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Blindness Following Cosmetic Injections of the Face

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Blindness Following Cosmetic Injections of the Face SPECIAL TOPIC Blindness following Cosmetic Injections of the Face Davide Lazzeri, M.D. Background: Complications following facial cosmetic injections have recently Tommaso Agostini, M.D. heightened awareness of the possibility of iatrogenic blindness. The authors Michele Figus, M.D., Ph.D. conducted a systematic review of the available literature to provide the best Marco Nardi, M.D. evidence for the prevention and treatment of this serious eye injury. Marcello Pantaloni, M.D. Methods: The authors included in the study only the cases in which blindness Stefano Lazzeri, M.D. was a direct consequence of a cosmetic injection procedure of the face. Pisa and Florence, Italy Results: Twenty-nine articles describing 32 patients were identified. In 15 pa- tients, blindness occurred after injections of adipose tissue; in the other 17, it followed injections of various materials, including corticosteroids, paraffin, sil- icone oil, bovine collagen, polymethylmethacrylate, hyaluronic acid, and cal- cium hydroxyapatite. Conclusions: Some precautions may minimize the risk of embolization of filler into the ophthalmic artery following facial cosmetic injections. Intravascular placement of the needle or cannula should be demonstrated by aspiration before injection and should be further prevented by application of local vasoconstrictor. Needles, sy- ringes, and cannulas of small size should be preferred to larger ones and be replaced with blunt flexible needles and microcannulas when possible. Low-pressure injec- tions with the release of the least amount of substance possible should be considered safer than bolus injections. The total volume of filler injected during the entire treatment session should be limited, and injections into pretraumatized tissues should be avoided. Actually, no safe, feasible, and reliable treatment exists for iatrogenic retinal embolism. Nonetheless, therapy should theoretically be directed to lowering intraocular pressure to dislodge the embolus into more peripheral vessels of the retinal circulation, increasing retinal perfusion and oxygen delivery to hypoxic tissues. (Plast. Reconstr. Surg. 129: 995, 2012.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, V. acial soft-tissue augmentation and rejuvena- cannula, and syringe size in causing retrograde tion procedures using various injections of flow of the substance to understand the conditions Ffiller materials are widely performed for cos- under which retrograde flow can lead to retinal metic enhancement because of their highly pre- circulation embolism and blindness. We sought to dictable, convenient, and pleasing outcomes.1,2 In elucidate risk factors for retinal vascular occlu- recent years, complications following facial cos- sion in addition to the cause, prevention, and metic injections have heightened awareness of the treatment options following cosmetic injections possibility of iatrogenic visual loss.3–31 Neverthe- into the face that resulted in blindness or severe less, transitory and permanent blindness has fol- visual disability, and we hope to provide a useful lowed routine aesthetic injection of the face dur- guide for physicians who perform these cos- ing which a serious injury is not expected.3–31 metic procedures. We reviewed and examined the influences of injection pressures; material type; and needle, PATIENTS AND METHODS We reviewed the available literature regarding the occurrence of blindness following injections From the Plastic and Reconstructive Surgery and Ophthal- mology Units, University Hospital of Pisa, and the Maxil- lofacial Surgery Unit, University of Florence. Received for publication September 12, 2011; accepted Oc- Disclosure: There are no financial conflicts or tober 5, 2011. interests to report in association with the content of Copyright ©2012 by the American Society of Plastic Surgeons this article. DOI: 10.1097/PRS.0b013e3182442363 www.PRSJournal.com 995 Plastic and Reconstructive Surgery • April 2012 of fillers of the face. Data were identified by nose15). In the remaining two cases, fat tissue was searches in MEDLINE, the Cochrane database, grafted to multiple regions of the face.9,12 Google and Google Scholar, Current Contents, Procedural details of the cannula, syringe, and and PubMed. We used the search terms “blindness needle used were available in only three articles. A after steroid injection,” “blindness after fat injec- 10-ml syringe was used twice: once with a 20-gauge tion,” “blindness after facial injections,” “blind- (0.812-mm) needle and once with a 16-gauge (1.291- ness after sclerotherapy,” “blindness after cosmetic mm) sharp needle.9 In one case, a 20-ml syringe was medicine,” “ischemic optic neuropathy after injec- used with a 2-mm-diameter cannula.7 tion of the face,” “emboli facial filler,” “arterial oc- In all cases described,3–15 the signs and symptoms clusion after soft tissue filler,” “blindness after facial of visual adverse effects were evident immediately filler,” and “arterial occlusion after facial filler.” All following the injection, characterized by complaint cases of blindness or visual impairment that were not of excruciating pain and a sudden blackout of the a direct consequence of an injection procedure into involved eye. Three cases5,7,10 presented with further the facial skin were excluded, as were those in which neurologic complications caused by cerebral vessel blindness was not produced by retinal or retinal embolus. Information such as history, family history, branch artery occlusion. Thus, cases of blindness and other physical findings was not available for any following intraturbinate steroid injections,32–36 anes- cases in this group.3–15 thetic injections into the nasal septal mucosa,37–40 In nine cases, no information about the treat- oral and palatal mucosal injections,41 and tonsillar ment was available.3–6,8–10 In six cases, therapy (oc- injections42,43 were excluded. A single case of visual ular massage,7 carbon dioxide rebreathing,7 hyper- impairment subsequent to the use of nasal decon- baric oxygen therapy,7,12 oral and intravenous gestant was also excluded.44 All articles that de- corticosteroids,11–14 antiplatelet drugs,11 and fibrino- scribed cases in which facial injection had no pure lytic agents12,15; or mechanical thrombolysis15) was cosmetic aim, such as sclerotherapy of vascular administered without effects. Neither the treated lesions45–51 and corticosteroid injections for the treat- nor the untreated patients had any return of ment of chalazia,52,53 were excluded. vision.3–15 RESULTS Other Injected Materials Group Using strict a priori criteria for our review, we Seventeen patients16–31 (15 women and two identified a total of 29 articles representing 32 men; mean age, 38 Ϯ 11.5 years; range, 24 to 65 cases.3–31 We divided patients into two groups: the years) who suffered transitory (three cases)18,26,29 or first group included patients (n ϭ 15)3–15 diag- permanent (14 cases)16,17,19–25,27,28,30,31 blindness fol- nosed with blindness following fat injection of the lowing the injection of materials other than adipose face for cosmetic reasons, and the second group tissue were identified (Table 2). The injected sub- included patients (n ϭ 17)16–31 diagnosed with stances included corticosteroids16,18,21 and filler ma- transitory or permanent blindness after facial aes- terials such as paraffin,17 silicone oil,19,22,28 bovine thetic injections of other materials. The results of collagen,20,23,30 polymethylmethacrylate,24,25 hyal- our review are summarized in Tables 1 and 2. uronic acid,26,31 and calcium hydroxyapatite.29 The nose (root,18,22,29 dorsum,21,22,25,29 and tip30,31) and the scalp16,18 were the most frequently injected sites, with Fat Tissue Injection Group seven and three cases, respectively; whereas the re- A review of the literature revealed a total of 15 maining seven cases involved the forehead,17,23 reports of blindness following cosmetic facial fat glabella,24,27 glabella and cheek20,26 (two cases for tissue transfer3–31 (mean age, 40.0 Ϯ 8.0 years; each area), and temple area28 (one case). The sy- range, 24 to 49 years), including 11 women3–7,10–15 ringe and needle used were described in only one and two men.7,8 In two cases, no demographic data case (25-gauge needle,21 0.455 mm). were available (Table 1).9 Three patients received Several different individualized treatments autologous fat injections into the lower third of were attempted in this group of patients. Systemic the face (nasolabial folds,6,13 lips, and chin).9 In corticosteroids29,31 were administered in two patients, seven cases, the site of injection was the upper diuretic agents (carbonic anhydrase inhibitors19,26,28) third of the face, including the forehead,4,5,14 were used in three cases, and vasodilators19 and anti- glabella,5,10,11 and nasal bridge,8 and in three cases, aggregant drugs (antiplatelet agents,30 aspirin31) were fat tissue was transferred to the mid third of the used in one case each. An alternative approach such as face (cheek,9 periorbita,7 and left side of the ocular massage16,19,28 was attempted in only three 996 Volume 129, Number 4 • Blindness after Facial Cosmetic Injection cases. Surgical treatment, specifically, anterior filler injection have the same pathophysiologic chamber paracentesis, was attempted in just one mechanism.55–64 Ocular circulation embolization patient.28 Data on local and systemic treatments requires the concurrent coexistence of three fac- were not available in nine patients.17,18,20,22–25,27 tors, including the retrograde flow caused by high Only three patients recovered their sight.18,26,29 injection pressure and a sufficient amount of ma- One patient recovered sight 5 minutes after in- terial delivered into the vessel.54,65,66 jection of corticosteroids for alopecia areata, but The injection of the filler into an artery will cause detailed information about the treatment was not retrograde flow if the injection pressure is greater available.18 In another case,26 vision recovered than the sum of the systolic arterial pressure and the completely and the visual field defect improved frictional forces caused by viscous flow pressure after prompt administration of acetazolamide drops within the vessel.
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