Case Reports

Chronic Eyelid Edema Following with a thin ring of fluid not amenable to aspiration. All other
investigations were normal.
Periocular Hyaluronic Acid Filler Discussions regarding the most appropriate options in
Treatment investigating this unexplained edema were undertaken. A bilat-
eral upper eyelid blepharoplasty was considered as it would
Jonathan T.S. Yu, M.A. (Cantab), M.B.B. Chir.*, allow histopathological examination of resected tissue. However,
Liam Peng, B.Sc., M.B.Ch.B.†, because the edema extended almost to the brows, an upper eyelid
and Sajid Ataullah, M.B.B.S., F.R.C. Ophth.* blepharoplasty would be of limited benefit. Furthermore, surgery
could exacerbate her edema, at least in the short term.
Abstract: A 54-year-old woman received multiple injections She had previously been treated with multiple injections
of hyaluronic acid filler to the brow region to address volume of HA filler (Restylane and Teosyal) to the brow region between
loss over a 21-month period. She then developed significant May 2005 and February 2007 to address volume loss. She first
pitting edema of both upper eyelids, which persisted for noticed a swelling in both her upper eyelids (Fig. A) on the
6 years. Hyaluronidase (Hyalase) was injected into the morning of her final treatment with Teosyal in February 2007.
subcutaneous brows and resulted in complete resolution of The swelling preceded these final HA injections.
the edema within 2 days. This confirms that the hyaluronic Although 6 years had elapsed between the most recent
acid injected into the brows was responsible for this patient’s HA filler injection and referral to the authors’ clinic, they pos-
chronic eyelid edema. This case illustrates an unusual long-
tulated that the upper eyelid edema may be secondary to the
term complication of periocular hyaluronic acid filler.
HA filler previously injected into the brows. Hyaluronidase
(Hyalase; Wockhardt, United Kingdom), 120 units, was injected
H yaluronic acid (HA) is a polysaccharide (a glycosaminogly-
can) found naturally in the body. It is an important compo-
nent of extracellular matrix and is found in blood vessels, skin,
into the subcutaneous brows, where previous HA injections had
been given. The eyelid edema completely resolved within 2 days
(Fig. B), with no evidence of recurrence 2 years later.
the central nervous system, and other tissues.1 The amount of
HA in the skin naturally decreases with age, and this plays a DISCUSSION
role in decreased tissue elasticity and the development of aging
features such as wrinkle formation. This is a highly unusual case of prolonged edema as a
HA is widely used as a dermal filler, most commonly for complication of periocular HA filler. It seemed unlikely that
facial contouring and rhytid correction,1 providing a nonsurgical the patient’s chronic edema would be due to residual HA from
alternative for temporary correction of cutaneous contour defi- injections performed 6 years previously. However, complete
ciencies. Various studies have shown superiority of HA fillers
compared with collagen fillers. HA fillers are associated with
a higher satisfaction rate, lower risk of side effects, and longer
duration of action (6–12 months) compared with collagen fill-
ers (2–3 months).2 Numerous brands of HA fillers are available,
such as Restylane (Galderma, Sweden) and Teosyal (Teoxane
n Laboratories, Switzerland).
y HA fillers have a minimal side-effect profile.
r Inflammatory reactions causing redness, bruising, pain, and
swelling lasting several weeks are highly uncommon,3 and
persistent granulomatous reactions are even more infrequent.
Long-term adverse effects after HA injections are very rare.
The authors report an unusual case of pitting edema of
both upper eyelids that persisted for 6 years after the patient had
HA filler injections.

CASE REPORT
A 54-year-old lady was referred with bilateral chronic
pitting upper eyelid edema lasting 6 years. Extensive investiga-
tions were carried out by her referring clinician to determine
the cause of her eyelid swelling. Rheumatological investiga-
tions ruled out connective tissue and autoimmune causes. MRI
revealed eyelid edema with no orbital pathology and subsequent
ultrasound illustrated subcutaneous edema in both upper eyelids

*Manchester Royal Eye Hospital, Manchester, M13 9WL; and †School of

Medicine, University of Manchester, Manchester M13 9PT, United Kingdom
Accepted for publication December 17, 2016.
Poster presentation at 32nd Annual Meeting of the European Society of
Ophthalmic Plastic and Reconstructive Surgery, Budapest, Hungary, 2014.
The authors have no conflicts of interest to disclose.
Address correspondence and reprint requests to Sajid Ataullah, Consultant
Oculoplastic Surgeon Manchester Royal Eye Hospital, Oxford Road, A, Bilateral periorbital edema with slight blue discoloration
Manchester, M13 9WL. E-mail: saj789@btinternet.com of the skin. B, Resolution of periorbital edema after
DOI: 10.1097/IOP.0000000000000871 hyaluronidase injection.

Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2017 e1

Copyright © 2017 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
 Case Reports Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2017
resolution of the following hyaluronidase injections proved that
HA injected 6 to 8 years previously was the cause of her eyelid
edema. The authors postulate that the HA may have impaired
the venous or lymphatic drainage, thereby causing the edema.
Adverse effects related to HA filler are commonly local-
ized to the injection site. They are usually minor in nature and
duration should they be experienced. Long-term complications
from HA filler injections are extremely rare; however, they
include multiple plaque-like elevations of the periorbital region
5 years following Restylane injection,4 and a patient with granu-
lomatous reactions 10 years after the injection of HA fillers.5
While there are a few case reports of eyelid swelling following
injection of HA fillers to eyelids,6–8 to the best of the authors’
knowledge, they report the first-time edema from HA fillers to
the brow has persisted for 6 years.
It is important for clinicians to fully understand the
safety profile of HA fillers. They should be aware of atypical
and potentially more problematic side effects. Clinicians should
consider HA as a possible cause of periocular edema in any-
one with a prior history of periocular HA treatment, regardless
of the time that has elapsed since the last treatment. A trial of
hyaluronidase should be considered to dissolve any residual HA
e2 © 2017 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2017 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
filler before embarking on more invasive investigations to iden-
tify an underlying cause for the edema.
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