Periocular ecchymosis is a rare finding with various, sometimes life-threatening pathologies. We report the case of a 48-year-old woman who presented with bilateral periocular ecchymosis after laser removal of xanthelasma palpebrarum. Her medical history was unremarkable. Amyloidosis could be excluded by histopathology. We suggest that periocular ecchymosis is a rare adverse event after minor (laser) surgery of the eyelids and discuss the possible pathogenesis and differential diagnoses.  </p

Uwe  Wollina

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107ACTA DERMATOVENEROLOGICA CROATICABilateral Periorbital Ecchymosis Following Ablative Laser Removal of Xanthelasma PalpebrarumUwe WollinaDepartment of Dermatology and Allergology, Städtisches Klinikum Dresden,  Academic Teaching Hospital, Dresden, GermanyCorresponding author:Professor Uwe Wollina, MDDepartment of Dermatology and AllergologyStädtisches Klinikum Dresden  Academic Teaching HospitalFriedrichstrasse 4101067 DresdenGermanyUwe.Wollina@klinikum-dresden.deReceived: September 2, 2018Accepted: June 8, 2019Acta Dermatovenerol Croat                               2019;27(2):107-110                             CLINICAL ARTICLEABstRACt Periocular ecchymosis is a rare finding with various, some-times life-threatening pathologies. We report the case of a 48-year-old woman who presented with bilateral periocular ecchymosis after laser re-moval of xanthelasma palpebrarum. Her medical history was unremark-able. Amyloidosis could be excluded by histopathology. We suggest that periocular ecchymosis is a rare adverse event after minor (laser) surgery of the eyelids and discuss the possible pathogenesis and differential di-agnoses.KEy woRds: perioral ecchymosis, amyloidosis, laser, lid surgery.INtRodUCtIoNPeriorbital ecchymosis is an uncommon clinical finding with various underlying pathologies. It is also known as panda sign, black eyes, or raccoon eyes. The color changes are due to bleeding into the soft tissue of the upper and lower eyelids. Traumatic and atraumatic causes have been described in the medi-cal literature (Table 1).The most important traumatic cause for perior-bital ecchymosis is skull base fracture. Typically, this condition is also accompanied by retro-auricular or mastoid ecchymosis along the posterior auricular ar-tery, also known as Battle’s sign (1,2). The most important atraumatic cause is immu-noglobulin light chain (AL) amyloidosis with bleed-ing, known as amyloid purpura. Other symptoms are fatigue and edema, neuropathy, weight loss with diarrhea or constipation, macroglossia and other hypertrophies, and internal (mostly gastrointesti-nal) bleeding. Cardiac and renal involvement have a worse prognosis. AL deposits stain positive with Con-go Red and show an apple-green birefringence with polarized light. AL amyloidosis may be associated with multiple myeloma. An early diagnosis helps to improve prognosis (3).Various traumatic and atraumatic causes have been described in the medical literature which are summarized in Table 1 (4-19).CAsE REPoRtAn otherwise healthy 48-year-old woman was re-ferred to our department due to the development of bilateral periorbital ecchymosis. Her medical history 108 ACTA DERMATOVENEROLOGICA CROATICAwas unremarkable. She had not taken any medica-tions. There had been no trauma, no invasive diag-nostics, and no surgery except an ablative laser treat-ment for xanthelasma palpebrarum with an erbium-YAG-laser after application of prilocaine/ lidocaine (EMLA®) cream. During the laser application she wore protective googles F18P1L12 Laservision (uvex safety group).We observed a bilateral ecchymosis of the upper and lower eyelids associated with a slight erythema and tarsal sparing (Figure 1). There was no infiltration, scaling, or pruritus. Examination of the skin and oral mucosa did not reveal other signs of bleeding, in par-ticular no Battle’s sign. We took a skin biopsy to exclude AL amyloidosis. The epidermis was slightly atrophic, showing dermal elastosis. Congo Red-stain remained negative. Rou-tine laboratory results were unremarkable. There was spontaneous improvement during follow-up (Figure 2), and a complete clearing of the ecchymosis was observed after 4 weeks. dIsCUssIoNBleeding into the soft tissue around the eyes is re-sponsible for the phenomenon of “raccoon eyes”. An ecchymosis is defined as an area of blood extravasa-tion >5 mm in size and is a consequence of small or medium sized blood vessel trauma. Petechial hemor-rhages are smaller (<2 mm) and typically due to dam-age to dermal capillaries. Confluent periorbital pete-chial hemorrhages are seen in amyloidosis (2,3). In traumatic periorbital ecchymosis, the blood becomes entrapped by the orbital septum inserting into the tarsal plate of the upper eyelid, thereby limit-ing extravasation. This results in tarsal plate sparing. table 1: Underlying pathologies of periorbital ecchymosisCause Disease ReferenceTraumatic Skull base fracture Herbella et al. 2001Rhinoplasty Al Arfaj 2015Ear surgery Rajati et al. 2013Sinus surgery Seredyka-Burduk et al. 2017Continuous positive airway pressure DelRosso et al. 2012Eyebrow plucking Kandogan et al. 2005Permanent tattoo Goldman & Wollina 2014Endoscopic retrograde cholangio-pancreatographyNasiri & Zamani 2017Proctoscopy Truniger & Gebbers 1998Neoplastic Neuroblastoma Smith et al. 2010Lymphoma Yuen et al. 2017Kaposi’s sarcoma Schwartz et al. 1995Light-chain (AL) amyloidosis Passos Rda et al. 2006Light-chain deposition disease  (kappa light chain)Pereira et al. 2014Systemic amyloidosis Kandavar et al. 2016Multiple myeloma Varım et al. 2016Figure 1. Initial presentation with sharply demarcated bi-lateral periocular ecchymosis and lid edema.Figure 2. Two weeks later with a marked spontaneous re-duction in edema and ecchymosis.Wollina  Acta Dermatovenerol CroatRemoval of xanthelasma palpebrarum 2019;27(2):107-110109ACTA DERMATOVENEROLOGICA CROATICAThe lower margin of orbital ecchymosis is defined by the orbital septum that arises as a fibrous extension of the arcus marginalis. In atraumatic cases, tarsal sparing is absent (20).In the present case, minor laser surgery for xan-thelasma palpebrarum was associated with bilateral periorbital ecchymosis. Laser treatment of xanthelas-ma palpebrarum has been reported with a great va-riety of laser types including carbon dioxide, yttrium aluminum garnet, pulsed dye, argon, and 1450 nm di-ode laser. All of the laser modalities offer moderate to excellent clearance rates with minimal adverse effects (21). One possible temporary adverse event after la-ser therapy is postinflammatory hyperpigmentation. This is rare in Caucasians after erbium-YAG laser (22).Periorbital ecchymosis in our case may be ex-plained by temporary increase in orbital venous hy-pertension and palpebral edema during local anes-thesia for laser therapy. Intravascular papillary endothelial hyperplasia should be considered in the differential diagnosis, which is a highly vascular lesion that can cause exces-sive intraoperative bleeding (23). However, our patient had no orbital mass and her ecchymosis was bilateral. Orbital vascular malformations are another theo-retical cause of periorbital ecchymosis often associ-ated with a reduction in visual acuity at presentation (24). In the present case, no visual symptoms had been reported. Another possibility is a petechial and purpuric reaction after the application of lidocaine/prilocaine cream for local anesthesia. This is due to a toxic reac-tion (25). Indeed, the patient had been treated with EMLA® cream before surgery.CoNCLUsIoN Periorbital ecchymosis is a possible adverse event in minor laser surgery of the eyelids, although the ex-act mechanism of bleeding has not been elucidated. However, application of EMLA® cream and local injec-tion anesthesia seem to be the most plausible cause.References:1. Watanabe K, Kida W. Images in clinical medicine. Battle’s sign. N Engl J Med. 2012;367:1135.2. Colucci G, Alberio L, Demarmels Biasiutti F, Lämm-le B. Bilateral periorbital ecchymosis. An often missed sign of amyloid purpura. Hämostaseolo-gie. 2014;34:249-52.3. Milani P, Merlini G, Palladini G. Light chain amy-loidosis. Mediterr J Hematol Infect Dis. 2018;10:e2018022.4. Herbella FA, Mudo M, Delmonti C, Braga FM, Del Grande JC. ‘Raccoon eyes’ (periorbital hae-matoma) as a sign of skull base fracture. Injury. 2001;32):745-7.5. Al Arfaj AM. The use of nasal packing post rhino-plasty: does it increase periorbital ecchymosis? A prospective study. J Otolaryngol Head Neck Surg. 2015;44:22.6. Rajati M, Bakhshaee M, Khazaeni K. Periorbi-tal ecchymosis and subconjunctival hemorr-hage following ear surgery. ISRN Otolaryngol. 2013;2013:791068. 7. Seredyka-Burduk M, Burduk PK, Wierzchowska M, Kaluzny B, Malukiewicz G. Ophthalmic complica-tions of endoscopic sinus surgery. Braz J Otorhi-nolaryngol. 2017;83:318-23.8. DelRosso L, McCarty DE, Hoque R. “Why did my CPAP beat me up?” Bilateral periorbital ecchymo-sis associated with continuous positive airway pressure therapy. J Clin Sleep Med. 2012;8:730-2. 9. Kandogan T, Aydar L, Yalciner B. Bilateral black eyes, „raccoon’s eyes“, resulting from plucking of eyebrows. Swiss Med Wkly. 2005;135:160.10. Goldman A, Wollina U. Severe unexpected adver-se effects after permanent eye makeup and their management by Q-switched Nd:YAG laser. Clin Interv Aging. 2014;9:1305-9.11. Nasiri J, Zamani F. Periorbital ecchymosis (raccoon eye) and orbital hematoma following endoscopic retrograde cholangiopancreatography. Case Rep Gastroenterol. 2017;11:134-41.12. Truniger B, Gebbers JO. PPPP (post-proctoscopy periorbital purpura). Schweiz Med Wochenschr. 1998;128:311. [in German]13. Smith SJ, Diehl NN, Smith BD, Mohney BG. In-cidence, ocular manifestations, and survival in children with neuroblastoma: a population-based study. Am J Ophthalmol. 2010;149:677-82.14. Yuen CA, Pula JH, Mehta M. Primary ocular adnex-al extranodal marginal zone mucosa-associated lymphoid tissue (MALT) lymphoma presenting as orbital apex syndrome. Neuro-Ophthalmol. 2017;41:94-8. 15. Schwartz RA, Spicer MS, Thomas I, Janniger CK, Lambert WC. Ecchymotic Kaposi’s sarcoma. Cutis. 1995;56:104-6.16. Passos Rda H, Pereira A, Neto AC, Ribeiro AF, Kutner J, Hamerschlak N, Scheinberg M. Clinical image: bilateral black eyes (raccoon’s eyes) in AL amyloidosis. Arthritis Rheum 2006;54:3724.17. Pereira VG, Jacinto M, Santos J, de Abreu TT. Pe-Wollina  Acta Dermatovenerol CroatRemoval of xanthelasma palpebrarum 2019;27(2):107-110110 ACTA DERMATOVENEROLOGICA CROATICAriorbital purpura (raccoon’s eyes). BMJ Case Rep. 2014;2014. pii: bcr2013201407. 18. Kandavar S, Varghese N, Rao M, Shetty S. Curious case of raccoon eye under general anaesthesia. Indian J Anaesth. 2016;60:442-3.19. Varım C, Ergenc H, Uyanık MS, Kaya T, Nalbant A, Karacaer C, et al. A very rare presentation of multi-ple myeloma: unilateral raccoon eye. Open Access Maced J Med Sci. 2015;3:436-8. 20. Al-Sardar H. Recurrent bilateral periorbital and circumoral bruising due to vomiting. BMJ Case Rep. 2014;2014. pii: bcr2013202495.21. Nguyen AH, Vaudreuil AM, Huerter CJ. Systematic review of laser therapy in xanthelasma palpebra-rum. Int J Dermatol. 2017;56:e47-e55. 22. Wollina U. Erbium-YAG laser therapy – analysis of more than 1,200 treatments. Glob Dermatol. 2016;3:268-72.23. Werner MS, Hornblass A, Reifler DM, Dresner SC, Harrison W. Intravascular papillary endothelial hyperplasia: Collection of four cases and a review of the literature. Ophthal Plast Reconstr Surg. 1997;13:48-56. 24. Sullivan TJ, Wright JE. Non-traumatic orbital hae-morrhage. Clin Exp Ophthalmol. 2000;28:26-31.25. de Waard-van der Spek FB, Oranje AP. Purpura caused by Emla is of toxic origin. Contact Derma-titis. 1997;36:11-3.Wollina  Acta Dermatovenerol CroatRemoval of xanthelasma palpebrarum 2019;27(2):107-110

Bilateral periorbital ecchymosis following ablative laser removal of xanthelasma palpebrarum

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