[Pemetrexed-induced eyelid edema]

BACKGROUND

Drug-induced eyelid edemas are rare. Herein, we describe a patient who developed this type of edema under chemotherapy.

PATIENTS AND METHODS

A 56-year-old male patient with a history of hypertension and adenocarcinoma of the lung with brain metastases consulted for incipient non-itchy eyelid edema with progressive worsening. The swelling occurred after 3 cycles of pemetrexed-carboplatin. There was no evidence of any other cause of edema. A diagnosis of pemetrexed-induced eyelid edema was made. Given the efficacy of this treatment and the patient's consent thereto, it was maintained.

DISCUSSION

Palpebral edemas secondary to pemetrexed are very rare, with only 22 published cases in the literature. Other differential diagnoses must be ruled out before considering this etiology. The pathogenesis of eyelid edema remains unknown. One hypothesis is capillary protein leakage inducing swelling in soft tissue and non-malignant effusion, as has been suggested for docetaxel. Other agents such as tyrosine kinase inhibitors (imatinib and nilotinib) and mTOR inhibitors (sirolimus) may also cause eyelid edema. Treatment of eyelid edema is difficult and one case of surgical treatment has been published with good results and no recurrence after 6 months.

Ocular Symptoms and Signs with Preserved and Preservative-Free Glaucoma Medications

PURPOSE

To compare the prevalence of side effects between eyedrops with or without preservatives, in terms of subjective symptoms and objective signs in patients with open-angle glaucoma.

METHODS

In a multicenter cross-sectional epidemiologic survey in four European countries, ophthalmologists in private practice enrolled 9658 nonconsecutive patients using preservative (P) or preservative-free (PF) beta-blocking eyedrops between June 1997 and December 2003. Subjective symptoms, conjunctival and palpebral signs, and superficial punctate keratitis were explored before and after a change in therapy. For statistical analysis, a Chi-square test was used to calculate the differences in the prevalence of symptoms and signs with or without preservatives.

RESULTS

A total of 74% of the patients used P, 12% PF, 10% a P-PF combination, and in 4% the type of medication was unknown. Each recorded symptom and all the palpebral, conjunctival, and corneal signs were significantly more frequent (p<0.0001) in the P-group than in the PF-group, such as pain or discomfort during instillation (48 vs 19%), foreign body sensation (42 vs 15%), stinging or burning (48 vs 20%), and dry eye sensation (35 vs 16%). A total of 68% of the patients had a sec-ond visit performed, of whom 63% (6083) had been evaluated on treatment difference. A significant decrease (p<0.0001) of all ocular symptoms and signs was observed in patients in whom the preserved eyedrops were diminished in number or altered into preservative free drops.

CONCLUSIONS

Compared to preserved eyedrops, preservative free eyedrops are significantly less associated with ocular symptoms and signs of irritation.

Allergic Contact Dermatitis Caused by Latanoprost Ophthalmic Solution

PURPOSE

Latanoprost is a prostaglandin F2 alfa analog that lowers intraocular pressure by increasing uveoscleral outflow. Herein we describe two cases of allergic contact dermatitis (ACD) to latanoprost.

METHODS

A 69-year-old man with open-angle glaucoma developed erythematous erosive swelling of bilateral eyelids after 4 months of latanoprost therapy. An 84-year-old man with open-angle glaucoma had pruritic erythematous plaques on the bilateral lower eyelids after latanoprost therapy for 4 months.

RESULTS

In both cases, latanoprost was discontinued and the condition gradually resolved in 1 month. The eyelid lesions recurred in days upon latanoprost rechallenge, but subsided after cessation of rechallenge.

CONCLUSIONS

ACD should be suspected if patients on latanoprost therapy have pruritus, erythema, swelling, or erosions on the eyelids even when the symptoms appear after several months of therapy, especially in the elderly.

Dermal filler-associated malar edema: Treatment of a persistent adverse effect

A 72-year-old Caucasian female presented for evaluation of bilateral lower eyelid "fluid filled" bags that had been present and slowly worsening for 7 years. She reported a history of lower eyelid blepharoplasty in her 40s, as well as hyaluronic acid tear trough fillers 8 years prior to presentation. Her malar edema completely resolved following injection of hyaluronidase. To our knowledge, this is the longest reported interval for presentation and treatment of hyaluronic acid associated malar edema.

Complications and Management of Polymethylmethacrylate (PMMA) Injections to the Midface

BACKGROUND

Polymethylmethacrylate (PMMA) has been used as an injectable filler to treat hollows and reduce rhytids. PMMA injections have been associated with several side effects, however, the literature is scarce on periorbital complications and their treatments.

OBJECTIVES

The purpose of this study is to report a series of complications after periorbital PMMA injections to the midface and to describe their management.

METHODS

Retrospective chart review, including photography and histopathology when available.

RESULTS

The authors identified 11 cases of complications of PMMA injections to the midface. Patient ages ranged from 36 to 62 years (mean, 47 years; median, 44 years). Two (18%) were males and 9 (82%) were females. Adverse effects began between 2 to 24 months after injection (mean, 7.2 months; median, 6 months). All patients had edema, erythema, and contour irregularity. Seven (64%) patients had nodules, 4 (36%) had yellow, xanthomatous skin changes, and 2 (18%) had eyelid malposition. Histopathology demonstrated a giant cell inflammation in 5 of 6 cases. Corticosteroid injection was tried in 6 cases but was associated with minimal clinical improvement. Surgical debulking of the implanted material was performed in 9 (82%) cases and was effective in improving edema, erythema, and nodularity.

CONCLUSIONS

PMMA injection to the midface may be associated with chronic inflammation, fibrotic nodules, yellowing of the skin, and eyelid malposition. Intralesional corticosteroid injections yielded minimal or no improvement; surgical debulking achieved favorable results. LEVEL OF EVIDENCE 4: Therapeutic.

Nonallergic Eyelid Edema After Botulinum Toxin Type A Injection: Case Report and Review of Literature

Periocular botulinum toxin type A (BoNTA) injections are generally safe. Ptosis is the most common adverse effect, whereas eyelid edema is rarely reported. There is no consensus on the latter's incidence, clinical course, or treatment strategy. Here we managed a 59-year-old woman who received BoNTA injections to her forehead, glabella, and eye corner. At 3-day follow-up, she presented with painless, nonpruritic, bilateral periorbital edema, and erythema. Preliminary diagnosis was a local allergic reaction, and topical corticosteroid was administered, but upon lack of improvement, edema secondary to venous and lymphatic congestion was hypothesized, and she was advised to apply hot pads over her eyes, blink frequently, and massage the area. Her eyelid edema resolved 2 weeks later. At 4-month follow-up, the patient requested and received another course of BoNTA at half the dose. Frequent blinking was instructed, and the patient reported a satisfactory outcome with no adverse effects. In our literature review, incidence of BoNTA-induced eyelid edema was 1.4% and showed Asian tendency. Although rare, BoNTA-induced periorbital edema is self-limiting, and normally resolves in 2 to 4 weeks without medical treatment. Patients at risk for edema, including Asian ethnicity, dermatochalasis, and poor periocular muscle tone, are advised to receive injections at half the dosage. Examination of the function and tone of the orbicularis oculi and levator palpebrae superioris muscles before treatment is recommended, and application of hot pads over the eyes, frequent blinking in the morning, and self-massage of the affected area to increase venous return have demonstrated to improve outcome.

Periocular changes in topical bimatoprost and latanoprost use

BACKGROUND/AIM

To evaluate the periocular changes due to topical bimatoprost and latanoprost use and to investigate their effects on the lacrimal drainage system.

MATERIALS AND METHODS

All participants (69 eyes of 43 patients, 52 eyes of 26 controls) were classified into three groups: bimatoprost (0.03%) users, latanoprost (0.005%) users, and healthy controls. Each patient was examined before prostaglandin therapy, and then at the first, third, sixth, and twelfth month of therapy. Palpebral fissure height, upper eyelid crease, and levator function were measured, and lacrimal system drainage irrigation was performed. Periocular hyperpigmentation and upper eyelid sulcus were also examined.

RESULTS

No significant change was identified in palpebral fissure height or levator function in any group. However, in upper eyelid crease, among bimatoprost users, a statistically significant increase was observed when compared to the control group (P < 0.001). Patients with skin type II and III, in bimatoprost users, and patients with skin type III, in latanoprost users, had statistically significant hyperpigmentation (P < 0.001) after the third month of therapy. During follow-up, no lacrimal drainage system obstruction was seen.

CONCLUSION

Topical bimatoprost therapy causes more periocular changes than latanoprost therapy. Thus, in unilateral cases, patients should be well informed about these probable changes before therapy.

Allergic Contact Dermatitis to White Petrolatum

White petrolatum is known for its nonsensitizing and nonirritating properties. Only a few cases of allergic contact dermatitis to white petrolatum have been reported. Although it is a rare event, the finding of contact sensitization to white petrolatum raises the potential problem of its usage of common topical agents or vehicles for patch testing. We herein report a case of allergic contact dermatitis to white petrolatum.

A novel solution for superficially placed calcium hydroxylapatite (Radiesse) in the inferior eyelid

Injectable fillers such as calcium hydroxylapatite (Radiesse) have become increasingly prevalent given their availability as an office procedure as well as their satisfying results. Calcium hydroxylapatite is well suited for use along bony structures in the face such as the inferior orbital rim and zygoma. On the other hand, it is not well suited for injection into the soft periorbital tissues and eyelid. In this case series we describe two cases of misplaced calcium hydroxylapatite in the inferior periorbita and eyelid; with a successful and relatively quick resolution of the complication using saline injections and erbium laser treatments.

Topical bimatoprost 0.03% and iatrogenic eyelid and orbital lipodystrophy

The prostaglandin F2a (PGF2a) analogue bimatoprost 0.03% (Allergan, Inc, Irvine, California) has been employed for the treatment of hypotrichosis since it gained Food and Drug Administration approval as Latisse in 2008. In this report, the authors retrospectively review the cases of 7 patients who presented to their outpatient ophthalmology clinic with glaucoma. These patients had periorbital hollowing due to fat atrophy as a side effect of topical ophthalmic bimatoprost therapy. The series of patients described in this report emphasizes the small but significant risk of periocular fat changes associated with bimatoprost 0.03%, which is the exact formulation marketed as Lumigan for glaucoma treatment. Patients using Latisse for its cosmetic enhancement of eyelash length should be warned of this potentially disfiguring side effect, since the cosmetic and ophthalmic preparations are identical. Such changes can be irreversible, and the implications of the decision to prescribe this drug either in the form of an eyelash application or for topical ophthalmic use should be clearly understood by both clinicians and patients alike.

Bisphosphonate-associated orbital inflammation--a case report and review

Bisphosphonates are becoming more widespread as indications for them broaden. Several ocular side effects due to bisphosphonates have been described, among the most potentially serious of which is orbital inflammation. Thirteen case reports of this side effect exist in the literature, with an additional case reported here. The most common presenting signs are lid edema, conjunctival hyperemia, and chemosis, while common symptomatology includes pain, diplopia, and blurry vision. A concomitant anterior uveitis is present in 30% of cases, and some degree of bilaterality is also seen in 30% of cases. There are two reported instances of profound visual loss, highlighting the importance of prompt recognition and treatment of this entity. Despite a paucity of rechallenge data, available reports suggest that development of orbital inflammation does not necessarily exclude patients from future bisphosphonate use.

Postoperative eyelid infection in a patient taking etanercept

Postoperative eyelid infections are a rare complication of eyelid surgery. The authors present a case of an eyelid infection occurring within the first week following surgery in a patient taking etanercept--a biologic anti-TNF-α agent used in the treatment of rheumatoid arthritis. The authors urge caution regarding the use of steroid/antibiotic combination ointments and systemic steroids in patients undergoing elective eyelid surgery who are on such medications. Perioperative discontinuation of etanercept in consultation with the prescribing physician may also be considered. Eyelid infections following eyelid surgeries such as blepharoplasty and ptosis correction are uncommon.( 1 , 2 ) A review of a large series of blepharoplasty procedures estimated the rate of postoperative infection at 0.2%.( 3 ) However, patients who are relatively immunosuppressed may be at a higher risk of developing skin and eyelid infections. We present a case of postoperative infection in a patient who was taking etanercept (Enbrel, Immunex Corporation, Thousand Oaks, CA) for rheumatoid arthritis.

Unilateral eyelid angioedema with congestion of the right bulbar conjunctiva due to loxoprofen sodium

Angioedema is a variant of urticaria that causes deep dermal and subcutaneous swelling. It frequently is a unilateral reaction and usually lasts for several hours but may persist for several days. We report 2 cases of angioedema that involved the right upper and lower eyelids and was associated with congestion of the right bulbar conjunctiva; the symptoms started approximately 1 to 2 hours after taking loxoprofen sodium. All of the symptoms subsided after oral corticosteroid therapy. In both cases, an oral challenge test with 60 mg of loxoprofen sodium (contained in a tablet) caused swelling of the right upper eyelid within several hours, followed by swelling of the right bulbar conjunctiva. We believe the drug reaction in both patients is angioedema.

Pemetrexed-induced eyelid edema: incidence and clinical manifestations

BACKGROUND

Pemetrexed-induced eyelid edema is a rare side-effect of pemetrexed treatment.

PATIENTS AND METHODS

Retrospective analysis of the incidence and severity of eyelid edema was conducted in patients treated with pemetrexed in a single institution.

RESULTS

Eighty-six patients received pemetrexed-containing chemotherapy either as a single agent (45 patients) or in combination with cis- or carboplatin (41 patients). Two patients (2.3%) with stage IV non-small cell lung cancer (NSCLC) presented the edema typically localized in the lower eyelid after first-line treatment with carboplatin-pemetrexed. The edema remained identical in both patients during treatment and regressed in one patient in whom treatment was withdrawn. No other localizations of edema were observed in these patients.

CONCLUSION

Pemetrexed-induced eyelid edema may be more frequent than originally reported. The physiopathological mechanism and, as a consequence, the treatment and/or prevention of this apparently benign side-effect remains unknown.

Periorbital contact sensitization

PURPOSE

To identify frequency and pattern of contact sensitization among patients with periorbital dermatitis.

DESIGN

Cross-sectional retrospective investigation of 1247 patients referred for patch testing over a 17-year period.

METHODS

Data were collected for patients undergoing patch testing to the standard and customized trays between January 1990 and December 2006 at the Massachusetts General Hospital, Contact Dermatitis Clinic. Our study group consisted of 266 patients affected by periorbital dermatitis. Findings were compared to 981 referrals without periorbital dermatitis (controls). Patch test results were read after 48 and 72 hours and classified as allergic, questionable, irritant, or negative. Statistical analyses were carried out by using chi(2) test and Fisher exact test.

RESULTS

General epidemiologic data among periorbital dermatitis patients showed significant predominance of female gender (87.6%) and of individuals aged 40 to 59 years (45.9%). Nickel (16.5%) and fragrance mix (13.2%) were the top-ranking sensitizers. Ingredients of topical ophthalmologic products did not result in significant sensitization. Comparison of the periorbital dermatitis group to the controls did not reveal significant differences in sensitization pattern. Patch testing confirmed the likelihood of allergic contact dermatitis in 50.8% of the periorbital dermatitis patients tested.

CONCLUSIONS

Allergic contact dermatitis is a common cause of periorbital dermatitis. Patch testing should be considered in all patients with periorbital dermatitis when suspecting contact allergy in order to identify and avoid offending allergens.

Ocular toxicities of epidermal growth factor receptor inhibitors and their management

Epidermal growth factor receptor (EGFR) inhibitors have become an important therapy for patients with malignant solid tumors, such as non-small cell lung, breast, ovarian, colorectal, renal, esophageal, sarcoma, mesothelioma, prostate, head and neck, and pancreatic cancers. Although these agents are generally well tolerated, some adverse effects will likely occur. The most common adverse effect associated with use of EGFR inhibitors is an acne-like rash. Less reported in the literature are adverse ocular reactions, which occur in approximately one third of patients and can cause significant discomfort. The ocular toxicities that may occur with use of EGFR inhibitors can be broadly categorized as changes in the eyelids (eg, squamous blepharitis, trichomegaly, meibomitis), changes in the tear film (eg, dysfunctional tear syndrome), and miscellaneous changes (eg, iridocyclitis, corneal epithelial defect). Early recognition and management of these adverse ocular reactions are necessary to improve patient comfort, to facilitate compliance, and to avoid interruption of therapy. This article describes the adverse ocular effects reported to occur with use of EGFR inhibitors and presents specific strategies to manage these effects. Mild eyelid and tear film changes usually can be managed by the oncology and nursing staff. More severe ocular reactions require involvement of an ophthalmologist.

Blue angioedema of eyelip after patent blue injection for lymphatic mapping procedure

Sentinel node biopsy using patent blue dye in breast cancer is a well-documented procedure to assess the axillary status. We presented an unusual and previously unreported complication of simple blue angioedema over bilaterally periorbital tissue after blue dye injection.

Docetaxel-induced Meibomian duct inflammation and blockage leading to chalazion formation

We report a 71-year male with castration-resistant metastatic prostate cancer who was treated with weekly docetaxel for 12 weeks and developed significant eye irritation and dryness during treatment. Subsequently, the patient presented with a lower eyelid mass, which on excision was demonstrated to be a chalazion. Docetaxel induced Meibomian duct inflammation and blockage is the likely cause of this presentation in a patient with no history of eyelid masses in the past.

Valproic acid-induced fetal malformations are reduced by maternal immune stimulation with granulocyte-macrophage colony-stimulating factor or interferon-gamma

Valproic acid, a drug commonly used to treat seizures and other psychiatric disorders, causes neural tube defects (NTDs) in exposed fetuses at a rate 20 times higher than in the general population. Failure of the neural tube to close during development results in exencephaly or anencephaly, as well as spina bifida. In mice, nonspecific activation of the maternal immune system can reduce fetal abnormalities caused by diverse etiologies, including diabetes-induced NTDs. We hypothesized that nonspecific activation of the maternal immune system with interferon-gamma (IFN-gamma) and granulocyte-macrophage colony-stimulating factor (GM-CSF) could reduce valproic acid (VA)-induced defects as well. Female CD-1 mice were given immune stimulant prebreeding: either IFN-gamma or GM-CSF. Approximately half of the control and immune-stimulated pregnant females were then exposed to 500 mg/kg VA on the morning of gestational day 8. The incidence of developmental defects was determined on gestational day 17 from at least eight litters in each of the following treatment groups: control, VA only, IFN-gamma only, IFN-gamma+VA, GM-CSF only, and GM-CSF+VA. The incidence of NTDs was 18% in fetuses exposed to VA alone, compared to 3.7% and 2.9% in fetuses exposed to IFN-gamma+VA, or GM-CSF+VA respectively. Ocular defects were also significantly reduced from 28.0% in VA exposed groups to 9.8% in IFN-gamma+VA and 12.5% in GM-CSF+VA groups. The mechanisms by which maternal immune stimulation prevents birth defects remain unclear, but may involve maternal or fetal production of cytokines or growth factors which protect the fetus from the dysregulatory effects of teratogens.

Itchy eyelids

Itchy eyelids is a symptom. This article outlines the steps for the practitioner to identify the cause of the itching and institute medical treatment.

Prevention of dermatologic side effects of bimatoprost 0.03% topical therapy

PURPOSE

To investigate the efficacy of reducing the drop-skin contact to prevent dermatologic side effects of bimatoprost 0.03% topical therapy.

DESIGN

Prospective, randomized, single-blinded, internally controlled study.

METHODS

Enrolled subjects started bimatoprost 0.03% therapy once at night in both eyes and were instructed to wipe selectively only one eye (eye 1) with an adsorbent pad during and after drops administration for four months. The fellow eye acted as the internal control. Eyelash growth, regional skin hypertrichosis, and pigmentation on the periocular skin were assessed at baseline and during the four months of follow-up.

RESULTS

A lower incidence of eyelash growth and skin pigmentation in the inferonasal pericanthal region were observed in eye 1. The incidence of pigmentation in the inferotemporal skin region and skin hypertrichosis were similar in the two eyes.

CONCLUSION

The reduction of the drop-skin contact affects the regional incidence and the extent of dermatologic skin changes that are related to bimatoprost 0.03% topical therapy.

Pemetrexed-induced edema of the eyelid

Pemetrexed is a novel antimetabolite that targets multiple enzymes in the folate pathway, and has exhibited clear antitumor activities in the treatment of malignant pleural mesothelioma and non-small cell lung cancer. Although many adverse events of pemetrexed, such as bone marrow suppression, have been reported, edema of the eyelid has been previously reported in only one case (0.2%, n=519), according to the Pemetrexed Clinical Investigator's Brochure, April 2005 version. We experienced a patient who developed the valuable edema of the eyelid. We believe that medical oncologists should be aware of this rare adverse event, although the mechanism responsible for it is not yet known.

Ocular findings in Japanese children with nephrotic syndrome receiving prolonged corticosteroid therapy

OBJECTIVE

To examine ocular findings in Japanese children with nephrotic syndrome who receive prolonged corticosteroid treatment.

METHODS

Information was retrospectively obtained from each patient's record.

RESULTS

A total of 45 children (30 boys and 15 girls) were enrolled. Twenty-one patients (46.7%) had epiblepharon with inverted eyelashes. The incidence of epiblepharon was associated with overweight and obesity. Fifteen patients (33.3%) developed posterior subcapsular cataract in both eyes. Of the 15 patients, 4 had visual acuity less than 0.4 and underwent cataract extraction in both eyes. Nine patients (20%) developed intraocular pressure higher than 22 mm Hg during corticosteroid treatment. The total dose and duration of corticosteroid treatment were associated with cataract formation but were unassociated with elevated intraocular pressure. One boy had elevated intraocular pressure after cessation of corticosteroid therapy and underwent trabeculectomy. One patient had repeated hordeolum in the left eyelid. Three patients had bilateral bacterial conjunctivitis.

CONCLUSION

Children with nephrotic syndrome who receive corticosteroid treatment may have epiblepharon, cataract, ocular hypertension, hordeolum and bacterial conjunctivitis.

[Eyelid contact allergic eczema caused by topical ketorolac tromethamine 0.5%]

CLINICAL CASE

A 65-year-old man had been treated with eye-drops containing NSAIDs (Ketorolac). He developed conjunctival injection, edematous swelling of the eyelids and periorbital dermatitis due to a contact allergy. Allergy to NSAIDs is uncommon.

DISCUSSION

This is an unusual case because topical application of ketorolac is safe in the vast majority of ophthalmologic patients. However adverse events associated with Ketorolac are similar to that of other NSAIDs.

[Hyperpigmentosis and hypertrichosis of the eyelids after use of bimatoprost eye drops]

After application of bimatoprost containing eye drops for four weeks, a 72 year-old patient, suffering from glaucoma, developed hyperpigmentation and hypertrichosis of the eyelids. These symptoms can be seen in 1-10% of the patients as side effects in local therapy with bimatoprost, a prostaglandin analogue. The changes persist for varying periods of time but are reversible. Although prostaglandin analogues are sometimes more effective in the reduction of the intraocular pressure than beta-adrenoreceptor blocking agents, they remain second-line choices because of their side effects. This case report is meant to re-stimulate interest in the as yet obscure role of prostaglandins in hair biology, in clarifying the underlying mechanisms, and in exploring the possible therapeutic use of prostaglandin analogues in the management of hair loss (e.g. in androgenetic alopecia) or hair depigmentation (e.g. poliosis, canities).

[Reasons for consulting related to skin-bleaching products used by 104 women in Brazzaville]

A prospective survey has been carried out in the Brazzaville (Congo) dermatology service in order to specify dermatosis linked to the use of bleaching agents in 104 Congolese women consulting for this problem. The used bleaching agents were topical corticoids based products for 40 cases, hydroquinone for 32 cases, and hydroquinone associated with topical dermocorticoids for 32 cases. Acne was the most frequent motive for consulting (24%), followed by the paradoxical peri-orbital hyperpigmentation (21.1%), profuse mycosis (16.3%) and vibices(8.6%). The results of this survey were not superimposable to those of Dakar where infectious dermatosis were the first reason for consulting.

Blepharoptosis and upper eyelid swelling due to lipogranulomatous inflammation caused by silicone oil

PURPOSE

Report of two patients who presented with unilateral upper eyelid swelling and ptosis 1 and 8 years, respectively, after vitreoretinal surgery with intraocular silicone oil.

DESIGN

Report of two cases.

METHODS

In the first case, the oil was still present in the eye. In the second case, the intraocular oil and an epibulbar buckle had been removed 7 years earlier.

RESULTS

Histopathology of upper eyelid skin and preaponeurotic fat revealed lipogranulomatous inflammation.

CONCLUSIONS

Leakage of intraocular silicone oil into the eyelid tissues may cause an inflammatory reaction resulting in eyelid swelling and ptosis. We presume that in the first patient, silicone oil had leaked from the eye during or after surgery; in the second patient, silicone oil had probably been left behind in the space previously occupied by the epibulbar buckle.

Bimatoprost-Induced Periocular Skin Hyperpigmentation

OBJECTIVE

To investigate light microscopic and ultrastructural changes in bimatoprost-induced skin hyperpigmentation.

METHODS

Eyelid biopsy specimens from bimatoprost-treated patients and matched controls were examined by light microscopy and transmission electron microscopy. Using an image analyzer, melanin granules were counted on Fontana-Masson-stained sections, and melanosomes were counted on electron micrographs. Immunohistochemical analysis was performed with antibodies against S100 and CD3. Positively labeled cells were counted.

RESULTS

By light microscopy, a marked increase in the number of melanin granules was noted in the bimatoprost-treated specimens. Electron microscopy demonstrated dermal melanocytes with prominent rough endoplasmic reticulum and abundant normal-sized melanosomes in different stages of maturation as compared with control specimens. Furthermore, the keratinocytes of the bimatoprost-treated specimens showed abundant mature melanosomes when compared with controls. Also of note, atypical melanocytes were absent in both specimens. The S100-positive melanocytes were comparable in bimatoprost-treated and control specimens. Few CD3- and CD68-positive cells in the bimatoprost-treated specimens were noted in both groups.

CONCLUSION

Bimatoprost-induced periocular hyperpigmentation is caused by increased melanogenesis. There was no evidence of melanocyte proliferation or prostaglandin-induced inflammation in the specimens that were examined.

Madarosis and facial alopecia presumed secondary to botulinum a toxin injections

PURPOSE

: Botulinum neurotoxins are considered relatively safe therapy for treatment of inappropriate muscle spasms. As seen in this report, undesirable consequences may result.

METHODS

: The author conducted a clinical interview and examination of the patient.

RESULTS

: Unilateral left-sided madarosis and facial alopecia were observed in a patient undergoing botulinum A toxin injections for the treatment of left oromandibular dystonia. The patient had started treatment 18 months previously. He received injections every 3 months in the left masseter and left temporalis muscles. He first noted loss of his left sideburn 8 months into treatment. After 10 months of treatment, he noted that he no longer needed to shave on the left side of his face. Eighteen months after receiving his first botulinum toxin injection, madarosis of the temporal aspect of the left lower lid was observed.

CONCLUSIONS

: This is the first case report documenting an idiosyncratic unilateral madarosis and facial alopecia as adverse side effects presumed secondary to botulinum A toxin injections.

Periocular petrolatum

PURPOSE

This report describes the clinical and histopathologic features and discusses the diagnostic difficulties and management of periocular deposition of petrolatum-based materials.

METHODS

Excision of orbital and eyelid tissue, tissue processing, and histopathologic examination was performed in patients with deposition of petroleum-based products. Transmission electron microscopy was performed in 3 cases.

RESULTS

Between 1983 and 2003, 11 patients were diagnosed with periocular petrolatum deposition, based on clinical history and the characteristic histopathologic features of polymorphic dropout spaces, and varied from a noninflammatory lesion (paraffinoma) to those with an associated granulomatous inflammatory reaction.

CONCLUSIONS

The diagnosis of petrolatum deposition can be challenging due to the range of symptoms and variable delay in presentation. Petrolatum products should be avoided during surgery and used judiciously in the postoperative period. To avoid confusion with nonspecific cases of lipogranulomatous inflammation, the terms "ointment granuloma" or "orbital paraffinoma" should be used to refer to patients presenting with orbital/eyelid lesions caused by ointment use.

Allergic reaction caused by articaine

We report the case of a 51-year-old woman who had an immediate skin reaction after subcutaneous administration of a local anesthetic (LA) composed of articaine and epinephrine before a dental procedure. The patient subsequently underwent further dental procedures without LA. Skin prick tests performed with commercial LAs (lidocaine, mepivacaine, bupivacaine and articaine) were negative with epinephrine and all LAs except articaine. In 10 healthy controls, skin prick tests with articaine were negative. Subcutaneous challenge test with mepivacaine (0.3 and 0.5 ml) was negative. Provocations with the remaining anesthetics of the amide group were not carried out due to the patient's refusal.

Deepening of lid sulcus from topical bimatoprost therapy

PURPOSE

To report a new adverse effect related to treatment with bimatoprost.

CASE REPORTS

Serial clinical examination of three patients was performed. In each of the three reported patients, alteration of eyelid appearance with deepening of the lid sulcus was evident as the result of topical bimatoprost therapy.

DISCUSSION

A comprehensive literature search of Medline using WebMd and MDConsult, was conducted to cross reference known side effects of topical prostaglandin analog treatment. The keywords utilized were prostaglandin analogs, prostaglandins, prostamide, glaucoma, ocular hypertension, intraocular pressure, side effects, adverse effects, bimatoprost, latanoprost, lumigan, and xalatan. This appears to be the first such report in the literature. Clinicians and patients should be made aware of this possible complication of topical bimatoprost therapy.