Hyaluronidase allergy after peribulbar anesthesia with orbital inflammation

A 70-year-old woman previously exposed to hyaluronidase during ophthalmic surgery had excision of hypertrophic bulbar conjunctival tissue in the right eye. Hyaluronidase was added to the peribulbar anesthetic agent. Five days postoperatively, the patient presented with proptosis in the right eye, extraocular muscle restriction, and decreased visual acuity. She was apyrexial with a normal white cell count; computed tomography of the orbits showed a diffuse increase in soft tissue density. Clinical features were unchanged after 24 hours of intravenous antibiotics, but subsequent administration of high-dose oral steroids led to clinical improvement.