Allergic reaction to hyaluronidase after retrobulbar anaesthesia: a case series and review

Conventional High-Dose vs Low-Dose Hyaluronidase for Skin Necrosis after Hyaluronic Acid Fillers: A Systematic Review and Pilot Meta-Analysis

BACKGROUND

Hyaluronidase remains the mainstay treatment for skin necrosis due to vascular occlusion after hyaluronic acid (HA) dermal fillers. There is wide variability in protocols for the administration of hyaluronidase. Most protocols, however, lack strong evidence regarding hyaluronidase dosages.

METHODS

We conducted a systematic review and pilot meta-analysis, searching four international databases from inception until December 2023 for clinical studies reporting on two or more patients receiving hyaluronidase for skin necrosis after hyaluronic acid fillers. Random-effects (DerSimonian and Laird) meta-analyses were conducted. The primary outcome was the pooled proportion of complete scar resolution. We rated intra-study risk of bias using the Joanna Briggs Institute checklists and assessed the certainty of evidence using the GRADE approach.

RESULTS

We included 15 studies totaling 223 patients. The pooled proportion of complete scar resolution after hyaluronidase administration was 77.8% (95%-CI: 65.5% to 86.6%, pegger = 0.093, low certainty). Patients treated with high doses of hyaluronidase (>500 international units [IUs]) had lower rates of resolution of 69.6% (95%-CI: 41.2% to 88.3%) compared to those treated with low doses (500IU or less) that had 88.1% rate of resolution (95%-CI: 86.0% to 96.2%), though not statistically significant (p= 0.18). The use of adjunct therapies did not have a statistically significant effect on outcomes.

CONCLUSION

A higher proportion of patients receiving low doses (500IU or less) (88.1%) had complete scar resolution compared to patients receiving high doses (69.7%), though not statistically significant (p=0.18). Future studies should provide more granular details on their protocols to benefit the formulation of evidence-based guidelines in future.

LEVEL OF EVIDENCE I

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 .

PROTOCOL REGISTRATION

CRD42024538661.

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 .

Hyaluronidase for Dermal Filler Complications: Review of Applications and Dosage Recommendations

BACKGROUND

Hyaluronidase (Hyal) can reverse complications of hyaluronic acid (HA) fillers, which has contributed substantially to the popularity of such procedures. Still, there are differing opinions regarding Hyal treatment, including dosage recommendations in filler complication management.

OBJECTIVE

We aimed to address unanswered questions regarding Hyal treatment for HA filler complications, including timing and dosage, skin pretesting, properties of various Hyals and interactions with HA gels, and pitfalls of the treatment.

METHODS

PubMed and Google Scholar databases were searched from inception for articles on Hyal therapy for filler complications. Articles were evaluated regarding their contribution to the field. The extensive literature review includes international leaders' suggestions and expert panels' recommendations.

RESULTS

There are limited controlled data but increasing clinical experience with Hyal treatment. The currently used Hyals provide good results and have an acceptable safety profile. Nonemergent complications such as the Tyndall effect, noninflamed nodules, and allergic or hypersensitivity reactions should be treated with low or moderate Hyal doses. Hyal should be considered with prior or simultaneous oral antibiotic treatment in managing inflammatory nodules. Hyal may be tried for granulomas that have not responded to intralesional steroids. Emergent complications such as vascular occlusion and blindness require immediate, high-dose Hyal treatment. Regarding blindness, the injection technique, retrobulbar versus supraorbital, remains controversial. Ultrasound guidance can increase the efficacy of the above interventions.

CONCLUSIONS

Hyal is essential in aesthetic practice because it can safely treat most HA filler complications. Immediate Hyal treatment is required for emergent complications. Aesthetic practitioners should be versed in using Hyal and effective dosage protocols.

Early ultrasound for diagnosis and treatment of vascular adverse events with hyaluronic acid fillers

BACKGROUND

Hyaluronic acid fillers are known for a reliable safety profile, but complications do occur, even serious vascular adverse events.

OBJECTIVE

To improve the treatment outcome after a vascular adverse event with use of hyaluronic acid filler treatments.

METHODS

Duplex ultrasonography is used to detect the hyaluronic acid filler causing the intra-arterial obstruction.

RESULTS

If treated in time, 1 single treatment of ultrasonographically guided injections of hyaluronidase into the filler deposit will prevent skin necrosis.

CONCLUSION

Because the use of duplex ultrasonography adds extra essential information, its use may become an integral part of the prevention and treatment of injection adverse events.

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.

Pretreatment with systemic corticosteroid can mask early symptoms of hypersensitivity reaction to hyaluronidase following peribulbar block

Hyaluronidase is a hydrolytic enzyme that helps in breaking down hyaluronic acid, a component of the extracellular tissue matrix, thereby facilitating the dispersion of local anaesthetic drugs through tissue planes. It is a key component in peribulbar anaesthesia for ocular surgeries. Allergic response to hyaluronidase is relatively rare but a potentially vision-threatening complication. A preoperative intradermal hypersensitivity test is useful to detect such cases and avoid potential complications. Here we report a case of hypersensitivity reaction to hyaluronidase after peribulbar anaesthesia for cataract surgery where an intradermal hypersensitivity test was falsely negative, and presentation was delayed due to the use of preoperative systemic corticosteroids. However, correct, and timely diagnosis and treatment saved the eye from permanent vision loss.

Hyaluronidase injection for improved tissue dissection in Baerveldt tube surgery

PURPOSE

To describe a novel technique for tissue dissection during Baerveldt tube surgery.

METHODS

We present a technique for posterior dissection of conjunctiva and Tenon tissue for the placement of a glaucoma drainage device. Hyaluronidase is used in the early stages of surgery in order to minimize tissue trauma and facilitate easy dissection even through existing adhesions and conjunctival scarring.

RESULTS

The technique facilitates convenient dissection through tissues. We did not experience any intraoperative or postoperative complications.

CONCLUSIONS

The described technique has substantial advantages for Baerveldt tube surgery, specifically in cases of previous ocular surgery and subsequent conjunctival scarring. It is safe and easy to perform, and should be considered in cases of glaucoma drainage device implantation surgeries.

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 Caveats in Treating Filler Complications

BACKGROUND

Most of the complications associated with hyaluronic acid (HA) fillers can be addressed by hyaluronidase. Extensive experience with this enzyme was accumulated in ophthalmology and anesthesia. In dermatologic use multiple aspects still remain controversial.

OBJECTIVE

To elucidate questions with regard to hyaluronidase use in HA-induced complications, including appropriate dosage, timing, and technique of delivery, differences in the activity of hyaluronidases of different origins, interaction between the enzymes and different HA gels, and safety issues.

MATERIALS AND METHODS

Extensive review of the relevant literature was conducted. The conclusions are based on this review and personal author's experience.

RESULTS

FDA-approved hyaluronidases provide predictable results and can be used interchangeably. A physician has to be closely familiar with specific characteristics of other hyaluronidases. Different brands of HA fillers have different sensitivity to degradation by hyaluronidase. For filler overcorrection or misplacement, low dose of the enzyme has to be injected directly into the palpable HA mass. In case of vascular accident, flushing of the ischemic area with high doses of hyaluronidase is required. Hypersensitivity reactions to hyaluronidase are so far not reported in dermatologic literature.

CONCLUSION

With increased popularity of HA fillers, hyaluronidase had become an indispensable tool in dermatology office. It is safe and reliable for treatment of HA-induced complications.

Ophthalmic regional blocks: management, challenges, and solutions

In the past decade ophthalmic anesthesia has witnessed a major transformation. The sun has set on the landscape of ophthalmic procedures performed under general anesthesia at in-hospital settings. In its place a new dawn has ushered in the panorama of eye surgeries conducted under regional and topical anesthesia at specialty eye care centers. The impact of the burgeoning geriatric population is that an increasing number of elderly patients will present for eye surgery. In order to accommodate increased patient volumes and simultaneously satisfy administrative initiatives directed at economic frugality, administrators will seek assistance from anesthesia providers in adopting measures that enhance operating room efficiency. The performance of eye blocks in a holding suite meets many of these objectives. Unfortunately, most practicing anesthesiologists resist performing ophthalmic regional blocks because they lack formal training. In future, anesthesiologists will need to block eyes and manage common medical conditions because economic pressures will eliminate routine preoperative testing. This review addresses a variety of topical issues in ophthalmic anesthesia with special emphasis on cannula and needle-based blocks and the new-generation antithrombotic agents. In a constantly evolving arena, the sub-Tenon's block has gained popularity while the deep angulated intraconal (retrobulbar) block has been largely superseded by the shallower extraconal (peribulbar) approach. Improvements in surgical technique have also impacted anesthetic practice. For example, phacoemulsification techniques facilitate the conduct of cataract surgery under topical anesthesia, and suture-free vitrectomy ports may cause venous air embolism during air/fluid exchange. Hyaluronidase is a useful adjuvant because it promotes local anesthetic diffusion and hastens block onset time but it is allergenic. Ultrasound-guided eye blocks afford real-time visualization of needle position and local anesthetic spread. An advantage of sonic guidance is that it may eliminate the hazard of globe perforation by identifying abnormal anatomy, such as staphyloma.

Delayed allergic reaction to secondary administrated epidural hyaluronidase

We are reporting a rare case of a delayed hypersensitivity reaction caused by hyaluronidase allergy following a lumbar transforaminal epidural block. Using an intradermal skin test, we have provided evidence that the systemic allergic reaction resulted from hypersensitivity to hyaluronidase. To our knowledge, this is a rare case of a delayed hypersensitivity reaction to epidural hyaluronidase, comprised of an initial exposure to hyaluronidase with no subsequent allergic response in prior block followed by a subsequent delayed reaction to hyaluronidase during a second epidural block.

The role of hyaluronidase in the treatment of complications from hyaluronic acid dermal fillers

Hyaluronidases, a family of enzymes that are able to degrade hyaluronic acid (HA), are employed in medicine to increase drug diffusion and reverse the effects of HA filler injections. Hyaluronidases are able to dissolve subcutaneous nodules or to correct excessive quantities of injected filler. Knowledge of the use, methods of application, and adverse effects of hyaluronidases is essential for the aesthetic practitioner. Therefore, we performed an extensive review of the available literature from 1928 to 2011 and compared the different enzymes available, recording each author's indications regarding usage and side effects.

Complications of injectable fillers, part I

Dermal filling has rapidly become one of the most common procedures performed by clinicians worldwide. The vast majority of treatments are successful and patient satisfaction is high. However, complications, both mild and severe, have been reported and result from injection of many different types of dermal fillers. In this Continuing Medical Education review article, the author describes common technical errors, the signs and symptoms of both common and rare complications, and management of sequelae in clear, easily adaptable treatment algorithms.

Allergic reactions to hyaluronidase in pain management -A report of three cases-

Hyaluronidase has been gaining interest because it reduces tissue edema and fibrosis. Although rare, hyaluronidase has been shown to cause allergic reactions. A few cases of allergic reactions following hyaluronidase administration have been reported. Most of the described patients presented allergic reactions after peribulbar anesthesia for eye surgery. In this report, we describe three patients who experienced with allergic reactions to hyaluronidase following pain management. Two of the patients had a history of uneventful injection with hyaluronidase. All patients were afebrile and blood tests results were normal. Intradermal skin tests were positive. These clinical findings were helpful in establishing the differential diagnosis of infection. Although allergic reaction to hyaluronidase is rare and mostly benign, this must be considered before treating patients.

Acute urticaria caused by the injection of goat-derived hyaluronidase

Hyaluronidase is a goat testicular protein that hydrolyzes hyaluronic acid, a structural component of the intercellular matrix. It is commonly used as a spreading factor to improve the diffusion of drugs, including local anesthetics and chemotherapeutics. We experienced a 55-yr-old female with generalized urticaria that developed within 1 hr after the epidural injection of hyaluronidase. She had a history of allergic rhinitis, and had suffered from post-herpetic neuralgia and a herniated disc for several years. To relieve her pain, she had been given epidural injections consisting of mepivacaine hydrochloride, triamcinolone acetonide, and morphine sulfate biweekly for one year. Hyaluronidase had been administered several times with these drugs before this episode of generalized urticaria. Skin prick testing showed a positive response to 1,500 IU/mL of hyaluronidase extract, as compared to histamine. The patient's serum hyaluronidase-specific IgE level, determined using an enzyme-linked immunosorbent assay (ELISA), was markedly elevated, as compared to unexposed healthy controls. An IgE immunoblot analysis using hyaluronidase extract and the patient's serum showed IgE binding components at 31 and 21 kDa, whereas no corresponding IgE binding component was found in healthy controls. An ELISA inhibition test showed significant, dose-dependent inhibition with the serial addition of hyaluronidase extract. This is the first case of an IgE-medicated allergic reaction to goat (Naemorhedus goral raddenus) hyaluronidase, demonstrated by skin testing and a specific IgE and immunoblot assay.