Ophthalmological complications related to the use of microfocused ultrasound in the periocular region and face

The authors describe a severe clinical case of ophthalmologic complications related to the use of microfocused ultrasound (MU) in the periocular region and face. It is extremely important to know about this possible complication of the use of MU. 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. She was assessed by an ophthalmologist who found a significant increase in eye pressure, iris retraction, areas of fibrosis (Fig. 1), 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. 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


Dear Editor,
The authors describe a severe clinical case of ophthalmologic complications related to the use of microfocused ultrasound (MU) in the periocular region and face.It is extremely important to know about this possible complication of the use of MU.
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.
She was assessed by an ophthalmologist who found a significant increase in eye pressure, iris retraction, areas of fibrosis (Fig. 1), 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.
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 ଝ Study conducted at the Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa da Misericórdia do Rio de Janeiro, Rio de Janeiro, RJ.Brazil.nerve.After six months of treatment, she showed partial remission of symptoms, but still uses eye drops every other day.
MU is used for the treatment of body flaccidity, contouring, and muscle anchoring. 1It 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). 1,2According to the vibratory frequency, its energy is concentrated on a certain layer of the superficial musculo-aponeurotic system and promotes the aforementioned process. 1,3Because of that, it is important to pay attention to the correct use of the technique, which consists in using the appropriate tip, respecting the preestablished 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. 2,3imilar cases have been previously observed, in which state-of-the-art devices were used and coursed with equiv-Figure 1 Patient's ophthalmoscopy, showing iris retraction and areas of fibrosis LETTER -CLINICAL alent alterations, that is, symptoms immediately after the procedure, cataracts in the shape of spicules and difficultto-control glaucoma.It is noteworthy that the patient had already undergone the same procedure before, with an older device, without complications.
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. 4,5he 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. 5

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Dear Editor,
Proliferating trichilemmal tumor (PTT) is a rare adnexal neoplasm 1,2 derived from the outer sheath of the hair follicle and may originate from a pre-existing pilar/trichilemmal cyst as a result of trauma and/or inflammation in the latter. 1,3It was first reported in 1966 by Wilson Jones 2,4,5 and it is benign in most cases 3,4 but eventually it can be malignant, recur locally, invade adjacent tissues and cause distant metastases. 1,3---5It often presents as a solitary, soft nodular lesion, measuring 1 to 10 cm in diameter, on the scalp of elderly women. 1,3and may be associated with an area of alopecia.More rarely, it can affect other topographies such ଝ Study conducted at the Private Practice, Porto Alegre, RS, Brazil.
as the neck, trunk, groin, mons pubis, vulva, gluteal region, and skull base. 1,3his report describes the case of a 52-year-old male patient, with no comorbidities, who sought medical care complaining of a lesion on the scalp, with discomfort on palpation, that had been growing for about a year.He had a personal history of scalp cyst removal years before.On clinical examination, a tumor-like, erythematous lesion with a pedunculated structure in the center, measuring approximately 3 cm in its largest diameter, was observed in the parieto-occipital region (Fig. 1).The main hypothesis was trichilemmal cyst with atypical clinical presentation and, for this reason, an incisional spindle biopsy was performed, measuring about 2 cm in its largest diameter for anatomopathological analysis.Histopathology showed a dermal tumor, with no connection with the epidermis, consisting of an expansive lobular proliferation of squamous cells with ample eosinophilic cytoplasm and abrupt keratinization, without the formation of a granular layer -trichilemmaltype keratinization ---in the central portion of the lobes (Fig. 2).Some of these cells had atypical nuclei, but no