Letters

motivated ophthalmology learners in the CSP group, we hope these results will be helpful in furthering the important missions of improving ophthalmic care to the underserved and improving undergraduate ophthalmology education. We and others have demonstrated that medical students’ direct ophthalmoscopy skills decrease over time without longitudinal skill reinforcement, signaling the importance of medical school curriculum reform to facilitate increased longitudinal exposure to ophthalmoscopy.2-4 In a study of 119 first-year medical students, Kelly et al5 assessed the use of fundus photographs in medical education in the Teaching Ophthalmoscopy to Medical Students (TOTeMS) study and compared the accuracy and preferences of medical students using direct ophthalmoscopy and fundus photographs. Students were more accurate and preferred using fundus photographs over direct ophthalmoscopy. In a 1-year follow-up study (TOTeMS II)2 of 107 of the students who participated in the original TOTeMS study, we demonstrated that the increased accuracy and student preference for fundus photographs over direct ophthalmoscopy persisted after 1 year, with no additional training. However, both the direct ophthalmoscopy and fundus photograph groups performed worse than 1 year prior, likely related to a lack of interim fundus examination skill reinforcement. Indeed, the self-reported median frequency of fundus examination during a general physical examination was less than 10%, and 20% of students cited discouragement from their preceptor as the primary reason for omitting a fundus examination. Certainly, continuing efforts are needed to combat the rising tide of indifference to ocular fundus examination in medical education and clinical practice. As innovative methods such as immersion experiences in ophthalmology-based CSPs and the increasing availability of nonmydriatic fundus cameras have the potential to infuse enthusiasm for ocular fundus examination into medical education, there is hope for the future of ophthalmoscopy.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. 1. Byrd JM, Longmire MR, Syme NP, Murray-Krezan C, Rose L. A pilot study on providing ophthalmic training to medical students while initiating a sustainable eye care effort for the underserved. JAMA Ophthalmol. 2014;132(3):304-309. 2. Mackay DD, Garza PS, Bruce BB, et al. Teaching ophthalmoscopy to medical students (TOTeMS) II: a one-year retention study. Am J Ophthalmol. 2014;157 (3):747-748. 3. Lippa LM, Boker J, Duke A, Amin A. A novel 3-year longitudinal pilot study of medical students’ acquisition and retention of screening eye examination skills. Ophthalmology. 2006;113(1):133-139. 4. Mottow-Lippa L, Boker JR, Stephens F. A prospective study of the longitudinal effects of an embedded specialty curriculum on physical examination skills using an ophthalmology model. Acad Med. 2009;84(11): 1622-1630. 5. Kelly LP, Garza PS, Bruce BB, Graubart EB, Newman NJ, Biousse V. Teaching ophthalmoscopy to medical students (the TOTeMS study). Am J Ophthalmol. 2013;156(5):1056-1061, e10.

Occlusion Caused by Cosmetic Facial Filler Injection

Funding/Support: This work was supported in part by an unrestricted departmental grant to the Department of Ophthalmology, Emory University School of Medicine from Research to Prevent Blindness and by core grant P30-EY06360 to the Department of Ophthalmology, Emory University School of Medicine from the National Eye Institute. Dr Newman was supported by the

To the Editor We read with interest the recent article by Carle et al1 describing cases of central retinal artery occlusion caused by cosmetic facial filler injection. However, we would like to point out some issues in 2 aspects regarding this article. First, they purported that this was the first report regarding blindness caused by filler injected into the forehead. However, our group previously reported 12 cases of cosmetic facial filler injection–related retinal artery occlusion2 and, more recently, 44 cases of nationwide survey results.3 Most were young women, and the glabella was the most commonly injected site. In our articles, the injection sites were mainly classified as glabella, nasolabial fold, or nasal dorsum for rhinoplasty. Injections in the forehead region were included in the glabella category for the following reasons. Many young patients received forehead and glabellar filler injections simultaneously with the purpose of augmenting or reshaping the forehead4,5 rather than simply improving a frown line in the glabella, which occurs as an aging process. Moreover, the presumed entry site for retrograde embolism in the glabella and forehead region may be the same artery, ie, the supratrochlear or supraorbital artery,2 which suggests that the glabella and forehead should be regarded as the same etiological region regarding cosmetic facial filler–associated retinal artery occlusion. Therefore, blindness caused by filler injection in the forehead is not a new finding but one that has already been reported in the literature even though it is roughly described as the glabella region. Second, they stated that cosmetic facial filler injection into the forehead is an off-label use and safety approved only in specific regions such as the nasolabial fold. This statement leads to misconception that nasolabial fold injection does not harbor the risk of retinal artery occlusions or at least that it is a safer region compared with the glabella or the forehead region. However, we noticed considerable cases of ophthalmic artery occlusion and occlusion of its branches that occurred after nasolabial injections (11 of 44 cases [25%] underwent nasolabial fold injections, 7 of which underwent nasolabial in-

JAMA Ophthalmology February 2015 Volume 133, Number 2 (Reprinted)

jamaophthalmology.com

Devin D. Mackay, MD Beau B. Bruce, MD, MS Nancy J. Newman, MD Valérie Biousse, MD Author Affiliations: Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia (Mackay, Bruce, Newman, Biousse); Department of Epidemiology, Rollins School of Public Health and Laney Graduate School, Emory University, Atlanta, Georgia (Bruce); Department of Neurology, Emory University School of Medicine, Atlanta, Georgia (Bruce, Newman, Biousse); Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia (Newman). Corresponding Author: Beau B. Bruce, MD, MS, Neuro-Ophthalmology Unit, Emory Eye Center, Emory Clinic, 1365-B Clifton Rd NE, Atlanta, GA (bbbruce @emory.edu). Published Online: October 23, 2014. doi:10.1001/jamaophthalmol.2014.4235. Conflict of Interest Disclosures: None reported.

224

Lew R. Wasserman Merit Award from Research to Prevent Blindness. Dr Bruce was supported by grant K23-EY019341 from the National Eye Institute.

Copyright 2015 American Medical Association. All rights reserved.

Downloaded From: http://archopht.jamanetwork.com/ by a University of Georgia User on 05/27/2015

Letters

jection without glabellar injection) and the consequences were as severe as cases associated with glabellar filler injections.3 Therefore, we think every cosmetic filler injection in the face has a possibility, even if the incidence is very rare, of dreadful and irreversible ophthalmic complications. Thus, thorough explanation and great caution are needed before and during procedures.

tive websites of societies or manufacturers. We had hoped to raise awareness of this potential complication, which has been described elsewhere in the facial structures. We are glad to see the nationwide survey results by Park et al6 that were recently published in JAMA Ophthalmology. As Kim and colleagues note, it is important to raise awareness of this uncommon complication of this common procedure.

Yong-Kyu Kim, MD Na-Kyung Ryoo, MD Kyu Hyung Park, MD, PhD

Michelle Valerie Carle, MD Richard H. Roe, MD, MHS Roger Lawrence Novack, MD, PhD

Author Affiliations: Department of Ophthalmology, Seoul National University College of Medicine, Seoul, South Korea; Department of Ophthalmology, Seoul National University Bundang Hospital, Seongnam, South Korea.

Author Affiliations: Now with EyeQ Vision Care, Fresno, California (Carle); Retina-Vitreous Associates Medical Group, Los Angeles, California (Carle, Roe, Novack).

Corresponding Author: Kyu Hyung Park, MD, PhD, Department of Ophthalmology, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seoungnam-si, Gyeonggi-do, 463-707, South Korea (jiani4@snu .ac.kr).

Corresponding Author: Michelle Valerie Carle, MD, EyeQ Vision Care, 7075 N Sharon Ave, Fresno, CA 93720 ([email protected]).

Published Online: October 23, 2014. doi:10.1001/jamaophthalmol.2014.4243. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Carle MV, Roe R, Novack R, Boyer DS. Cosmetic facial fillers and severe vision loss. JAMA Ophthalmol. 2014;132(5):637-639. 2. Park SW, Woo SJ, Park KH, Huh JW, Jung C, Kwon OK. Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections. Am J Ophthalmol. 2012;154(4):653-662, e1. 3. Park KH, Kim YK, Woo SJ, et al; Korean Retina Society. Iatrogenic occlusion of the ophthalmic artery after cosmetic facial filler injections: a national survey by the Korean Retina Society. JAMA Ophthalmol. 2014;132(6):714-723. 4. Busso M, Howell DJ. Forehead recontouring using calcium hydroxylapatite. Dermatol Surg. 2010;36(suppl 3):1910-1913.

Published Online: October 23, 2014. doi:10.1001/jamaophthalmol.2014.4247. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Additional Contributions: David S. Boyer, MD, Retina-Vitreous Associates Medical Group, Los Angeles, California, contributed to the writing of this article; he received no compensation for his contributions. 1. Lee CM, Hong IH, Park SP. Ophthalmic artery obstruction and cerebral infarction following periocular injection of autologous fat. Korean J Ophthalmol. 2011;25(5):358-361. 2. Whiteman DW, Rosen DA, Pinkerton RM. Retinal and choroidal microvascular embolism after intranasal corticosteroid injection. Am J Ophthalmol. 1980;89 (6):851-853. 3. Egbert JE, Schwartz GS, Walsh AW. Diagnosis and treatment of an ophthalmic artery occlusion during an intralesional injection of corticosteroid into an eyelid capillary hemangioma. Am J Ophthalmol. 1996;121(6):638-642.

5. Carruthers J, Carruthers A. Volumizing the glabella and forehead. Dermatol Surg. 2010;36(suppl 3):1905-1909.

4. Schanz S, Schippert W, Ulmer A, Rassner G, Fierlbeck G. Arterial embolization caused by injection of hyaluronic acid (Restylane). Br J Dermatol. 2002;146(5):928-929.

In Reply Much literature has been published for several decades regarding injection sites in and around the facial area for cosmetic and medical reasons, which can result in vision loss or worse consequences.1-5 The glabella has been reported several times and is in close proximity to the main arterial supplies, the supratrochlear and supraorbital arteries, which, as Kim and colleagues correctly identified, are the likely arteries inadvertently cannulated during the procedure. Our series, however, was focused on purely higher forehead injection, which, owing to the more distal location, may provide a false sense of security to physicians doing the injection as the branched arteries are smaller in these regions. We wanted to ensure that “forehead” was cited as a distinct entity, not “roughly described” and included in the glabellar region. As well, we by no means are trying to insinuate that onlabel use of these fillers is without risk to the patient. We agree wholeheartedly that every injection, cosmetic or otherwise, has a possibility of irreversible ophthalmic complications. An article by Lee et al1 describing ophthalmic and cerebral infarctions following periocular autologous fat injection highlights the severity of potential complications from such procedures. This procedure carries very low risk, but not no risk. We had found in our patient series that visual consequences are not mentioned by physicians or on the informa-

5. Peter S, Mennel S. Retinal branch artery occlusion following injection of hyaluronic acid (Restylane). Clin Experiment Ophthalmol. 2006;34(4):363-364.

jamaophthalmology.com

6. Park KH, Kim YK, Woo SJ, et al; Korean Retina Society. Iatrogenic occlusion of the ophthalmic artery after cosmetic facial filler injections: a national survey by the Korean Retina Society. JAMA Ophthalmol. 2014;132(6):714-723.

Loop-Mediated Isothermal Amplification for Rapid Diagnosis of Tubercular Uveitis To the Editor We read with great interest the article by Sharma et al1 on loop-mediated isothermal amplification (LAMP) assay for the rapid diagnosis of tubercular uveitis. The article is very informative and reiterates the utility of this test. However, it is not the first report of using this test in the diagnosis of tubercular uveitis. Prior to this publication, we reported the utility of LAMP assay for the diagnosis of ocular tuberculosis.2 We tested 14 samples (10 aqueous and 4 vitreous) from patients with clinically suspected tubercular uveitis. Sensitivity, specificity, and positive and negative predictive values of our LAMP assay were 85.7%, 100%, 100%, and 90.9%, respectively. We also compared our LAMP assay results with multitarget polymerase chain reaction (PCR). Of the 14 tested samples from patients with presumed ocular tuberculosis, LAMP assay was positive in 12 samples (85.7%) and multitarget PCR was positive in 9 samples (64.3%). (Reprinted) JAMA Ophthalmology February 2015 Volume 133, Number 2

Copyright 2015 American Medical Association. All rights reserved.

Downloaded From: http://archopht.jamanetwork.com/ by a University of Georgia User on 05/27/2015

225

Occlusion caused by cosmetic facial filler injection.

Occlusion caused by cosmetic facial filler injection. - PDF Download Free
66KB Sizes 0 Downloads 7 Views