Hyaluronidase toxicity: a possible cause of postoperative periorbital inflammation

Medication-associated orbital inflammation: A systematic review

We performed a comprehensive systematic review to identify medication-associated orbital inflammation and to characterize its clinico-radiological features. We reviewed English-language articles describing medication-associated orbital inflammation (i.e., orbital myositis, dacryoadenitis and orbital fat) published to June, 2023. Isolated inflammation of the intraocular structures or globe alone (i.e. uveitis, scleritis, optic neuritis and perineuritis) were excluded. In medication-associated orbital inflammation, the extraocular muscles are preferentially affected, occurring in isolation or in combination with other orbital and/or intraocular structures. Clinico-radiological manifestations may be non-specific; however, certain medications may be distinguished according to the presence of systemic prodrome, laterality, associated intraocular inflammation, and predisposition to involve certain orbital structures. Rapid identification, discontinuation of the provoking medication, and systemic corticosteroid therapy (if appropriate) typically achieves a favorable visual prognosis. As new medications become adopted by clinicians, rare adverse effects will be further delineated.Medication-associated orbital inflammation is an important diagnostic consideration in orbital inflammatory disease. A careful medication history and clinical assessment may be revealing, permitting timely discontinuation of the offending agent and initiation of appropriate management.

Allergic Complications of Hyaluronidase Injection: Risk Factors, Treatment Strategies, and Recommendations for Management

BACKGROUND

Hyaluronidase is used as a reversal agent for hyaluronic acid fillers and to increase the diffusion of other medications after infiltration. Cases of hyaluronidase allergy have been described in the literature since 1984. However, it is still frequently misdiagnosed. This review aims to summarize the current literature to describe the clinical picture of hyaluronidase allergy and identify any risk factors associated with its development, as well as provide recommendations for management in plastic surgery.

METHODS

A digital search of PubMed, Scopus, and Embase databases was performed by two reviewers following the PRISMA guidelines. This search identified 247 articles.

RESULTS

Two hundred forty-seven articles were identified, and 37 of them met the eligibility criteria. One hundred six patients with a mean age of 54.2 years were included in these studies. History of allergy to other substances (timothy grass, egg white, horse serum, penicillin, insect bites, wasp venom, thimerosal, potassium, histamine, phenylmercuric acetate, and nickel) and allergic diseases (asthma, dermatitis, atopy, rhinitis) was reported. A large portion of the patients with a history of repeated exposure (2-4) experienced the symptoms with their second injection. Nonetheless, there was no significant association between time to allergy development and the number of exposures (P = 0.3). Treatment with steroids +/- antihistamines resulted in the rapid and predominantly complete reversal of the symptoms.

CONCLUSIONS

Prior injections or sensitization by insect/wasp venom might be the primary factor associated with hyaluronidase allergy development. The time between the repeated injections is not a likely contributor to the presentation.

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 .

Efficacy of submucosal injection of hyaluronidase after mandibular third molar surgery: a randomized controlled trial

Objectives

This study aimed to investigate the efficacy of postoperative submucosal injection of hyaluronidase (HUD) for reducing sequelae and quality of life (QOL) after mandibular third molar (M3M) surgery.

Materials and Methods

Participants with bilateral impacted M3M underwent surgical extraction with a split-mouth randomized controlled study design. M3M were removed by the same surgeon in 2 sessions, one a control and the other experimental. Submucosal injection of HUD was performed in the experimental session and submucosal injection of saline in the control session. Mouth opening, facial swelling, and pain intensity were measured before surgery, and then 2 and 7 days after surgery. The QOL of participants following surgery was evaluated by means of a patient-centered outcome questionnaire (PCOQ).

Results

A total of 36 patients was included in the final data analysis. There was a significant reduction in the maximal mouth opening and postoperative pain in the experimental side at the 2 and 7 days after surgery (P<0.05), and a remarkable difference in facial swelling was reported on the experimental side 7 days after surgery (P<0.05). The PCOQ demonstrated that participants reported less pain and swelling on the experimental side.

Conclusion

The present study provides clinical evidence that submucosal administration of HUD immediately after M3M surgery reduced postoperative discomfort and improved patients' QOL.

Extracellular matrix degrading enzyme with stroma-targeting peptides enhance the penetration of liposomes into tumors

Various anti-tumor nanomedicines have been developed based on the enhanced permeability and retention effect. However, the dense extracellular matrix (ECM) in tumors remains a major barrier for the delivery and accumulation of nanoparticles into tumors. While ECM-degrading enzymes, such as collagenase, hyaluronidase, and bromelain, have been used to facilitate the accumulation of nanoparticles, serious side effects arising from the current non-tumor-specific delivery methods limit their clinical applications. Here, we report targeted delivery of bromelain into tumor tissues through its covalent attachment to a hyaluronic acid (HA)-peptide conjugate with tumor ECM targeting ability. The ECM targeting peptide, collagen type IV-binding peptide (C4BP), was chosen from six candidate-peptides based on their ability to bind to frozen sections of triple-negative breast cancer, 4T1 tumor ex vivo. The HA- C4BP conjugate showed a significant increase in tumor accumulation in 4T1-bearing mice after intravenous administration compared to unmodified HA. We further demonstrated that the systemic administration of bromelain conjugated C4BP-HA (C4BP-HA-Bro) potentiates the anti-tumor efficacy of liposomal doxorubicin. C4BP-HA-Bro decreased the number and length of collagen fibers and improved the distribution of doxorubicin within the tumor. No infusion reaction was noted after delivery of C4BP-HA-Bro. C4BP-HA thus offers a potential for effective and safe delivery of bromelain for improved intratumoral delivery of therapeutics.

Bridging a Century-Old Problem: The Pathophysiology and Molecular Mechanisms of HA Filler-Induced Vascular Occlusion (FIVO)-Implications for Therapeutic Interventions

Biocompatible hyaluronic acid (HA, hyaluronan) gel implants have altered the therapeutic landscape of surgery and medicine, fostering an array of innovative products that include viscosurgical aids, synovial supplements, and drug-eluting nanomaterials. However, it is perhaps the explosive growth in the cosmetic applications of injectable dermal fillers that has captured the brightest spotlight, emerging as the dominant modality in plastic surgery and aesthetic medicine. The popularity surge with which injectable HA fillers have risen to in vogue status has also brought a concomitant increase in the incidence of once-rare iatrogenic vaso-occlusive injuries ranging from disfiguring facial skin necrosis to disabling neuro-ophthalmological sequelae. As our understanding of the pathophysiology of these injuries has evolved, supplemented by more than a century of astute observations, the formulation of novel therapeutic and preventative strategies has permitted the amelioration of this burdensome complication. In this special issue article, we review the relevant mechanisms underlying HA filler-induced vascular occlusion (FIVO), with particular emphasis on the rheo-mechanical aspects of vascular blockade; the thromboembolic potential of HA mixtures; and the tissue-specific ischemic susceptibility of microvascular networks, which leads to underperfusion, hypoxia, and ultimate injury. In addition, recent therapeutic advances and novel considerations on the prevention and management of muco-cutaneous and neuro-ophthalmological complications are examined.

Research Progress of Drug Prophylaxis for Lens Capsule Opacification after Cataract Surgery

Phacoemulsification combined with intraocular lens (IOL) implantation is the international standard operation procedure for cataract and has been generalized worldwide. However, lens capsule opacification, one of the common complications after cataract surgery, impacts the recovery of patients' visual function to a large extent. Lens capsule opacification has two types, anterior capsule opacification (ACO) and posterior capsule opacification (PCO), according to the location. There is not an accepted approach to treat ACO. Nd : YAG laser capsulotomy, the common treatment of PCO, can effectively improve the vision, but may cause a series of complications and is inappropriate for children who are too young to cooperate with this treatment. It is generally known that the responses of lens epithelial cells (LECs) after cataract surgery, including cell proliferation, migration, and epithelial-mesenchymal transition (EMT), play a key role in the pathogenesis of lens capsule opacification. Scholars found that substantial drugs can reduce the occurrence of lens capsule opacification by inhibiting, clearing, or killing LECs, and made great efforts as well as innovations on the exploration of drug species or modes of administration. This article is a systematic interpretation and elaboration about how to prevent lens capsule opacification after cataract surgery via different drugs.

The Efficacy of Hyaluronidase in Early Surgery of Nasal Bone Fracture

A nasal bone fracture is one of the most common facial injuries and is often treated by closed reduction. Typically, 2 to 3 weeks are needed for patients to return to daily life because the operation is performed after swelling around the fracture site is reduced. This study aimed to investigate that hyaluronidase injection could reduce swelling, perform early operation and return to daily life accelerated.From January 2017 to December 2017, 181 patients with nasal bone fracture were analyzed. 60 patients underwent hyaluronidase injection and massage to reduce edema, then performed surgery within 2 to 4 days. The remaining patients were treated conservatively (massage alone); they then underwent surgery. Ultrasonography was used to measure changes in skin thickness, and the treatment duration, outcome, and patient satisfaction were compared.The duration from injury to surgery was short in the early operation group, and the period of recovery and return to ordinary life was significantly shorter than in the conventional group. The difference in skin thickness after hyaluronidase injection and massage was 0.8 mm in the early operation group; there was no significant difference in the conventional group. There was no statistically significant difference in satisfaction between the 2 groups, but the mean satisfaction was higher in the early operation group.In patients with nasal bone fracture after facial trauma, hyaluronidase injection, and massage led to reduced edema. This might improve patient satisfaction by allowing earlier operation and earlier return to daily life.

Compressive optic neuropathy secondary to an allergic reaction to hyaluronidase

A 58 year-old woman presented with severe chemosis and ophthalmoparesis on her left eye 8hours after uncomplicated cataract surgery under sub-tenon anaesthesia. Recovery of extrinsic motility was observed after corticosteroid and antihistamine treatment, but a non-haemorrhagic papillary oedema and a concentric defect of visual field were found. It progressed to papillary atrophy with preserved central vision, but with a significant visual field constriction. The aetiological study revealed an allergy to hyaluronidase that was used as adjuvant to the anaesthesia. This complication needs to be promptly diagnosed and treated, as the swelling of the orbital tissues can cause damage to the optic nerve.

Controllable drug release from nano-layered hollow carrier by non-human enzyme

Natural polymers are widely used in biomedical applications because of their numerous effects. Especially, plant-derived natural polymers extracted from cell walls, especially wood, which is abundant, inexpensive and nontoxic to cells, have high mechanical strength to retain their turgor pressure. Plant-derived polymers are also unaffected by enzymes present in the human body, having a strong possibility to create a polymeric structure that releases drugs only exactly where needed. Therefore, plant-derived polymers are suitable for use in drug delivery systems (DDS) as they have durability with few drug leakage issues in the body. Here, to improve drug incorporation and release efficiency, we prepared a multilayer nanofilm from tannic acid (TA) and lignin extracted from plants and wood. We used a strategy involving film degradation by tannase and laccase, which are not present in humans, to depolymerize TA and lignin, respectively. The TA and lignin film was highly stable for 7 days at pH 3-7 and was readily degraded after enzyme treatment. We also observed controllable drug release and anticancer effect from the TA and lignin hollow carriers depending on enzymatic activity. By taking advantage of plant-derived polymers and non-toxic enzymatic reactions, we have demonstrated the film growth and degradation mechanism in depth and explored their use in a smart DDS with easily controlled release kinetics, which is useful as a DDS platform.

Allergic reaction to hyaluronidase use after hyaluronic acid filler injection

Hyaluronic acid (HA) is biocompatible, easy to use and reversible. HA fillers are considered to be safe, although some complications can occur. At this time, hyaluronidase is used off-label for correction. A 41-year-old woman presented to our clinic for focal erythematous plaque on hyaluronidase injection site. She got the injection for correction of HA filler excess. The skin lesion continued for 7 days. Histopathologic findings were nonspecific. On intradermal skin test, allergic reaction to hyaluronidase were confirmed. Adverse effects of this hyaluronidase are uncommon with local injection site reactions most frequently reported. Allergy to hyaluronidase should be included in the differential diagnosis when focal erythema and swelling occur after hyaluronidase injection.

Hyaluronidase in ophthalmic evisceration surgery

Background

To research the effectiveness of hyaluronidase in evisceration surgery.

Methods

A total of 34 patients were studied as three groups: conventional surgery group ( n = 13); isotonic fluid group ( n = 8); and hyaluronidase group ( n = 13). Hyaluronidase and isotonic fluid were introduced into the uveo-scleral space. Intraocular content was removed, if possible by a one-scoop method, with the aid of a spoon.

Results

Removing all the intraocular content as a one-scoop method was achieved in 10 of 13 (77%) in the hyaluronidase group and four of eight (50%) in the isotonic fluid group. The one-scoop method was not possible in any case without the introduction of fluid. The mean durations for the evisceration procedure were 32, 36.6 and 40.5 min in the three groups, respectively ( P < 0.05).

Conclusions

Using hyaluronidase in evisceration surgery greatly facilitates and speeds up the removal of all the intraocular content in ophthalmic evisceration surgery.