Letter – Clinical
Ophthalmological complications related to the use of microfocused ultrasound in the periocular region and face
Mariana Marques Rechuan
, Jordana Cezar Vaz, Fernanda de Azevedo Pereira Marques, David Rubem Azulay
Corresponding author
Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa da Misericórdia do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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It is extremely important to know about this possible complication of the use of MU.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 50-year-old female patient sought dermatological care for facial rejuvenation. After evaluation, MU was employed on the face and periocular region, with carboxytherapy being performed on the eyelids. There were no complications during the procedures, which were followed by the application of Cicaplast® cream on the palpebral region. Immediately after the procedure, she complained of visual blurring, initially attributed to the use of Cicaplast®. On the first and second days after the procedure, she developed edema and erythema limited to the orbicularis region, while the visual blurring persisted and she started to have scotomas, lacrimation, and, finally, eye pain. On the third day, she experienced worsening of the ophthalmological condition, making it impossible to perform her daily activities, due to visual blurring and pain.</p><p id="par0015" class="elsevierStylePara elsevierViewall">She was assessed by an ophthalmologist who found a significant increase in eye pressure, iris retraction, areas of fibrosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and crystalline lens atrophy in the shape of spicules, and she was diagnosed with acute angle-closure glaucoma and cataracts in the shape of spicules.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Treatment was implemented with maximum doses of timolol, brimonidine, bimatoprost, and acetazolamide eye drops; however, there was some difficulty in reducing ocular pressure and little improvement of symptoms. Surgical intervention was then considered to preserve the optic nerve. After six months of treatment, she showed partial remission of symptoms, but still uses eye drops every other day.</p><p id="par0025" class="elsevierStylePara elsevierViewall">MU is used for the treatment of body flaccidity, contouring, and muscle anchoring.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It acts by emitting vibrating waves, which generate molecular friction and heat, creating an area of coagulation. This leads to a tissue healing and retraction process (lifting).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> According to the vibratory frequency, its energy is concentrated on a certain layer of the superficial musculo-aponeurotic system and promotes the aforementioned process.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> Because of that, it is important to pay attention to the correct use of the technique, which consists in using the appropriate tip, respecting the pre-established number of discharges for each area and, above all, never pointing the transducer towards the eyes, when it is used on the periocular or facial regions.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Similar cases have been previously observed, in which state-of-the-art devices were used and coursed with equivalent alterations, that is, symptoms immediately after the procedure, cataracts in the shape of spicules and difficult-to-control glaucoma. It is noteworthy that the patient had already undergone the same procedure before, with an older device, without complications.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Due to these significant adverse effects, the Brazilian Society of Glaucoma sent a letter in November 2019 to the Brazilian Society of Dermatology, issuing the necessary warning and highlighting the peculiar finding of a “spiky” cataract. It is important to emphasize that ophthalmological complaints after dermatological procedures should be evaluated by an ophthalmologist.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The authors consider this communication to be opportune because it serves as a warning to colleagues, who must be very attentive to the use of new technologies. In the present case, specifically, the possible severe ophthalmological complications related to the use of MU.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors' contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Mariana Marques Rechuan: Drafting and editing of the manuscript.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Jordana Cezar Vaz: Drafting and editing of the manuscript.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Fernanda de Azevedo Pereira Marques: Drafting and editing of the manuscript.</p><p id="par0065" class="elsevierStylePara elsevierViewall">David Rubem Azulay: Drafting and editing of the manuscript; critical review of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors' contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-08-09" "fechaAceptado" => "2021-12-13" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa da Misericórdia do Rio de Janeiro, Rio de Janeiro, RJ. Brazil.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1560 "Ancho" => 1675 "Tamanyo" => 147108 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient’s ophthalmoscopy, showing iris retraction and areas of fibrosis</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of micro-focused ultrasound for skin tightening of mid and lower face" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D. Shome" 1 => "S. Vadera" 2 => "S. Ram" 3 => "S. Khare" 4 => "R. Kapoor" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Plas Reconstr Surg Glob Open." "fecha" => "2019" "volumen" => "7" "paginaInicial" => "2498" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Microfocused ultrasound for skin tightening" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "K. Gutowski" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Plastic Surg." "fecha" => "2016" "volumen" => "43" "paginaInicial" => "577" "paginaFinal" => "582" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complications from microfocused transcutaneous ultrasound: case series and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D. Friedmann" 1 => "G. Bourgeois" 2 => "H.L. Chan" 3 => "A.C. Zedlitz" 4 => "K.J. Butterwick" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Lasers Surg Med." "fecha" => "2018" "volumen" => "50" "paginaInicial" => "13" "paginaFinal" => "19" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Signs, symptoms, and clinical forms of cataract in adults" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Delbarre" 1 => "F. Froussart-Maille" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Fr Ophtalmol." "fecha" => "2020" "volumen" => "43" "paginaInicial" => "653" "paginaFinal" => "659" "itemHostRev" => array:3 [ "pii" => "S0967586815001848" "estado" => "S300" "issn" => "09675868" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Glaucoma" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Jonas" 1 => "T. Aung" 2 => "R. Bourne" 3 => "A. Bron" 4 => "R. Ritch" 5 => "S. Panda-Jonas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(17)31469-1" "Revista" => array:6 [ "tituloSerie" => "Lancet." "fecha" => "2017" "volumen" => "390" "paginaInicial" => "2183" "paginaFinal" => "2193" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28577860" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009800000006/v2_202310301240/S0365059623001411/v2_202310301240/en/main.assets" "Apartado" => array:4 [ "identificador" => "95153" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter - Clinical" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009800000006/v2_202310301240/S0365059623001411/v2_202310301240/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059623001411?idApp=UINPBA00008Z" ]
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