Type IV hypersensitivity reactions to upper lid gold weight implants-is patch testing necessary?

[Clinical and morphological aspects of the use of palpebral implants made of noble metals]

Loading of the upper eyelid with palpebral implants made of noble metals is the modern standard of surgical treatment for paralytic lagophthalmos, and is aimed at increasing the mobility of the upper eyelid and normalizing involuntary blinking movements. This review presents the results of morphological studies, including immunohistochemical studies, reflecting the features of biointegration of palpebral implants in uncomplicated and complicated course of the postoperative period, and describes the modern understanding of the causes and immunopathological processes underlying the development of nonspecific inflammatory response, which is one of the most serious complications that often becomes an indication for implant removal.

The impact of implantation site on procedure success in patients with unresolved facial palsy treated with upper-eyelid gold weight loading

Loading of the upper eyelid is a well-established procedure for the correction of incomplete eyelid closure due to unresolved facial palsy. Some incurable complications are attributed to type IV hypersensivity reaction, but there is no confirmation of this hypothesis. The aim of the study was to show the impact of gold weights on eyelid tissues depending on the implantation site. Out of 94 total patients (aged 53 ± 17 years) treated from July 2009-2021, since 2014 thirty consecutive patients were randomised into one of 3 groups: the GLE group (gold weight fixed 2 mm above the eyelash line), the GUE group (gold weight fixed at the border of the tarsus and the levator aponeurosis), and the PUE group (platinum chain fixed in the same way as in the GUE group). In the cases of complications, the explanted weights were evaluated histopathologically. The outcomes were compared between groups. Incomplete eyelid closure was corrected in all patients. Serious complications were noted in 100% of patients in the GLE group and 20% in the GUE group (p < 0.0001). A slight lymphocytic reaction was observed in the GUE group. A moderate to significant lymphocytic reaction was observed in the GLE group (p < 0.001). Adverse reactions of the upper eyelid microenvironment resulting from gold weights seem to be dependent on mechanical damage to the eyelid structures, rather than on implants themselves. The site of placement of the weight in the upper eyelid may be critical for procedure success.

[Nonspecific inflammatory reaction after implantation of palpebral implants]

PURPOSE

To identify the possible cause of an inflammatory reaction to a Russian-manufactured palpebral implant made of gold in the long term after surgery, and to determine the clinical and morphological changes in the tissues of the upper eyelid when the presence of the implant caused the inflammatory reaction.

MATERIAL AND METHODS

The results of 150 operations with placement of a palpebral implant were analyzed. In 12 cases, a nonspecific inflammatory reaction was revealed within 2 to 4 weeks after the operation, in 7 cases it necessitated explantation, in 5 cases the local long-term use of an ointment with a corticosteroid made it possible to avoid extrusion and explantation. Chemical microanalysis of the palpebral implant and fragments of the removed capsule was performed using scanning electron microscopy (SEM), as well as immunohistochemical (IHC), macro- and microscopic examination of the fragments of connective tissue capsule was carried out after removal of the palpebral implant.

RESULTS

The obtained data confirm the chemical purity of the implant, the absence of abnormal accumulation of metals in the tissues of the eyelid. IHC, macro- and microscopic examination of the presented fragments of the connective tissue capsule revealed signs characteristic of an inflammatory reaction to a foreign body.

CONCLUSION

Further research is needed to establish the factors and predictors for the development of inflammatory reactions to a foreign body and, in particular, to gold.

Titanium Allergy Caused by Dental Implants: A Systematic Literature Review and Case Report

(1) Background: Hypersensitivity reactions to metals may arise in predisposed patients chronically exposed to metallic materials, including dental implants made of titanium alloys. The purpose of this article was to systematically review titanium allergy manifestations in patients treated with dental implants and report a clinical case; (2) Methods: A systematic electronic search was performed for articles published in the English language until July 2021. The following eligibility criteria were adopted: (1) Population: individuals undergoing titanium and/or titanium alloy implant-supported rehabilitations; (2) Exposure: peri-implant soft tissue reactions attributable to implant insertion; (3) Outcome: evidence of titanium allergy, diagnostic methods, and forms of resolution; (3) Results: The included studies, in summary, presented evidence that titanium should not be considered an inert material, being able to trigger allergic reactions, and may be responsible for implant failure. A 55-year-old male patient received 3 implants in the posterior region of the left mandible and presented an epulis-like lesion developed from the peri-implant mucosa. The immunohistochemical analysis of the biopsy specimen confirmed the initial diagnosis of allergic reaction to titanium; (4) Conclusions: Although the evidence is weak, and titanium allergy has a low incidence, hypersensitivity reactions should not be underestimated. A rapid and conclusive diagnosis is mandatory to prevent further complications.

Late outcomes of gold weights and platinum chains for upper eyelid loading

AIM

To identify late outcomes of gold weights (GWs) and platinum chains (PCs) for upper eyelid loading in the management of lagophthalmos.

METHODS

A retrospective case series of upper eyelid GWs and PCs at a single centre over a 10-year period (2004-2013). Two independent, blinded assessors graded standard photographs for any weight-related morbidity (poor upper eyelid contour, weight prominence and migration).

RESULTS

Primary upper eyelid loading (high-tarsal technique) was performed in 154 eyelids of 136 patients (facial nerve palsy, n=99; non-paralytic, n=37). A total of 127 eyelids of 110 patients had primary GW insertion. Of these, 40.9% (52/127) had revision surgery: exchange of GW for PC (58%), GW repositioning (25%) and removal of GW (17%). Only 22.2% (6/27 eyelids) with primary PCs required revision surgery. In those not requiring revision surgery, photograph grading showed that both GWs and PCs had weight-related morbidity at late follow-up (median=37.5 months, range 12-110 vs median=33.5 month, range 15-106). GWs had significantly higher rate of weight prominence (p=0.001) and migration (p<0.001) compared with PCs. All PC revisions required one procedure only compared with 10% of GWs revisions requiring two or more procedures. Incidence of gold allergy was 7% (8/110 patients). There was no association between the choice of weight material, physical weight or suture material and eyelid morbidities.

CONCLUSION

GWs were found to be associated with higher complications and twice more likely to require long-term revision surgery compared with PCs. Despite weight fixation at a high-tarsal location, prominence of PCs can still occur.

[Correction of paralytic lagophthalmos]

Current options for correction of paralytic lagophthalmos are either temporary (external eyelid weight placement, hyaluronic acid gel or botulinum toxin A injection) or permanent (various procedures for narrowing of the palpebral fissure, upper eyelid weights or spring implantation). Neuroplastic surgery (cross-facial nerve grafting, nerve anastomoses) and muscle transposition surgery is not effective enough. The majority of elderly and medically compromised patients should not be considered for such complicated and long procedures. Upper eyelid weight implantation thus appears the most reliable and simple treatment.

Periocular and anterior orbital necrosis after upper eyelid gold weight loading: operation-related or self-inflicted?

A 44-year-old woman, who had undergone gold-weight implantation due to facial palsy and lagophthalmos, arrived at the ophthalmology ward with eyelid swelling and erythema, which rapidly deteriorated under intravenous antibiotics to a necrotic process involving the periocular tissues, the eye, and the anterior orbit. Despite prompt removal of the gold weight, the patient’s ocular and systemic condition continued to deteriorate, necessitating evisceration and debridement of necrotic tissue. Cultures showed growth of Staphylococcus epidermidis, Staphylococcus capitis, Candida glabrata, and Candida albicans, and histopathology demonstrated an acute nonspecific necrotizing panophthalmitis. Later on, the patient was admitted to a plastic surgery ward with recurrent severe burns of her thigh, which were highly suggestive of being self-induced, raising the possibility of self-induced damage.

Noninfectious inflammatory reaction to a gold weight eyelid implant: A case report and literature review

Upper eyelid loading with a gold weight is a generally well-tolerated procedure that helps reduce corneal exposure in patients with lagophthalmos. Complications of this procedure are infrequent. The authors present a rare case of a noninfectious inflammatory response to an eyelid gold weight implant in a 48-year-old woman and summarize all previously published cases. This particular patient presented with incomplete left eyelid closure secondary to a trauma. After having a gold weight inserted into her eyelid to improve closure, she returned with edema and erythema of the eyelid. The inflammation did not respond to oral antibiotics; however, oral steroid therapy resulted in prompt resolution of her symptoms. Her symptoms recurred after discontinuing steroid use and she subsequently required removal of her gold weight implant for permanent resolution of her eyelid inflammation. Although rare, this reaction poses a serious management issue, because it does not respond to antibiotics or short-term steroid use and, in most cases, requires removal of the gold implant.

Facial nerve palsy: anatomy, etiology, evaluation, and management

The ophthalmologist may be the first clinician to see a patient who presents with acute facial nerve palsy. Under such circumstances the ophthalmologist should make every effort to establish the underlying cause of the facial palsy and ensure that the patient's cornea is adequately protected. This article reviews the anatomy of the facial nerve, the varied disorders that may cause a facial palsy, a detailed evaluation of such a patient, and the various medical and surgical treatments available.

Corneal Astigmatism With Upper Eyelid Gold Weight Implantation Using the Combined High Pretarsal and Levator Fixation Technique

PURPOSE

To evaluate corneal astigmatism with the combined high pretarsal and levator fixation gold weight implantation technique.

METHODS

Twenty-one eyelids of 21 patients with facial nerve palsy were prospectively enrolled. All patients underwent upper eyelid gold weight implantation using the combined high pretarsal and levator fixation technique. Keratometry and automated refraction were performed preoperatively and postoperatively. Five patients were excluded from final analysis because of incomplete keratometry data. The data were analyzed looking for statistically significant changes in lagophthalmos, automated refraction, and keratometry.

RESULTS

A statistically significant improvement in lagophthalmos with spontaneous blinking (p = 0.0014), and gentle (p = 0.0016) and forced (p = 0.0027) closure was noted postoperatively. No significant differences were found when comparing preoperative and postoperative automated refraction readings (p = 0.89, p = 0.88), automated refraction axis (p = 0.71), keratometry readings (p = 0.40, p = 0.77), or keratometry axis (p = 0.63).

CONCLUSIONS

Implantation of a gold weight in the upper eyelid with the combined high pretarsal and levator fixation technique does not appear to cause a significant change in corneal astigmatism. This is contrary to data for pretarsal gold weight implantation, which does induce significant with-the-rule corneal astigmatism.

[Restoration of lid function in peripheral facial palsy by implanting gold weights]

BACKGROUND

Lagophthalmos is a common functional and aesthetic problem in patients with facial palsy. The implantation of a rigid gold weight is one technique to improve eyelid closure. The effectiveness of lid loading was investigated, taking into consideration complications ascribed to rigid implants.

PATIENTS AND METHODS

We present 11 patients with facial palsy treated with that technique between April 2001 and October 2005. Before and after operation ophthalmological investigations were performed. The patients were questioned about their subjective satisfaction, and the remaining eye lid gap in the closed state was assessed.

RESULTS

A good up to perfect lid closure could be achieved. Of the 11 patients, 9 reported being very contented with the result. Except for one case of extrusion, disturbed healing processes did not occur. We did not observe any occurrence of astigmatism as a result of the rigid lid load. All patients reduced their use of eye ointment and eye covers. We observed a visible bulging of the implant contour in 4 of 11 patients. However, not one of them felt discontented. All patients stated that they would undergo the lid loading procedure again.

CONCLUSIONS

The implantation of rigid gold weights for lid loading in patients suffering from lagophthalmos due to peripheral facial palsy is considered a simple and effective treatment for improving eyelid closure. Whether or not flexible implants will lead to better results needs to be further investigated.

Changes in Corneal Topography With Upper Eyelid Gold Weight Implants

PURPOSE

To determine the effect of upper eyelid gold weight implantation on corneal astigmatism.

METHODS

This is a prospective, cohort study. Eighteen eyes of 18 patients underwent upper eyelid gold weight implantation for facial nerve palsy. Nine of these patients recovered facial nerve function and underwent elective removal of the gold weight. Corneal topography was performed before and after gold weight implantation. Corneal topography was also performed after gold weight removal in patients who recovered from facial nerve paralysis.

RESULTS

With-the-rule corneal astigmatism increased significantly by 1.4 diopters (D) +/-2.0, from a mean of 0.3 to 1.7 D after gold weight implantation (p = 0.034). With-the-rule corneal astigmatism in patients who had gold weight removal decreased by 1.2 +/- 2.1 D, from 2.2 to 1.0 D after gold weight removal (p = 0.136).

CONCLUSIONS

Upper eyelid gold weight implantation causes an increase in corneal astigmatism, predominantly in the vertical axis, which appears to be reversible on removal of the gold weight.