving a hyaluronic acid (HA) filler injection into the left glabellar area. On ophthalmological examination, an ophthalmic artery occlusion (OAO) was diagnosed upon identification of a "cherry-red spot". Magnetic resonance imaging (MRI) revealed a left ischemic optic neuropathy. Supportive therapy and hyaluronidase injections were initiated. A follow-up MRI of the head performed two months after presentation corresponded to stable MRI findings. The patient had irreversible and complete vision loss of the left eye, however, the ptosis resolved. Case 2: A 29-year-old woman was admitted to hospital a few hours after a rhinoplasty and cheek augmentation with hyaluronic acid, presenting with acute monocular vision loss in the right eye, retrobulbar pain, fatigue and vomiting. In addition, the patient presented a harbinger of impending skin necrosis and a complete oculomotor nerve palsy on the right side, choroidal ischemia and vision impairment. Supportive treatment and hyaluronidase injections into the ischemic tissue were initiated. A small scar at the tip of the nose, vision impairment and an irregular pupillary margin on the right side persisted at follow-up. CONCLUSION These two case reports and the literature review emphasize the pathophysiological mechanisms leading to potentially devastating complications. In order to reduce the risk of vision loss secondary to cosmetic filler injections, practitioners should possess a thorough knowledge of anatomy and preventive strategies.
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Affiliation(s)
- Alexandra Lucaciu
- Department of Neurology, Center of Neurology and Neurosurgery, University Hospital and Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.
| | - Patrick Felix Samp
- Department of Neuroradiology, University Hospital and Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Elke Hattingen
- Department of Neuroradiology, University Hospital and Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Roxane-Isabelle Kestner
- Department of Neurology, Center of Neurology and Neurosurgery, University Hospital and Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
| | - Petra Davidova
- Department of Ophthalmology, University Hospital and Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Thomas Kohnen
- Department of Ophthalmology, University Hospital and Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Jasmin Rudolph
- Department of Ear, Nose and Throat Surgery, University of Leipzig, Leipzig, Germany
| | - Andreas Dietz
- Department of Ear, Nose and Throat Surgery, University of Leipzig, Leipzig, Germany
| | - Helmuth Steinmetz
- Department of Neurology, Center of Neurology and Neurosurgery, University Hospital and Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Department of Neurology, Center of Neurology and Neurosurgery, University Hospital and Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
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Enz TJ, Tschopp M. Assessment of Orbital Compartment Pressure: A Comprehensive Review. Diagnostics (Basel) 2022; 12:diagnostics12061481. [PMID: 35741290 PMCID: PMC9221953 DOI: 10.3390/diagnostics12061481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/09/2022] [Accepted: 06/15/2022] [Indexed: 11/16/2022] Open
Abstract
The orbit is a closed compartment defined by the orbital bones and the orbital septum. Some diseases of the orbit and the optic nerve are associated with an increased orbital compartment pressure (OCP), e.g., retrobulbar hemorrhage or thyroid eye disease. Our aim was to review the literature on the different approaches to assess OCP. Historically, an assessment of the tissue resistance provoked by the retropulsion of the eye bulb was the method of choice for estimating OCP, either by digital palpation or with specifically designed devices. We found a total of 20 articles reporting direct OCP measurement in animals, cadavers and humans. In nine studies, OCP was directly measured in humans, of which five used a minimally invasive approach. Two groups used experimental/custom devices, whilst the others applied commercially available devices commonly used for monitoring the compartment syndromes of the limbs. None of the nine articles on direct OCP measurements in humans reported complications. Today, OCP is mainly estimated using clinical findings considered surrogates, e.g., elevated intraocular pressure or proptosis. These diagnostic markers appear to reliably indicate elevated OCP. However, particularly minimally invasive approaches show promises for direct OCP measurements. In the future, more sophisticated, specifically designed equipment might allow for even better and safer measurements and hence facilitate the diagnosis and monitoring of orbital diseases.
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Affiliation(s)
- Tim J. Enz
- Department of Ophthalmology, University of Basel, CH-4031 Basel, Switzerland
- Lenzburg Eye Clinic, CH-5600 Lenzburg, Switzerland
- Correspondence:
| | - Markus Tschopp
- Department of Ophthalmology, Cantonal Hospital Aarau, CH-5001 Aarau, Switzerland;
- Department of Ophthalmology, Inselspital, University of Bern, CH-3010 Bern, Switzerland
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Mortada H, Seraj H, Barasain O, Bamakhrama B, Alhindi NI, Arab K. Ocular Complications Post-Cosmetic Periocular Hyaluronic Acid Injections: A Systematic Review. Aesthetic Plast Surg 2022; 46:760-773. [PMID: 35091771 DOI: 10.1007/s00266-021-02730-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/12/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND With the global rise in the use of hyaluronic acid (HA) fillers as a minimally invasive cosmetic procedure, significant adverse effects such as vascular compromise and blindness have become common. Hence, we present the first systematic review aimed to investigate ocular complications secondary to a facial HA injection and to understand the presentation, cause, management, and outcome of these complications. METHODS The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used to report this review. A systematic search was performed in July 2021 for published literature using the PubMed, MEDLINE, and Cochrane databases. The following terms were used: facial fillers, facial injections, hyaluronic acid, blindness, ophthalmoplegia, diplopia, ptosis, ophthalmic artery occlusion, posterior ciliary artery occlusion, and ocular ischemic syndrome. RESULTS A total of 2496 publications were searched, and 34 articles published between January 2000 and July 2021 were included. Twenty-seven case reports and seven case series were evaluated. The nose was the most common site of injection (n = 25; 40.67%). Ocular pain was the most common initial symptom of ocular complications (n = 13, 22.41 %). The most common complication was vision loss (n = 17, 50%). The majority of patients received hyaluronidase, aspirin, and steroids. Regarding the outcome, 15 (45.45%) of the published studies showed no improvement in complications even after management. CONCLUSION HA is gaining popularity in cosmetic applications. Post-HA ocular complications nearly always have an immediate onset. Proper knowledge of potential adverse events is crucial for clinicians to attempt to decrease complications and improve outcomes. LEVEL OF EVIDENCE III 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.
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Affiliation(s)
- Hatan Mortada
- Division of Plastic Surgery, Department of Surgery, King Saud University Medical City, King Saud University and Department of Plastic Surgery & Burn Unit, King Saud Medical City, Riyadh, Saudi Arabia.
| | - Hadeel Seraj
- Department of Ophthalmology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Omar Barasain
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Basma Bamakhrama
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Khalid Arab
- Division of Plastic Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Bhattacharjee K, Mohapatra SSD, Mehta A. Venous Malformations (VM) Distensible/Lymphatico-Venous Malformations (LVM). ATLAS OF ORBITAL IMAGING 2022:499-505. [DOI: 10.1007/978-3-030-62426-2_104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/04/2023]
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Park SSE, Barmettler A. Vision Loss Secondary to Facial and Periorbital Steroid Injection: A Systematic Review. Ophthalmic Plast Reconstr Surg 2021; 37:511-521. [PMID: 33481540 DOI: 10.1097/iop.0000000000001910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The risk of ophthalmic and retinal artery occlusions following facial and periorbital steroid injection has not been explored. This systematic review examines the prevalence, risk factors, and treatment outcomes of steroid-induced vision losses. METHODS A literature search in Evidence Based Medicine Reviews, MEDLINE, Embase, Pubmed, ClinicalTrials, and WHO ICTRP was performed for vision loss following facial and periorbital corticosteroid injections through July 2020. RESULTS Of 35 case reports, series, and reviews, 49 patients (56 eyes) with steroid-induced vision loss were analyzed. Injection sites predominantly involved the nose (45%) and periocular regions (10%). The most common type of steroid is triamcinolone (54%). Most cases were unilateral, except 7 cases of bilateral vision losses, 4 of which resulted from unilateral steroid injection. Symptoms were reported during or immediately after injections in 49% of cases. Most occlusions occurred in the ophthalmic (53%) or central retinal artery (33%). Vision most commonly presented as no light perception (37%), and 90% were 20/200 or worse. Final visual outcomes varied from 20/200 or worse (56%), 20/40 or better (30%), to in between (13%). CONCLUSION Most vision losses resulted from steroid injections in the nasal and periorbital area. Triamcinolone was the most common offending agent, likely due to large particle size, low solubility, and extensive particle aggregation. Dexamethasone has the opposite pharmacologic properties and has never been reported in association with vascular occlusion related vision loss. Careful steroid selection, injection techniques, and treatment strategies should be considered to prevent and treat artery occlusion.
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Affiliation(s)
| | - Anne Barmettler
- Department of Ophthalmology and Visual Sciences, Montefiore Medical Center, Bronx, NY
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Dalla S, Champion M, Ajlan R, Sutphin JE, Sokol JA. Unilateral retinopathy post perilesional interferon α2b injections for ocular surface squamous cell carcinoma. Am J Ophthalmol Case Rep 2021; 24:101196. [PMID: 34485759 PMCID: PMC8405888 DOI: 10.1016/j.ajoc.2021.101196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 08/11/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose To describe the clinical course of a patient presenting with unilateral retinopathy after perilesional interferon alpha injections for treatment of ocular surface squamous cell carcinoma. Observations A patient, who was being treated with interferon alpha for ocular squamous cell carcinoma, presented with new onset decreased vision in her left eye. Upon examination, she was found to have cotton wool spots and retinal hemorrhages in the affected eye. Conclusions and Importance Retinopathy is a well-documented side effect of systemic usage of interferon alpha. However, retinopathy has not been well discussed in the scenario of perilesional injections of interferon. It is important for clinicians to monitor for such pathology when using interferon alpha not only systemically, but also locally.
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Affiliation(s)
- Shiv Dalla
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Mary Champion
- University of Kansas Medical Center, Department of Ophthalmology, Kansas City, KS, USA
| | - Radwan Ajlan
- University of Kansas Medical Center, Department of Ophthalmology, Kansas City, KS, USA
| | - John E Sutphin
- University of Kansas Medical Center, Department of Ophthalmology, Kansas City, KS, USA
| | - Jason A Sokol
- University of Kansas Medical Center, Department of Ophthalmology, Kansas City, KS, USA
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Kim JH, Lam JM. Paediatrics: how to manage infantile haemangioma. Drugs Context 2021; 10:dic-2020-12-6. [PMID: 33889196 PMCID: PMC8029639 DOI: 10.7573/dic.2020-12-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/03/2021] [Indexed: 11/21/2022] Open
Abstract
Infantile haemangiomas (IHs) are relatively common benign vascular tumours found in the paediatric population. They have varying sizes and involve different depths in the skin leading to various colours, shapes and textures. Although considered harmless in most cases, they may lead to life-threatening complications or cause permanent disfigurations and organ dysfunction. For problematic IHs, the treatment options include oral and topical beta-blockers, systemic corticosteroids, laser treatment, and surgery. In this narrative review, the treatment options for problematic IH are compared and delivered concisely to facilitate the clinical decisions from practitioners, including those in primary care settings. Oral propranolol is currently considered the first-line intervention for problematic IHs. For superficial lesions, there is robust evidence for the use of topical timolol maleate. Systemic corticosteroids are sometimes used in specific situations such as resistance or contraindications to beta-blockers. Surgical excision can be considered in cases requiring urgent intervention such as airway obstruction; this can be done alongside laser therapies for the removal of residual tissue or when reconstructing areas of deformity. The combination of multiple treatment modalities may lead to a more rapid clinical response.
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Affiliation(s)
- Jason Hs Kim
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joseph M Lam
- Department of Pediatrics and Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Abstract
BACKGROUND Injectable fillers have become an integral part of facial rejuvenation, but vascular occlusion is a dreaded complication of such injections. OBJECTIVE To determine the force required by the fingertip onto the plunger of the syringe to cause retrograde migration. METHODS In this cadaver study, twelve 2-cm arterial segments and 4 fillers were tested. Injection pressure required to force a column of filler for 1 cm was measured. Five oculoplastics specialists were subsequently recruited and asked to inject the filler at a typical injection pressure. RESULTS The nonhyaluronic acid filler required significantly more pressure to cause propagation of the material compared with all other fillers (p < .01). None of the other fillers differed significantly from each other. Typical injection pressures generated by experienced injectors were significantly lower than that required to cause propagation of filler at the desired velocity and significantly lower than mean arterial pressure. Measured pressure required to cause filler propagation was well within the normal range of the finger strength that can be generated by humans. CONCLUSION Typical injection pressures from fingertip to plunger are lower than required to cause propagation of filler intravascularly.
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Lee JS, Kim JY, Jung C, Woo SJ. Iatrogenic ophthalmic artery occlusion and retinal artery occlusion. Prog Retin Eye Res 2020; 78:100848. [PMID: 32165219 DOI: 10.1016/j.preteyeres.2020.100848] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 01/19/2023]
Abstract
Iatrogenic ophthalmic artery occlusion (IOAO) is a rare but devastating ophthalmic disease that may cause sudden and permanent visual loss. Understanding the possible etiologic modalities and pathogenic mechanisms of IOAO may prevent its occurrence. There are numerous medical etiologies of IOAO, including cosmetic facial filler injection, intravascular procedures, intravitreal gas or drug injection, retrobulbar anesthesia, intraarterial chemotherapy in retinoblastoma. Non-ocular surgeries and vascular events in arteries that are not directly associated with the ophthalmic artery, can also cause IOAO. Since IOAO has a limited number of treatment modalities, which lead to poor final visual prognosis, it is imperative to acknowledge the information regarding medical procedures that are etiologically associated with IOAO. We accumulated all searchable and available IOAO case reports (our cases and previous reported cases from the literature), classified them according to their mechanisms of pathogenesis, and summarized treatment options and responses of each of the causes. Various sporadic cases of IOAO can be categorized into three mechanisms as follows: intravascular event, orbital compartment syndrome, and increased intraocular pressure. Embolic IOAO, which is considered the primary cause of the condition, was classified into three subgroups according to the pathway of embolic movement (retrograde pathway, anterograde pathway, pathway through collateral channels). Despite the practical limitations of treating spontaneous (non-iatrogenic) retinal artery occlusion, this article will contribute in predicting and improving the prognosis of IOAO by recognizing the treatable factors. Furthermore, it is expected to provide clues to future research associated with the treatment of retinal artery occlusion.
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Affiliation(s)
- Jong Suk Lee
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jun Yup Kim
- Department of Neurology, Seoul National University College of Medicine, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Se Joon Woo
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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Gholizadeh N, Sadrzadeh-Afshar MS, Sheykhbahaei N. Intralesional corticosteroid injection as an effective treatment method for oral lesions: a meta-analysis. BRAZ J PHARM SCI 2020. [DOI: 10.1590/s2175-97902019000418077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Abstract
BACKGROUND Small-bore needles reduce the complications associated with soft tissue filler injection. Gel particles must be sized appropriately to pass through fine-bore needles with an acceptable extrusion force. However, most soft tissue filler particles are larger than the inner diameter of the needle. The authors hypothesized that the physical properties of these particles change as the gel passes through the needle. OBJECTIVE The authors aimed to investigate whether the predesigned physical and rheological properties of the filler change after passage through the small-bore needle. METHODS AND MATERIALS Particle sizes of 4 hyaluronic acid (HA) fillers were analyzed using a particle size analyzer. Five soft tissue fillers with different particle sizes were subjected to rheological characterization. All tests were performed using fillers with and without a 30-G needle. RESULTS Monophasic HA fillers with smaller particle sizes exhibited small changes between particle sizes but no differences in rheological properties. Biphasic HA fillers with larger particle sizes exhibited remarkable changes in particle size and rheological properties. Calcium fillers exhibited changes in rheological properties. CONCLUSION Injection through small-bore needles can alter the physical properties and rheological equilibrium of soft tissue fillers. The authors suggest avoiding small-bore needles as they may affect the rheological equilibrium and clinical performance of fillers.
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Cho KH, Dalla Pozza E, Toth G, Bassiri Gharb B, Zins JE. Pathophysiology Study of Filler-Induced Blindness. Aesthet Surg J 2019; 39:96-106. [PMID: 29873688 DOI: 10.1093/asj/sjy141] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background A number of authors have proposed retrograde arterial embolism as the responsible mechanism for filler-induced blindness. However, no previous human study has substantiated this proposed mechanism. Objectives The aim of this study was to investigate the pathophysiology of filler-induced blindness using a fresh cadaver perfusion technique. Methods A fresh cadaver head perfusion model that simulates both physiologic blood pressure and flow rate of the carotid artery, ophthalmic artery, and supratrochlear artery was used. The common carotid artery was cannulated and the internal jugular vein exposed for open venous drainage. A plasma-based perfusate was circulated through the cadaver head, which was connected to a perfusion system consisting of a roller pump, preload reservoir, and pressure monitor. The hyaluronic acid filler mixed with methylene blue was injected into the cannulated superficial branch of the supratrochlear artery. Cadaver dissection, angiographic study, and histology were used to investigate filler-induced blindness. Results Cannulation of the superficial branch of the supratrochlear artery was successful in all six cadavers. Emboli to the ophthalmic artery was successfully demonstrated in the three out of 6 fresh cadaver heads. The C-arm angiogram documented a cut-off sign in the ophthalmic artery due to hyaluronic acid filler emboli. An average intravascular volume of the intraorbital part of the supratrochlear artery was 50.0 µL. The average depth of location of the superficial branch of the supratrochlear artery from the epidermal surface was 1.5 mm. Conclusions Our cadaveric study demonstrated that retrograde hyaluronic acid filler emboli to the ophthalmic artery could be produced by the cannulation of the supratrochlear artery. The superficial location of the supratrochlear artery, the rich vasculature surrounding it, and the variability in the anatomy make this possible.
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Affiliation(s)
- Ki-Hyun Cho
- Department of Plastic Surgery and the Cerebrovascular Center Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Edoardo Dalla Pozza
- Department of Plastic Surgery and the Cerebrovascular Center Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Gabor Toth
- Department of Plastic Surgery and the Cerebrovascular Center Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Bahar Bassiri Gharb
- Department of Plastic Surgery and the Cerebrovascular Center Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - James E Zins
- Department of Plastic Surgery and the Cerebrovascular Center Neurological Institute, Cleveland Clinic, Cleveland, OH
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Krowchuk DP, Frieden IJ, Mancini AJ, Darrow DH, Blei F, Greene AK, Annam A, Baker CN, Frommelt PC, Hodak A, Pate BM, Pelletier JL, Sandrock D, Weinberg ST, Whelan MA. Clinical Practice Guideline for the Management of Infantile Hemangiomas. Pediatrics 2019; 143:peds.2018-3475. [PMID: 30584062 DOI: 10.1542/peds.2018-3475] [Citation(s) in RCA: 207] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Infantile hemangiomas (IHs) occur in as many as 5% of infants, making them the most common benign tumor of infancy. Most IHs are small, innocuous, self-resolving, and require no treatment. However, because of their size or location, a significant minority of IHs are potentially problematic. These include IHs that may cause permanent scarring and disfigurement (eg, facial IHs), hepatic or airway IHs, and IHs with the potential for functional impairment (eg, periorbital IHs), ulceration (that may cause pain or scarring), and associated underlying abnormalities (eg, intracranial and aortic arch vascular abnormalities accompanying a large facial IH). This clinical practice guideline for the management of IHs emphasizes several key concepts. It defines those IHs that are potentially higher risk and should prompt concern, and emphasizes increased vigilance, consideration of active treatment and, when appropriate, specialty consultation. It discusses the specific growth characteristics of IHs, that is, that the most rapid and significant growth occurs between 1 and 3 months of age and that growth is completed by 5 months of age in most cases. Because many IHs leave behind permanent skin changes, there is a window of opportunity to treat higher-risk IHs and optimize outcomes. Early intervention and/or referral (ideally by 1 month of age) is recommended for infants who have potentially problematic IHs. When systemic treatment is indicated, propranolol is the drug of choice at a dose of 2 to 3 mg/kg per day. Treatment typically is continued for at least 6 months and often is maintained until 12 months of age (occasionally longer). Topical timolol may be used to treat select small, thin, superficial IHs. Surgery and/or laser treatment are most useful for the treatment of residual skin changes after involution and, less commonly, may be considered earlier to treat some IHs.
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Affiliation(s)
- Daniel P Krowchuk
- Departments of Pediatrics and Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina;
| | - Ilona J Frieden
- Departments of Dermatology and Pediatrics, School of Medicine, University of California, San Francisco, San Francisco, California
| | - Anthony J Mancini
- Departments of Pediatrics and Dermatology, Feinberg School of Medicine, Northwestern University and Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - David H Darrow
- Departments of Otolaryngology and Pediatrics, Eastern Virginia Medical School and Children's Hospital of the King's Daughters, Norfolk, Virginia
| | - Francine Blei
- Donald and Barbara Zucker School of Medicine, Northwell Health, New York City, New York
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Aparna Annam
- Department of Radiology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Cynthia N Baker
- Department of Pediatrics, Kaiser Permanente Medical Center, Los Angeles, California
| | - Peter C Frommelt
- Department of Pediatrics, Cardiology, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Amy Hodak
- American Board of Pediatrics, Chapel Hill, North Carolina
| | - Brian M Pate
- Department of Pediatrics, University of Kansas School of Medicine-Wichita, Wichita, Kansas
| | | | - Deborah Sandrock
- St Christopher's Hospital for Children and College of Medicine, Drexel University, Philadelphia, Pennsylvania
| | - Stuart T Weinberg
- Departments of Biomedical Informatics and Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | - Mary Anne Whelan
- College of Physicians and Surgeons, Columbia University, New York City, New York
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Dehghani A, Rezaei L, Ghanbari H, Nasrollahi K, Tavakoli M. Ophthalmic Artery Occlusion Following Facial Sclerosing Therapy. J Ophthalmic Vis Res 2018; 13:351-354. [PMID: 30090194 PMCID: PMC6058543 DOI: 10.4103/jovr.jovr_29_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Purpose: To describe a case of ophthalmic artery occlusion and complete ophthalmoplegia after intralesional injection of a sclerosing agent into a subcutaneous hemangioma on the forehead. Case Report: A 16-year-old girl underwent direct injection of 3 mL of sodium tetradecyl sulfate (Fibrovein) emulsion 1% (10 mg/mL) with a 23-gauge needle into a subcutaneous hemangioma on the forehead. Immediately after the injection, she developed sudden loss of vision and lid swelling of the left eye. Her visual acuity in the left eye became no light perception. Her left eye also developed a dilated pupil, ptosis, and complete external ophthalmoplegia. Funduscopy of the left eye revealed signs of central retinal artery occlusion. Magnetic resonance imaging of the orbit showed thickening of the medial and lateral rectus muscles of the left eye. Magnetic resonance venography of the brain was normal with no evidence of cavernous venous thrombosis. After 3 months, her ptosis and ophthalmoplegia resolved but her visual acuity remained no light perception. Conclusion: Persistent total visual loss should be kept in mind as a disastrous complication of sclerosing therapy in a patient with facial hemangioma.
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Affiliation(s)
- Alireza Dehghani
- Eye Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Leila Rezaei
- Emam Khomeini Eye Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | | | - Kobra Nasrollahi
- Eye Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Tavakoli
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Florida, USA
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Irreversible Blindness Following Periocular Autologous Platelet-Rich Plasma Skin Rejuvenation Treatment. Ophthalmic Plast Reconstr Surg 2017; 33:S12-S16. [DOI: 10.1097/iop.0000000000000680] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hu XZ, Hu JY, Wu PS, Yu SB, Kikkawa DO, Lu W. Posterior Ciliary Artery Occlusion Caused by Hyaluronic Acid Injections Into the Forehead: A Case Report. Medicine (Baltimore) 2016; 95:e3124. [PMID: 26986163 PMCID: PMC4839944 DOI: 10.1097/md.0000000000003124] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although cosmetic facial soft tissue fillers are generally safe and effective, improper injections can lead to devastating and irreversible consequences. We represent the first known case of posterior ciliary artery occlusion caused by hyaluronic acid. A 41-year-old female presented with right visual loss 7 hours after receiving cosmetic hyaluronic acid injections into her forehead. Examination revealed no light perception in the right eye and multiple dark ischemic area of injection over the forehead and nose. The right fundus revealed a pink retina with optic nerve edema. Fluorescein angiogram showed several filling defects in the choroidal circulation and late hyperfluorescence in the choroid. A right posterior ciliary artery occlusion and embolic occlusion of facial artery braches was diagnosed. With hyaluronidase injection, hyperbaric oxygen therapy, oral aspirin, oral acetazolamide and dexamethasone venotransfuse treatment, the patient's forehead and nasal skin improved and vision recovered to hand movements. With proper technique, vascular occlusion is rare following facial filler injection. Vision consequences can be severe if filler emboli enter the ocular circulation. Physicians should be aware of this potential side effect, recognize its presentation, and be knowledgeable of effective management.
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Affiliation(s)
- Xiu Zhuo Hu
- From the Department of Ophthalmology (XZH, JYH, PSW, WL), The Second Hospital of Dalian Medical University, Dalian, Liaoning Province, China; Department of Anatomy (SBY), Dalian Medical University, Dalian, China; Division of Ophthalmic Plastic and Reconstructive Surgery (DOK), UC San Diego Department of Ophthalmology, Shiley Eye Institute, CA
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Abstract
Infantile hemangiomas (IHs) are the most common tumors of childhood. Unlike other tumors, they have the unique ability to involute after proliferation, often leading primary care providers to assume they will resolve without intervention or consequence. Unfortunately, a subset of IHs rapidly develop complications, resulting in pain, functional impairment, or permanent disfigurement. As a result, the primary clinician has the task of determining which lesions require early consultation with a specialist. Although several recent reviews have been published, this clinical report is the first based on input from individuals representing the many specialties involved in the treatment of IH. Its purpose is to update the pediatric community regarding recent discoveries in IH pathogenesis, treatment, and clinical associations and to provide a basis for clinical decision-making in the management of IH.
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Bhushan G, Gupta S, Bhushan U, Raina UK. Central Retinal Artery Occlusion as an Iatrogenic Complication of Treatment of Central Giant Cell Granuloma of the Mandible. J Oral Maxillofac Surg 2015; 73:933.e1-6. [DOI: 10.1016/j.joms.2015.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 01/16/2015] [Accepted: 01/20/2015] [Indexed: 11/30/2022]
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Ricci LH, Navajas SV, Carneiro PR, Söderberg SA, Ferraz CA. Ocular adverse effects after facial cosmetic procedures: a review of case reports. J Cosmet Dermatol 2015; 14:145-51. [DOI: 10.1111/jocd.12141] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Lucas H. Ricci
- School of Medicine; Anhembi Morumbi University; Laureate International Universities; São Paulo SP Brazil
| | - Samia V. Navajas
- School of Medicine; Anhembi Morumbi University; Laureate International Universities; São Paulo SP Brazil
| | - Paula R. Carneiro
- School of Medicine; Anhembi Morumbi University; Laureate International Universities; São Paulo SP Brazil
| | - Stephanie A. Söderberg
- School of Medicine; Anhembi Morumbi University; Laureate International Universities; São Paulo SP Brazil
| | - Caroline A. Ferraz
- School of Medicine; Anhembi Morumbi University; Laureate International Universities; São Paulo SP Brazil
- Department Ophthalmology; School of Medicine; Anhembi Morumbi University; Laureate International Universities; São Paulo SP Brazil
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Hsiao SF, Huang YH. Partial vision recovery after iatrogenic retinal artery occlusion. BMC Ophthalmol 2014; 14:120. [PMID: 25306218 PMCID: PMC4197310 DOI: 10.1186/1471-2415-14-120] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 10/08/2014] [Indexed: 11/10/2022] Open
Abstract
Background To describe the first case of partial vision recovery in a 32-year-old woman with iatrogenic retinal artery occlusion (RAO) following glabella calcium hydroxylapatite (CaHA) injection, and to explore appropriate diagnostic and therapeutic measures according to a literature review. Case presentation A 32-year-old woman had left eye RAO and a bilateral visual field defect after CaHA injection into the glabella region. Topical and systemic intraocular pressure lowering agents, isovolemic hemodilution, globe massage, and anticoagulation with acetylsalicylic acid were prescribed. Carbogen inhalation and oral corticosteroids were also given. In addition to the above therapies, hyperbaric oxygen therapy (HBOT) was implemented as adjuvant treatment. The final best corrected visual acuity (BCVA) of the left eye improved from hand motion at 15 cm to 0.1. Improved retinal circulation and decreased retinal vessel leakage were found in the follow-up fluorescein angiography. However, there were still multiple emboli in the conjunctival and retinal arteries. Conclusion This is the first case report on partial recovery of BCVA after iatrogenic RAO following cosmetic CaHA injection. Because no reliable treatments have been reported for such complications, HBOT may be considered as an alternative adjuvant therapy.
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Affiliation(s)
| | - Yi-Hsun Huang
- Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng Li Rd, Tainan, Taiwan.
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Abstract
PURPOSE OF REVIEW Children and their parents typically present to pediatricians to discuss treatment options for melanocytic nevi, nevus sebaceus, port-wine stains, and hemangiomas. Each of these conditions may be medically managed, but in some situations surgical intervention may be preferable. RECENT FINDINGS Although recent studies have improved our understanding of melanoma risk among patients with congenital nevi, prospective trials are needed to more accurately assess whether surgical excision mitigates this risk. The risk of basal cell carcinoma within nevus sebaceus appears to be low, but more conclusive data requires further studies with modern immunohistochemical analysis. Pulsed dye laser is effective for treating port-wine stains, although the optimal timing is controversial. While oral and topical beta blockers have revolutionized the treatment of proliferating infantile hemangiomas, laser and/or surgical excision are useful in selected situations. SUMMARY Excisional and/or laser surgery are indicated for certain common dermatologic conditions in children, although the optimal timing of these interventions is often subjective. Pediatricians should be familiar with why and when to refer patients for surgery of these common dermatological conditions.
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Affiliation(s)
- Julianne A Mann
- Department of Dermatology and Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
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A clinical update and radiologic review of pediatric orbital and ocular tumors. JOURNAL OF ONCOLOGY 2013; 2013:975908. [PMID: 23577029 PMCID: PMC3610355 DOI: 10.1155/2013/975908] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 01/14/2013] [Accepted: 01/20/2013] [Indexed: 12/15/2022]
Abstract
While pediatric orbital tumors are most often managed in tertiary care centers, clinicians should be aware of the signs of intraocular and orbital neoplasms. In the pediatric population, a delay in diagnosis of orbital and intraocular lesions, even if benign, can lead to vision loss and deformity. Intraocular lesions reviewed are retinoblastoma, medulloepithelioma, and retinal astrocytic hamartoma. Orbital neoplasms reviewed are rhabdomyosarcoma, neuroblastoma metastases, optic pathway glioma, plexiform neurofibroma, leukemia, lymphoprolipherative disease, orbital inflammatory syndrome, dermoid and epidermoid inclusion cysts, and Langerhans' cell histiocytosis. Vascular lesions reviewed are infantile hemangioma and venous lymphatic malformation. In conjunction with clinical examination, high-resolution ophthalmic imaging and radiologic imaging play an important role in making a diagnosis and differentiating between benign and likely malignant processes. The radiologic imaging characteristics of these lesions will be discussed to facilitate prompt diagnosis and treatment. The current treatment modalities and management of tumors will also be reviewed.
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Reply. Plast Reconstr Surg 2012. [DOI: 10.1097/prs.0b013e318267d84a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Samimi DB, Alabiad CR, Tse DT. An anatomically based approach to intralesional corticosteroid injection for eyelid capillary hemangiomas. Ophthalmic Surg Lasers Imaging Retina 2012; 43:190-5. [PMID: 22432604 DOI: 10.3928/15428877-20120315-03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 02/21/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To describe a corticosteroid injection technique for eyelid capillary hemangiomas that minimizes the risk of a central retinal artery occlusion and is based on anatomic, physiologic, and pharmacologic rationales. PATIENTS AND METHODS In this retrospective, non-comparative, interventional case series, the medical records of 50 eyes of 50 patients over a 10-year period were reviewed for retinal complications associated with the described injection technique. RESULTS Ophthalmoscopy showed no retinal complications in the 50 eyes treated with this injection technique. CONCLUSION The risk of central retinal artery occlusion from retrograde embolization can be minimized by using an anatomically based injection technique that prevents canalization of an artery and avoids injection pressures exceeding the mean systemic arterial pressure.
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Affiliation(s)
- David B Samimi
- Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida 33136, USA
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Wester ST, Johnson TE. Echographic evidence of regression of a periocular infantile capillary hemangioma treated with systemic propranolol. Ophthalmic Surg Lasers Imaging Retina 2011; 42 Online:e18-21. [PMID: 21323190 DOI: 10.3928/15428877-20110203-04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Accepted: 12/02/2010] [Indexed: 11/20/2022]
Abstract
This article documents quantitative changes in the size of a periocular capillary hemangioma using sequential echographic testing in a patient receiving off-label treatment with systemic propranolol therapy. The patient presented at 7 weeks old with a right periocular capillary hemangioma. Systemic propranolol therapy was elected. Diagnostic B-scan and quantitative A-scan echography documented the lesion size at presentation as 22.3 mm in greatest dimension. The tumor decreased in size to 20.0 mm after 2½ weeks of treatment and 16.0 mm after 6½ weeks of treatment. No adverse side effects have been noted. Echography is an excellent modality for documenting the regression of periocular capillary hemangiomas during treatment with systemic propranolol.
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Affiliation(s)
- Sara Tullis Wester
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida 33136, USA.
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Li YC, McCahon E, Rowe NA, Martin PA, Wilcsek GA, Martin FJ. Successful treatment of infantile haemangiomas of the orbit with propranolol. Clin Exp Ophthalmol 2010; 38:554-9. [PMID: 20491798 DOI: 10.1111/j.1442-9071.2010.02327.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Propranolol is a novel therapeutic agent in the treatment of cutaneous infantile haemangiomas. We assessed the effect of propranolol therapy in infantile haemangiomas of the orbit. METHODS A case series of four patients with orbital infantile haemangiomas were referred for management in our tertiary referral hospitals. Two of the patients had inadequate responses to prior corticosteroid therapy. One of the patients was commenced on propranolol at 2.5 years of age when the lesion was not in the proliferative phase. This represented the first case report of propranolol treatment for infantile haemangioma outside infancy. The other three children were in their infancy when propranolol was commenced. The patients were treated with oral propranolol. RESULTS All patients had significant improvement in their physical appearance, ocular examination findings and size of their lesions on radiological evaluation. No side-effects of propranolol treatment were observed. CONCLUSIONS Propranolol is a promising treatment against infantile haemangiomas in the orbit, not only in infants but also in an older child with a stable lesion.
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Affiliation(s)
- Yi-Chiao Li
- Sydney Eye Hospital, Sydney Eye Hospital, Sydney, New South Wales, Australia.
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Abstract
The clinical study included 30 patients with complicated cutaneous haemangioma (ulceration, bleeding, obstruction of anatomical orifices, and interference with function or movement). The patients were studied regarding the age group, sex, site of lesion, size of lesion, and the percentage of regression after treatment with steroid. The age ranged from three months to six years, there were 20 female patients and 10 male patients. We used local injection of diluted triamcinolone 4 mg with 5 ml. 0.9% NACI (normal saline), injected through 23-guage syringe under local or general anaesthesia every two weeks for six to eight sessions depending on the severity of the case, followed by a local pressure dressing. We measured the size of the lesion before each session and recorded the regression of the lesion. The patients were followed up for two years. Haemangioma commonly presents in infants and children, most commonly in females, especially in the head and neck and are usually of a small size. It regresses if the treatment is started earlier.
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Affiliation(s)
- Kamal H Saleh
- Department of Plastic Surgery, Al Emadi Hospital, Doha, Qatar
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Abstract
Background: Intralesional steroid (ILS; usually triamcinolone acetonide) is commonly used, and the literature contains much information about its use in keloids, hemangiomas, and alopecia areata. Little has been written about its use in inflammatory dermatoses such as psoriasis and localized dermatitis since the 1960s, the conditions for which it was originallymost studied and used. Objective: To clarify the use of ILS and to encourage its use in psoriasis and localized dermatitis. Methods: Medline peer-reviewed literature in English (1956–2008) was searched for the use of ILS in all skin diseases. Six standard textbooks of dermatology were reviewed. Information as to how they used ILS was obtained from a questionnaire completed by 33 dermatologists and from personal discussions with 15 other dermatologists. Additional information was obtained from 40 years of personal ILS use and from observation of 42 dermatologists working intermittently in our office over the past 25 years. ILS product package inserts and company drug monographs were reviewed. Results: ILS is used by most dermatologists, but there are considerable divergences in technique and dosing. Current textbooks contain little on its use in psoriasis and localized dermatitis. There have been no clinical studies since the 1960s, and their end points and descriptions were somewhat vague by today's standards. Product package inserts are dated and not helpful. Nevertheless, the use of ILS is safe and economical, and the original authors and our office have found it consistently to be virtually 100% effective at 2.5 mg/mL in small plaques of psoriasis on the trunk and limbs and highly effective in localized dermatitis (such as lichen simplex chronicus, prurigo nodularis, and nonspecific eczema). Clinical studies indicate that we can safely increase our ILS from the usual 3 cc (7.5 mg) to 6 cc (15 mg) or even to 8 cc (20 mg) for patients over 50 kg every 3 to 4 weeks. Serum cortisol can be performed if there are concerns about adrenal suppression, with use in periorbital hemangiomas and with intranasal ILS. Blindness (from central artery occlusion) was reported with injections of ILS around the eyes wih older products during the early development stages; and more recently with the use of ILS for periorbital hemangiomas and with ILS used intranasally. It has never been reported with low pressure injections of ILS using triamcinalone acetonide at 2.5 mg around the eyes. Limitations: No formal clinical studies since the 1960s. Poor statistical end points. Conclusions: ILS at 2.5 mg/cc is safe, economical, and effective and its greater use should be encouraged in inflammatory dermatoses such as psoriasis and localized dermatitis. Further well-designed research would be helpful.
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Affiliation(s)
- Robert N. Richards
- From Department of Medicine (Dermatology), North York General Hospital, Toronto, ON
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Nguyen J, Fay A. Pharmacologic Therapy for Periocular Infantile Hemangiomas: A Review of the Literature. Semin Ophthalmol 2009; 24:178-84. [DOI: 10.1080/08820530902805602] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Pandey A, Gangopadhyay AN, Gopal SC, Kumar V, Sharma SP, Gupta DK, Sinha CK. Twenty years' experience of steroids in infantile hemangioma--a developing country's perspective. J Pediatr Surg 2009; 44:688-94. [PMID: 19361627 DOI: 10.1016/j.jpedsurg.2008.10.038] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Revised: 10/05/2008] [Accepted: 10/06/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hemangioma is a common vascular tumor. Though it involutes spontaneously, results are unpredictable. Steroid therapy is an effective mode of its regression. We present our experience of largest series and possible recommendations for treatment. MATERIALS AND METHODS A total of 2398 patients were treated during the study period of 20 years. They were given oral prednisolone, intralesional triamcinolone, or combination of both as per the protocol and followed for the response. Response to the treatment was graded as excellent, good, poor, or no response. RESULTS The male-to-female ratio was 1:2.3. In 81% of patients, hemangioma was noticed within first month of life. The commonest site of involvement was head and neck (57%). The commonest clinical presentation was discoloration and swelling. Mean age and size were 8.43 +/- 7.04 months and 23.64 +/- 20.13 cm(2). Response rate was highest for superficial type using any modality of treatment. Patients younger than 1 year showed better response (90.3%) in comparison with children older than 1 year (80.8%). The specific complications occurring were infections in 249 (12.4%), cushingoid facies and growth delay in 62 (3.1%), and hypertension in 51 (2.5%) patients. CONCLUSION Steroid therapy either oral or intralesional as per the requirement is an easy and safe modality. Results are good to satisfactory in most patients. The complications are minimal. If treatment is needed, it should be used as a first-line therapy, especially when cost is an important concern.
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Affiliation(s)
- Anand Pandey
- Department of Pediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, UP, India
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Use of ultrasonic dissection in the early surgical management of periorbital haemangiomas. J Plast Reconstr Aesthet Surg 2008; 61:1479-85. [DOI: 10.1016/j.bjps.2007.09.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2006] [Accepted: 09/24/2007] [Indexed: 11/22/2022]
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Treatment with Interferon-α-2b in Children with Life-Threatening Hemangiomas. Dermatol Surg 2008. [DOI: 10.1097/00042728-200805000-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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JIMÉNEZ-HERNÁNDEZ ELVA, DUEÑAS-GONZÁLEZ MARÍATERESA, QUINTERO-CURIEL JOSÉLUIS, VELÁSQUEZ-ORTEGA JOSÉ, MAGAÑA-PÉREZ JOSÉA, BERGES-GARCÍA ADOLFINA, ARELLANO-GALINDO JOSÉ. Treatment with Interferon-α-2b in Children with Life-Threatening Hemangiomas. Dermatol Surg 2008; 34:640-7. [DOI: 10.1111/j.1524-4725.2007.34120.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Verity DH, Rose GE, Restori M. The effect of intralesional steroid injections on the volume and blood flow in periocular capillary haemangiomas. Orbit 2008; 27:41-7. [PMID: 18307146 DOI: 10.1080/01676830701378029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIM To examine the effect of steroid therapy on the volume estimates and blood flow characteristics of childhood periorbital capillary haemangiomas. PATIENTS AND METHODS Children at risk of amblyopia due to periorbital haemangiomas were treated with intralesional steroid injections (between 1 and 4 courses) and serial assessment of the volume and blood-flow characteristics of the lesions measured using colour Doppler ultrasonography. The characteristics of the haemangiomas in these children were compared with a cohort of untreated cases. RESULTS Eight of nine treated children were female, this proportion being significantly different from the equal sex distribution of an untreated cohort (p < 0.05). All children in the steroid-treated group presented within 1 month of birth, compared to the untreated children, who presented at an average of 2.1 months of age (range 0-14, median 2.9 months) (p = 0.04) and they required significantly longer follow-up in the Orbital service (mean 65 months, range 26-105), compared with an average of 35 months (range 4-92, median 23) in the untreated group (p = 0.002). The maximum estimated volume of the lesions were significantly larger in the treated group (treated group mean 8.9 ml, untreated group mean 4.1 ml; p = 0.016), with a trend towards higher maximum measured blood velocities in the treated group (treated mean 64 cm compared with untreated mean 52 cm; p = 0.1). Steroid injections appear to reduce the volume and blood flow of haemangiomas, this suppression persisting for several months (between 5 and 20) before the lesion later displays the cyclic fluctuations in volume and flow seen with untreated lesions. All treated haemangiomas had some residual vascular anomaly, detectable on ultrasonography, at last follow-up--this being despite absence of clinical signs in most cases. CONCLUSION Periorbital capillary haemangiomas requiring steroid therapy for risk of amblyopia were significantly commoner in females, were larger lesions and presented at an earlier age. Intralesional steroids appear to cause a reduction of blood flow, with a transient reduction in volume and a suppression of the natural cyclic variation seen without treatment. The changes after a course of steroid therapy appear to last for between 5 and 20 months, this period of suppression of the lesion probably being particularly useful during infancy and early childhood when the child is at greatest risk of amblyopia.
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Affiliation(s)
- David H Verity
- Orbital Clinic, Moorfields Eye Hospital, London, England
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A review of 58 patients with periorbital haemangiomas to determine appropriate cases for intervention. J Plast Reconstr Aesthet Surg 2008; 61:138-49. [DOI: 10.1016/j.bjps.2007.08.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2007] [Accepted: 08/28/2007] [Indexed: 11/20/2022]
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Tronina SA, Bobrova NF, Khrinenko VP. Combined surgical method of orbital and periorbital hemangioma treatment in infants. Orbit 2008; 27:249-257. [PMID: 18716962 DOI: 10.1080/01676830802250101] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
PURPOSE To analyze the results of application of combined surgical treatment in different forms of hemangioma in infants. MATERIALS AND METHODS One hundred seventy-four children with different forms of orbital and periorbital hemangiomas aged 1-16 months (mean age 5.2 + 1.97 months) were operated on at the pediatric ophthalmology department. Fast growth of hemangioma, both superficial (intradermal) and deep (subdermal and orbital) localization, significant deformity of eyelids, with narrowing of eye fissure were the indications for surgical treatment. The combined-staged method, including cryosurgery of superficial intradermal lesions and surgical excision of subdermal and/or orbital parts of the tumor in different combinations depending on the form and depth of hemangioma spreading, was applied. RESULTS Usage of cryodestruction usually on the first stage of treatment allowed gentle scarring of the angiomatously changed skin areas. Surgical excision of the deep part of the tumor eliminated disfigurement and visual axis occlusion, avoiding amblyopia development. Good cosmetic and anatomic result was achieved in 90.4% of cases. CONCLUSION Combined surgical method of treatment of progressive capillary hemangiomas by using cryosurgery and surgical excision in infants allows the choice of optimum tactics depending on features of the course and clinical picture in each individual case and provides achievement of high cosmetic and functional result of treatment. The early beginning of treatment in cases of fast progressing of the tumor allows prevention of extensive skin affection and amblyopia development.
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Affiliation(s)
- Svetlana A Tronina
- The Filatov Institute of Eye Diseases and Tissue Therapy, Odessa, Ukraine.
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Weiss AH, Kelly JP. Reappraisal of astigmatism induced by periocular capillary hemangioma and treatment with intralesional corticosteroid injection. Ophthalmology 2007; 115:390-397.e1. [PMID: 17588666 DOI: 10.1016/j.ophtha.2007.03.077] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Revised: 03/02/2007] [Accepted: 03/10/2007] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To document refractive status and visual acuity before and after intralesional corticosteroid injection in children with astigmatism induced by periocular capillary hemangioma (PCH). DESIGN Retrospective, interocular comparison, interventional case series. PARTICIPANTS Thirteen infants with anisometropic astigmatism of at least 1.50 diopters (D) induced by PCH. INTERVENTION All infants had one or more intralesional corticosteroid injections of a PCH between 2 and 10 months of age. Injections of 0.3 to 1.0 ml of a 50:50 mixture of triamcinolone (40 mg/ml) and dexamethasone phosphate (4 mg/ml) were given at a single site under deep sedation. MAIN OUTCOME MEASURES Refraction and acuity using Teller acuity cards before and after injection. RESULTS In affected eyes, mean astigmatisms were 3.75 D (pretreatment) and 1.25 D (posttreatment), and mean spherical errors were 0.75 D (pretreatment) and 1.50 D (posttreatment). Reduction in astigmatism was observed within 1 to 14 months after the injection. Despite reciprocal changes in astigmatism and spherical error, the amount of anisometropia (spherical equivalent) remained constant. Amblyopia was not observed before treatment and was observed in only 2 of 13 children after treatment. Complications were limited to adrenal suppression with transient reductions of linear growth and localized eyelid necrosis. CONCLUSIONS Intralesional corticosteroid injections given in infancy (between 2 and 10 months) resulted in a 63% reduction in the mean amount of astigmatism induced by PCH. The reciprocal changes of astigmatism and spherical error without changes in anisometropia suggest that the treatment effect was due to restoration of the spherical shape of the cornea. Before 3 years of age, visual immaturity exceeded the optical blur related to astigmatism induced by PCH. Therefore, astigmatism, not anisometropia or amblyopia, is the immediate indication for treatment of PCH with intralesional corticosteroids. Injection of corticosteroid at a single site minimizes the potential for severe ocular complications owing to tissue pressure and tumor volume considerations.
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Affiliation(s)
- Avery H Weiss
- Division of Ophthalmology, Children's Hospital and Regional Medical Center, Seattle, Washington 98105, USA
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Schwartz SR, Blei F, Ceisler E, Steele M, Furlan L, Kodsi S. Risk factors for amblyopia in children with capillary hemangiomas of the eyelids and orbit. J AAPOS 2006; 10:262-8. [PMID: 16814181 DOI: 10.1016/j.jaapos.2006.01.210] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2005] [Revised: 11/29/2005] [Accepted: 11/29/2005] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Capillary hemangiomas are the most common orbital tumors of childhood and can cause amblyopia secondary to occlusion of the pupil, anisometropia, or strabismus. We undertook this study to describe the clinical characteristics of children with capillary hemangiomas and to propose a classification system to guide clinical treatment decisions. METHODS A retrospective review of the records of 129 patients with 132 capillary hemangiomas in two pediatric ophthalmology practices was conducted. Hemangiomas were classified based on size. Presence of aniosometropic astigmatism, ptosis, pupillary occlusion, lid margin change, proptosis, globe displacement, and strabismus was recorded. RESULTS Thirty-one hemangiomas measured less than 1 cm in greatest dimension and were not associated with amblyogenic factors. Seventy-five patients had hemangiomas that measured greater than 1 cm, 40 of which were associated with amblyopia. Eighteen children had diffuse hemangiomas that could not be measured and 14 of these were associated with amblyopia. Five of seven hemangiomas in six patients with PHACES syndrome were associated with amblyopia. CONCLUSION This study is the largest review of capillary hemangiomas of the orbit and eyelids. Our findings suggest that size greater than 1 cm in largest diameter is an important predictor of amblyogenic factors and approximately half of these patients will require treatment. Diffuse hemangiomas and hemangiomas in patients with PHACES syndrome will cause amblyopia in the majority of cases.
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Affiliation(s)
- Shirah R Schwartz
- Department of Ophthalmology, North Shore-Long Island Jewish Health Systems, Great Neck, New York, USA
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Allali J, Bernard A, Assaraf E, Bourges JL, Renard G. Embolisations multiples des branches de l’artère ophtalmique : complication grave et encore méconnue des chirurgies faciales. J Fr Ophtalmol 2006; 29:51-7. [PMID: 16465125 DOI: 10.1016/s0181-5512(06)73748-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We present a patient with ocular ischemia following autologous refined fat injection (lipostructure) into the glabellar area to treat wrinkles. We think this visual loss is directly a consequence of the surgery, by retrograde arteriolar microembolus into the ophthalmic artery via peripheral anastomoses with the arteries of the face. These complications are on the rise because of the esthetic facial injections of viscous materials. We explain the pathophysiology and present a review of the litterature.
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Affiliation(s)
- J Allali
- Service d'Ophtalmologie, Hôpital Hôtel-Dieu, 1 place du parvis de Notre Dame, 75181 Paris Cedex 04.
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Abstract
Hemangiomas of infancy are the most common tumors of childhood. They are clinically heterogeneous and as such require individualized treatment plans. Although there are no Food and Drug Administration (FDA)-approved agents for treatment of hemangiomas of infancy, there are many widely used therapeutic options available. This review highlights the treatments currently in use and the factors that direct treatment.
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Affiliation(s)
- Victoria R Barrio
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, WI, USA
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45
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Abstract
Haemangiomas are common, benign tumours of the vascular endothelium which present within the first few weeks of life. Clinically, they are very heterogeneous, with size, location and rate of proliferation having a significant effect on the risk of complications. Most haemangiomas are uncomplicated, and can be observed for spontaneous involution. However, some may be life- or function-threatening and require treatment. Corticosteroids, which may be used topically, intralesionally or systematically, are the mainstay of therapy. IFN-alpha, vincristine and cyclophosphamide are therapeutic options for complicated haemangiomas which do not respond to corticosteroids. Vascular-specific laser therapy may be considered for superficial haemangiomas, ulcerated haemangiomas or postinvolution sequelae, such as telangiectasia. A periorbital haemangioma that obstructs the visual axis or exerts pressure on the globe is an ocular emergency; systemic corticosteroids and patching of the unaffected eye should be instituted as soon as possible.
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Affiliation(s)
- Yuin-Chew Chan
- National Skin Centre, 1 Mandalay Road, Singapore 308205.
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46
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Abstract
Infantile hemangiomas are the most common tumors of infancy, but less common vascular tumors also can affect young infants and children. In most cases, the diagnosis of IH can be made clinically, but imaging studies and even biopsy may be required in less-than-typical cases. With a careful history and physical examination focusing on the timing, location, and type of hemangioma, as well as extracutaneous signs and symptoms, the general pediatrician will know when to be concerned about a high risk vascular tumor and proceed with referral or further evaluations.
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Affiliation(s)
- Tara Miller
- University of California, San Fransisco, CA, USA
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47
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Abstract
PURPOSE OF REVIEW Our knowledge base in the area of vascular anomalies is growing rapidly. With greater understanding of classification and diagnosis, as well as with the numerous areas of research bringing further awareness on the complexity of these lesions, we are improving our ability to treat them. We will attempt in this article to summarize the developments in the field of vascular anomalies over the last year. RECENT FINDINGS Emphasis on correct classification is still a high priority in the literature and yet there remains a great deal of misinformation. Many new developments in the basic science of these lesions are allowing better understanding of why these lesions occur while improving our management in these patients. Advances in laser surgery as well as sclerotherapy techniques have improved our ability to treat extensive lesions and also improve patients' quality of life. SUMMARY Many new and exciting areas of discovery occur almost daily in the field of vascular anomalies. Due to the breadth of this topic, it is certain that not all articles can be reviewed however the author has tried to present the most recent and clinically relevant breakthroughs in the field.
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Affiliation(s)
- Lisa M Buckmiller
- Department of Otolaryngology, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas 72202, USA.
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49
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Abstract
PURPOSE To report the results of a survey of the members of the American Association of Pediatric Ophthalmology and Strabismus (AAPOS) regarding the treatment of periocular capillary hemangiomas. METHODS A survey was delivered to the 600 members of AAPOS. Surveys were returned via facsimile. Results were collected in a computerized spreadsheet and then tabulated and analyzed. RESULTS Of the 600 AAPOS members, 225 responded to the survey. The results showed that intralesional steroid injection is the most commonly used treatment modality for periorbital capillary hemangiomas. Oral steroids and excision were also commonly used in the treatment of these lesions. CONCLUSIONS Further controlled studies are needed to determine which treatment modality offers the most benefit and least risk. More standardization based on these studies is necessary to improve treatment of periocular capillary hemangiomas.
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Affiliation(s)
- Barry N Wasserman
- Cooper University Hospital, UMDNJ-Robert Wood Johnson Medical School, Camden, NJ. USA
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Apte RS, Solomon SD, Gehlbach P. Acute choroidal infarction following subcutaneous injection of micronized dermal matrix in the forehead region. Retina 2003; 23:552-4. [PMID: 12972773 DOI: 10.1097/00006982-200308000-00021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Rajendra S Apte
- Vitreoretinal Division, The Wilmer Ophthalmological Institute, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287-9277, USA
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