Abstract
Supplemental Digital Content is available in the text.
Hyaluronidase is very effective in liquefying hyaluronic acid filler gel and reversing vascular occlusion in the face.1 However, blindness with hyaluronic acid occlusion in the retinal artery remains an unsolved problem because of the difficulty of getting the medication around or into the retinal artery.2 There is evidence that hyaluronidase is safe to retinal cells using intravitreous injection for vitreous hemorrhage.3
Despite the grim outlook of this problem, there are 2 recent reports of possible partial blindness reversal with supraorbital notch injection with hyaluronidase.4,5 We therefore set out to see where hyaluronidase goes when it is injected in and around the eye.
The authors use video to illustrate 4 injection techniques on 5 human cadaver heads (10 halves). The goal was to see where hyaluronidase diffuses when it is injected with 4 following approaches: inferolateral orbit, supraorbital foramen, infraorbital foramen, and intravitreous. We also attempted to dissolve intravascular hyaluronic acid filler in the retinal vessels after injecting Juvederm-Volbella (Allergan Inc., ON, Canada) mixed 9:1 with methylene blue into each of the 10 angular and/or facial arteries of the 10 head halves. We injected hyaluronidase 1500 iU/ml (York Downs, ON, Canada) mixed 9:1 with dye. Each area was injected until the dye was seen bulging the eyelid fat underneath the skin.
Thirty to 40 minutes after the injections, globe dissection was performed in all 10 orbits with enucleation and examination of the retinal neurovascular bundles to see where the hyaluronic acid and hyaluronidase went with their different colored dyes. (See Video 1 [online], which demonstrates lateral orbital injection.) (See Video 2 [online], which demonstrates supraorbital foramen injection.) (See Video 3 [online], which demonstrates infraorbital foramen injection.) (See Video 4 [online], which demonstrates intravitreous injection.)
Video 1. This Video demonstrates lateral orbital injection.
Video 2. This Video demonstrates supraorbital foramen injection.
Video 3. This Video demonstrates infraorbital foramen injection.
Video 4. This Video demonstrates intra-vitreous injection.
We did not get the hyaluronic filler to reach the retinal artery in any of the cadavers as we were not able to get the filler into smaller arteries in this model. Although the colored solution containing hyaluronidase was clearly seen to get into the fat surrounding the retinal neurovascular bundle in the back of the orbit with all 4 of the approaches, we could not see it penetrating the fascia surrounding the retinal vascular bundle and therefore did not get into the fat just adjacent to the retinal artery.
We were not able to demonstrate adequate hyaluronidase perivascular or intravascular infiltration in or around the retinal artery with any of the 4 approaches in this cadaver model.
Supplementary Material
Footnotes
Published online 9 September 2019
Disclosure: The authors have no financial interest to declare in relation to the content of this article.
Related Digital Media is available in the full-text version of the article on www.PRSGlobalOpen.com.
The study was conducted after obtaining ethics approval through the human donation program, Dalhousie University.
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