Allergic reaction to hyaluronidase: A rare cause of orbital inflammation after cataract surgery

Purpose: The aim of this study was to present a series of patients with acute orbital inflammatory symptoms secondary to peribulbar hyaluronidase allergy and to discuss the diagnostic and management modalities. Methods: Review of clinical records of all patients with acute orbital inflammatory symptoms after uneventful cataract surgery, seen at two ophthalmology departments. The main outcome measures included clinical signs and symptoms, imaging findings, post-operative course, skin allergy testing, and final outcome. Results: There were five patients (four women, one man) with a mean age of 78±7.0 years. Signs and symptoms appeared 12-72 h after cataract surgery and included axial proptosis, periorbital erythema with swelling, and extraocular muscle (EOM) function restriction (5/5), periorbital pain or itchiness (3/5), and conjunctival chemosis (4/5). Computerized tomography showed increased orbital fat haziness and enlargement of EOM. Treatment with a combination of oral antibiotics and steroids or antihistamines resulted in resolution of signs and symptoms after 3-5 days. Intradermal and/or skin prick allergy tests were positive for hyaluronidase and negative for all other perioperative medications used. Conclusion: Although uncommon, allergy to peribulbar hyaluronidase injected during cataract surgery should be considered in the differential diagnosis of patients who present with acute post-operative orbital signs and symptoms.