Periorbital myxedema treated with intralesional hyaluronidas
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Periorbital myxedema is one the most challenging symptoms for patients with Graves' eye disease (GED). The treatment of this condition is complex and often unsatisfactory. This case demonstrates the use of intralesional hyaluronidase to treat cosmetically concerning periorbital myxedema.

A 45-year-old woman with a 10-year history of GD, initially treated with radioactive iodine and now maintained in a euthyroid state with levothyroxine, presents with gradual upper and lower eyelid swelling over the same period (Fig. 1). A diagnosis of periorbital myxedema with dermatopathy was made. Author has had extensive experience using hyaluronidase to treat complications arising from hyaluronic acid fillers and after a discussion of the risks and possible benefits, the patient was offered a trial of intralesional injection with hyaluronidase (ILH). The author used an established protocol of 10 units of hyaluronidase per 0.1 cc of presumed hyaluronic acid-based on observation of the amount of skin distortion compared to similar distortions The Author have seen with lumps from HA fillers.

The patient was treated with a total of 120 units of hyaluronidase (Vitrase; hyaluronidase Ovine 200 USP Units/ml, Bausch and Lomb) mixed 1:1 with xylocaine with epinephrine (1:100,000) injected into the dermis and subcutis of each lesion. The dose rationale was based on the standard use of hyaluronidase used for treating the undesired effects of hyaluronidase fillers. The hyaluronidase was injected in the subcutis covering the entire area involved with approximately .1 cc per each involved centimeter. Some immediate improvement was noted, and the patient reported no adverse effects except swelling and mild bruising. The injections yielded dramatic improvement over the next 7 days and the improvements persisted for one year after the injection (Fig. 2). She will pursue further treatment with ILH in the future if needed.