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 patients, blindness occurred after injections of adipose tissue; in the other 17, it followed injections of various materials, including corticosteroids, paraffin, silicone oil, bovine collagen, polymethylmethacrylate, hyaluronic acid, and calcium 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, syringes, and cannulas of small size should be preferred to larger ones and be replaced with blunt flexible needles and microcannulas when possible. Low-pressure injections 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. A mean pressure drop from (500 mg). A healthy 25-year-old man had com- the eyelid to the apex of the orbit is calculated to be plete recovery of visual acuity, oculomotor nerve approximately 23 mmHg at a mean flow rate of 4 palsy, and skin necrosis after treatment with oral ml/minute, assuming an axial distance to the medial and topical corticosteroid tapers,29 although his orbit of 4.5 cm and a lumen diameter of 0.05 cm for dilated pupil did not improve. Permanent visual an arteriole.54,65–67 The calculated resistance to flow68 loss without light perception persisted in all the (8L␩/pr4) is less within a terminal artery than in remaining patients regardless of the type of treat- capillaries69,70; thus, the injected material will flow ment attempted.16,18,19,21–25,28,30,31 In three cases, predominantly in the direction of least resistance. As outcomes were not available.17,20,27 the distance between the injection site and the retinal circulation increases, higher injection pressures DISCUSSION are required to generate retrograde flow until the Pathophysiology ophthalmic artery. Retrograde flow caused by high injection pres- Central retinal artery embolization is related sure may lead to retinal embolism only when a suf- to the retrograde arterial displacement of the in- ficient amount of product is propelled into the ves- jected products from peripheral vessels into the sel. The proximity of the injection site to the orbit ophthalmic arterial system proximal to the central also modulates the probability of symptomatic ob- retinal artery and follows the subsequent anterior struction: injections closer to the orbit increase the movement of the injected substance (Fig. 1). This probability that a meaningful volume of injected may occur when the wall of a distal branch is filler will gain access to the ophthalmic artery prox- accidentally perforated by the injecting needle or imal to the central retinal artery. Egbert et al. bril- cannula. In this case, the force of the injection liantly demonstrated this concept.54 Occlusion of a used for the product delivery exerted on the nourishing arteriole of the retina proximal to the plunger of a syringe can significantly expand these central retinal artery would theoretically require the arterioles many times their normal caliber and can minimum amount of material to occlude the lumen cause retrograde flow. Once an injection pressure 33,54 and, subsequently, the vessel’s blood flow. A volume higher than systolic arterial pressure is applied, of 0.01 ml should occlude an arteriole 4.5 cm from the injected material displaces the arterial blood the medial orbit with a diameter of 0.05 cm.54,67 and travels proximally past the origin of the retinal However, this estimation is not realistic because it artery. When the plunger is released, the arterial does not adequately address the complexity of the systolic pressure then propels the resulting col- orbital circulation web and the many nourishing umn of material into the ophthalmic artery and its vessels branching from the ophthalmic artery67 or branches. Although larger particles can block the exact location of the injection site. These com- larger and more consequential vessels, ophthal- plex elements, particularly when combined with the mic artery and central retinal artery blockage can unpredictable dispersion of the product during follow wedging of a very small amount of material travel, preclude an accurate calculation of the exact in the retinal artery. volume of injected material required to cause ocular Just as the pressure exerted during injection embolization. may push a column of filler into the ophthalmic The risk of retrograde flow caused by high in- artery, a higher injection pressure may cause the jection pressure should not be avoided by adjusting retrograde migration of the column in the inter- the size of the needle and the syringe. The plunger nal carotid artery, permitting cerebrovascular em- of a 50-ml syringe has a greater cross-sectional area bolization and stroke.30,50 Discoloration and ne- than the plungers of smaller syringes and should crosis of the facial skin and cerebral ischemia after therefore theoretically allow lower pressure injec-

997 Plastic and Reconstructive Surgery • April 2012

Table 1. Review of 15 Cases of Visual Loss after Facial Cosmetic Injection of Fat Tissue

Diameter/Size of Complaint of Symptoms Age Aesthetic Injecting the Cannula/Needle Procedure/Symptoms Reference (yr) Sex Procedure(s) Physician (Gauge or mm) Interval Teimourian, 19883 45 F Fat grafts to improve glabellar Plastic surgeon N/A Immediately: loss of vision frown lines and excruciating pain in the RE Dreizen and Framm, 44 F Several milliliters of Plastic surgeon N/A Immediately: severe right 19894 autologous fat injection into hemicranial pain and the forehead to remove total RE loss of vision facial wrinkles

Egido et al., 19935 47 F Autologous fat injection into N/A N/A During the injection the forehead area a sudden, severe periocular pain with complete visual loss in RE

Lee et al., 19966 42 F 0.5 ml of autologous fat Plastic surgeon N/A During the injection: transplantation to her headache and dyspnea, nasolabial groove irritability, and felt in an unconscious state

Feinendengen et al., 45 M Autologous fat injection into N/A 20-ml syringe and 2-mm- 7 hr later: global aphasia 19987 the nasolabial folds, lower diameter cannula and mild right lip and chin sensorimotor hemiparesis CT and MRI: infarction of the temporoparietal region of the left MCA

47 F Autologous fat injection into N/A N/A Immediately: LE pain and the periorbital areas to violent headaches; correct crow’s feet complete flaccid right hemiplegia, global aphasia and deviation of the head and eyes toward the left

Danesh-Meyer et al., 43 M Autologous fat injection on N/A N/A Within 10 minutes: eye 20018 the left side of the bridge of and head pain, the nose (0.5 ml), each disorientation, and nasolabial fold (3 ml each) aphasic with right and the upper and lower hemiparesis lips (3 ml)

Coleman, 20029 N/A N/A Injection of 3 ml of Unspecified 10-ml syringe with a 20- After recovering from autologous fat into the operating gauge Angiocath general anesthesia: cheek to fill a small surgeon needle unilateral blindness deficiency N/A N/A Fat injection of 0.5 ml in each Unspecified A 16-gauge sharp needle During the injection of oral commissure and lateral operating from a 10-ml syringe the forehead: unilateral canthal area, 0.25 ml in surgeon with the assistance of a blindness and each nasojugal trough, and Dispos-a-ject excruciating 1.5 ml into a transverse scar mechanical gun hemicranial pain and wrinkle in the forehead

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Table 1. (Continued)

Immediate Time When Risk Ocular Pathogenesis/ Therapy Factors Situation Diagnosis Started Therapy Outcomes N/A N/A Retinal arterial occlusion N/A N/A Totally and permanently probably secondary to blind in RE fat particle embolism N/A N/A Multiple fat emboli N/A N/A On day 75: BCVA RE: no occlusions of distal light perception branches of the BCVA LE: 20/25 ophthalmic artery Fundus: pale ONH and few scattered retinal hemorrhages, no cherry-red macular spot No cardiovascular BCVA RE: no light perception Choroidal and retinal N/A N/A On day 21: no light risk factor Pupil: nonreactive to light, but infarction caused by fat perception consensual reflex still present; embolism and emboli complete left hemiplegia into the branches of the involving the lower face upper division of the Fundus: pale ONH and several MCA and ophthalmic retinal arteries occluded arteries N/A Left pupil: nonreactive to direct CRAO caused by Not specified Ocular massage, carbon After 1 wk: Recovery of light stimulus and reactive to autologous fat emboli dioxide, oxygen the mental status but indirect therapy loss of VA Fundus: a cherry-red spot on the After 3 mo: No light macula, marked retinal perception in LE with ischemia and multiple emboli a thick fibrous in retinal arterioles membrane on the FA: decreased caliber of the left posterior pole and ophthalmic artery leading to optic atrophy ophthalmic artery insufficiency and disappearance of the image of ocular blush Concomitant Fundus: multiple fat emboli in the Multiple branch occlusions Not specified Not specified On day 3: bilateral neck and right retinal and choroidal of the retinal and Fundus: no evidence of face rhytidectomy arterioles choroidal arterioles by multiple fat embolisms and liposuction of fat emboli in the retinal and the cheeks; high choroidal arterioles level of TG and 10-mo follow-up: no low level of HDL report about ocular situation Excision of a Baker’s Pupils: symmetrical Multiple branch occlusions Not specified Not specified On day 1, CT: large cyst, removal of Left pupil: weakly reactive to of the retinal artery by hypodensities in the femoral varices, direct light stimulation fat emboli left frontotemporal cosmetic Few hours later, areactive and Selective angiography: area the next day correction of the mydriatic pupil occlusion of left carotid After several weeks: no inframammary Fundus: papilledema and artery with cerebral restoration of LE vision folds, and ischemia of the retina infarction liposuction of the thighs 4 days prior; patent foramen ovale N/A BCVA LE: no light perception Fat embolism to branches N/A N/A Over the ensuing 5 days, Pupil: amaurotic of the left MCA and the the LE remained blind; Fundus: pale ONH and ophthalmic artery no longer follow-up widespread retinal whitening has been described with visible emboli in several retinal arterioles; preretinal and intraretinal hemorrhages N/A Fundus: an embolus in the central CRAO Not specified Not specified Follow-up not specified: retinal artery permanent unilateral blindness

N/A N/A CRAO N/A N/A N/A

(Continued)

999 Plastic and Reconstructive Surgery • April 2012

Table 1. (Continued)

Diameter/Size of Complaint of Symptoms Age Aesthetic Injecting the Cannula/Needle Procedure/Symptoms Reference (yr) Sex Procedure(s) Physician (Gauge or mm) Interval Yoon et al., 200310 39 F 5 ml of autologous fat N/A N/A 1 minute later: mental injection into the glabella to change, aphasia, and correct frown lines right hemiplegia

Allali et al., 200611 49 F Autologous fat injection into N/A N/A 24 hr after the aesthetic the glabellar area to treat procedure: a sudden, wrinkles severe ocular pain with complete visual loss in RE

Mori et al., 200712 30 F Cosmetic fat injection into N/A N/A Immediately: nausea, breasts, nose, and glabellar pain, and visual loss area in RE

Park et al., 200813 27 F Autologous fat injection into Unspecified N/A Within 10 minutes: the right nasolabial fold surgeon sudden visual loss operating in a plastic surgery clinic

Lee et al., 201014 24 F Autologous fat transplantation N/A N/A On the day of the to her forehead for soft- procedure: impossible tissue augmentation in the to open both eyes face because of the swelling of her eyelids

Park et al., 201115 39 F Autologous fat injection into Plastic surgeon N/A Immediately: sudden pain the left side of the nose and vision loss in her (dosage not specified) LE

F, female; RE, right eye; N/A, not available; BCVA, best corrected visual acuity; ONH, optic nerve head; MCA, middle cerebral artery; LE, left eye; FA, fluorescein angiography; CRAO, central retinal artery occlusion; VA, visual acuity; M, male; CT, computed tomography; MRI, magnetic resonance imaging; TG, triglyceride; HDL, high-density lipoprotein; VEP, visual evoked potentials; OAO, ophthalmic artery occlusion; IOP, intraocular pressure.

1000 Volume 129, Number 4 • Blindness after Facial Cosmetic Injection

Table 1. (Continued)

Immediate Time When Risk Ocular Pathogenesis/ Therapy Factors Situation Diagnosis Started Therapy Outcomes None 30 minutes later: Occlusion of the ocular — None After 2 days: necrosis of LE: midline fixed and facial vessels and the LE Pupil: dilated and unresponsive to branches of the external After 4 days: patient died direct light stimulation carotid arteries Corneal opacity IOP: 0 mmHg None Pupil: fixed mid dilated Multiple BRAOs by fat After more Intravenous No visual recovery Fundus: retinal ischemic edema with emboli with posterior than 24 hr corticosteroids and segmentary occlusions of multiple ciliary arteries antiplatelet therapy branches of the central retinal involvement artery by yellow emboli, serous macular detachment, absence of cherry-red macular spot ONH: pale and edematous Ptosis. FA: choroidal and retinal unilateral occlusion N/A BCVA RE: no light perception OAO Not specified Drip infusion of No improvement Funduscopy: widespread retinal urokinase and whitening and obstruction of the hyperbaric oxygen retinal vessels of the fundus with therapy remarkable edema of the entire Subsequent retina administration of FA: no filling of the retinal arterioles corticosteroid None BCVA RE: hand motion Choroidal infarctions On day 5 Methylprednisolone 1 After 6 mo: no change in Right upper eyelid: slight ptosis caused by multiple g/day intravenously vision Pupil: fixed and mid-dilated occlusions of the short for 3 days and dose FA: multiple whitish patchy lesions posterior ciliary artery tapering with oral with macular and ONH edema administration and deterioration of choroidal circulation with patchy choroidal filling Fundus: absence of a cherry-red spot Flash VEP: no response None Swelling and redness of the OAO with infarction of the Not specified 1 g/day intravenous On the first postoperative eyelids ONH and retina (at least 24 methylprednisolone day: visual loss in the LE, hr later) for 3 consecutive days decreased sensation on the forehead and scalp 3 days after BCVA: no light perception; ptosis; restricted extraocular motility in all directions LE: afferent pupillary defect Fundus: LE ONH swelling and widespread retinal whitening 5 months later: BCVA: no light perception Fundus: severe retinal fibrosis None BCVA LE: no light perception OAO from the proximal Some hours Pharmacomechanical 6 days later: Corneal edema segment with thrombus later thrombolysis with a BCVA: no light perception; No pupillary reflex, total and flow stagnation in microwire and no corneal edema and ophthalmoplegia, and large-angle the distal segment 500,000 IU of improved choroidal and (45 prism diopters) exotropia of urokinase and 500 ␮g retinal perfusion the LE of tirofiban 17 mo later BCVA: no light Fundus: ischemic retina with multiple perception intraarterial yellowish emboli in Fundus LE: fibrous the LE membrane on the FA: minimal choroidal perfusion with posterior pole with a the absence of central retinal large region of necrosis arterial filling in the nasal retina After 1 day: Corneal edema Complete recovery of ocular FA: complete recanalization of the movement ophthalmic artery with Nasal sectorial iris atrophy visualization of the choroidal blush

1001 Plastic and Reconstructive Surgery • April 2012

Table 2. Review of 17 Cases of Visual Loss after Facial Cosmetic Injection of Various Substances

Diameter/Size of the Complaint of Symptoms Age Injecting Cannula/Needle (Gauge Procedure/Symptoms Reference (yr) Sex Aesthetic Procedure(s) Physician or mm) Interval von Bahr, 196316 25 F 8-ml injection of a suspension of Dermatologist N/A During the procedure: hydrocortisone into the bare pain in the head and spots on the scalp (left in the LE anterior part of the crown, a few centimeters within the frontal limit of the hair)

Lee et al., 196917 50 F Subcutaneous injection of N/A N/A Immediately: loss of vision paraffin on the forehead

Baran, 1964* 24 F Injection of hydrocortisone N/A N/A N/A suspension for alopecia areata Baran, 1965* 31 F Injection of methylprednisolone N/A N/A Immediately: transitory acetate suspension for blindness alopecia areata Shin et al., 198819 30 F Injection of silicone oil N/A N/A Sudden loss of vision and subcutaneously at the root of pain RE of 24-hr her nose duration

Castillo, 198920 34 F Injection of Zyderm collagen N/A N/A Few minutes: sudden implant into glabellar lines amaurosis and acne scars in the cheeks Shafir et al., 199921 37 F Long-acting steroid to Unspecified 25-gauge needle Within seconds of the last subcutaneous scarring of the surgeon injection: no light dorsum of the nose perception; no pupillary reflex could be elicited Jee and Lee, 200222 44 F Augmentation rhinoplasty using N/A N/A 1 day after injection: liquid silicone acute visual loss in LE and RE hemiplegia

Apte et al., 200323 48 F Intradermal injection of 0.5 ml N/A N/A 10 minutes later: nausea, of Cymetra to improve the diaphoresis, and left contour of a depressed side periocular pain forehead scar After 30 minutes: blurred vision

Silva and Curi, 52 F Aesthetic PMMA injection into Plastic surgeon N/A Immediately after 200424 the glabellar area injection: severe RE pain and visual loss

1002 Volume 129, Number 4 • Blindness after Facial Cosmetic Injection

Table 2. (Continued)

Time When Pathogenesis/ Therapy Risk Factors Immediate Ocular Situation Diagnosis Started Therapy Outcomes Three previous Immediately: no light perception; CRAO Few minutes Massage of the eye On day 9, BCVA: treatments with the direct pupillary reaction later perception of “hand same substance abolished movements” in the Fundus: block of several arterial temporal VF only branches of the retina and LE pupil: moderately choroid by small deposits of a reactive light substance ONH: slightly pale On day 1: Retina: white and opaque LE BCVA: “hand motions” in the macular region LE pupil: relatively wide and very Fovea: brownish and slightly reactive to direct light surrounded by a yellow ONH: normal; marked ischemic zone turbidity on the macula and 4 mo later: unchanged interruption of the blood column in some parts N/A Immediately: loss of vision CRAO and thrombosis N/A N/A N/A of the ophthalmic vein N/A N/A N/A N/A N/A Persistent impairment of sight N/A N/A N/A N/A N/A After 5 minutes: return of vision

N/A BCVA RE: “counting fingers,” RE CRAO and PCAOs Immediately Digital massage, On day 9, BCVA: no afferent papillary defect vasodilators, and improvement Fundus: pale, partially opacified, acetazolamide Fundus: retinal hemorrhage edematous retina extending FA: no dye filling of the from the ONH toward the white vessel, ONH dye fovea; in the center of this leakage, zones of retinal zone a white retinal vessel; ischemia edema of RNFL in the inferior VF examination: inferior nasal margin altitudinal defect, central scotoma, RNFL defect in the superior temporal region N/A N/A N/A N/A N/A N/A

N/A N/A Central retinal Immediately Routine treatment for After 4 yr: no recovery of embolus and vascular occlusion vision choroidal occlusion of the bulb

N/A N/A CRAO N/A N/A On day 30: development of right carotid cavernous fistula with right ocular pain Concomitant injection of After several hours: BCVA of CRAO and PCAOs N/A N/A 2 mo later, 1.0 ml of Cymetra to “hand motions,” papillary BCVA: light perception; the bilateral nasolabial afferent defect, mild ptosis, marked afferent pupillary regions and 0.5 ml of and exotropia defect; mild left Cymetra to the hypertropia and bilateral oral exotropia, without ptosis, commissure regions large areas of RPE under a local atrophy anesthetic without FA: large areas of choroidal incident nonperfusion in the posterior pole and temporal peripheral retina None BCVA RE: no light perception; CRAO and PCAOs N/A N/A 10 mo later, white opacity in the right BCVA: no light perception; cornea and iris atrophy; total total right ophthalmoplegia ophthalmoplegia (Continued)

1003 Plastic and Reconstructive Surgery • April 2012

Table 2. (Continued)

Diameter/Size of the Complaint of Symptoms Age Injecting Cannula/Needle (Gauge Procedure/Symptoms Reference (yr) Sex Aesthetic Procedure(s) Physician or mm) Interval Kubota and Hirose, 29 F Injection of 0.7 ml of MetaCrill Cosmetic N/A After 15 minutes: ocular 200525 into the dorsum of the nose surgeon pain and a decrease of without local anesthetics vision in RE to “hand motion”

Peter and Mennel, 48 M Injection of hyaluronic acid in N/A N/A 1 minute after: partial 200626 the glabellar area and in the visual loss in the cheeks for wrinkles inferior half of the VF of his RE

Kang et al., 200727 65 F Injection of a filler into the N/A N/A Sudden visual loss glabellar area Tangsirichaipong, 36 F Silicone injection in the temple N/A N/A Immediately: RE sudden 200928 area painful visual loss and headache

Sung et al., 201029 25 M Calcium hydroxyapatite filler Dermatologist N/A Immediately: injection for nose blepharoptosis and augmentation orbital pain on the right side Some hours later: central necrosis and surrounding reddish reticular pattern affecting the right eyelid

Kwon et al., 201030 39 F Injection of collagenous filler An acquaintance A self-manufactured Immediately: complete material into the left anterior performed syringe loss of vision in her left nasal septum for a nasal tip- this eye and a headache plasty procedure illegally at a beauty salon

Kim et al., 201131 30 F Injection of 0.8 ml of hyaluronic N/A N/A Immediately: visual loss in acid in the nasal tip and the LE bridge as an augmentation and contouring

F, female; LE, left eye; N/A, not available; BCVA, best corrected visual acuity; ONH, optic nerve head; CRAO, central retinal artery occlusion; VF, visual field; RE, right eye; RNFL, retinal nerve fiber layer; PCAO, posterior ciliary artery occlusion; FA, fluorescein angiography; RPE, retinal pigment epithelium; PMMA, polymethylmethacrylate; AC, anterior chamber; MRI, magnetic resonance imaging; M, male; BRAO, branch retinal artery occlusion. *Selmanowitz VJ, Orentreich N. Cutaneous corticosteroid injection and amaurosis: Analysis for cause and prevention. Arch Dermatol. 1974; 110:729–734.

1004 Volume 129, Number 4 • Blindness after Facial Cosmetic Injection

Table 2. (Continued)

Time When Pathogenesis/ Therapy Risk Factors Immediate Ocular Situation Diagnosis Started Therapy Outcomes N/A Pupil: dilated but still reactive Direct toxic effect N/A N/A 4-mo follow-up, Ocular motility: restricted on because of a BCVA RE: no light upward and leftward gaze with foreign body perception; full ocular temporary displacement of the reaction and motility and no eyeball vasculitis secondary blepharoptosis; clear Blepharoptosis; on day 1, BCVA to BRAO cornea RE: light perception Fundus: ONH atrophy Biomicroscopy: corneal edema and 2ϩ cells in the AC MRI: orbital inflammation Tobacco abuse; no BCVA RE: 6/7.5 BRAO of the superior Immediately 500 mg of BVCA: complete recovery; previously systemic After 24 hr, BCVA RE: 6/6 temporal artery acetazolamide visual field defect embolic episodes Funduscopy: evidence of an improved embolus in the peripheral retinal associated with retinal edema N/A Necrosis of the glabellar area Retinal branch artery N/A N/A N/A occlusion No medical problem BCVA RE: No light perception CRAO for silicone After 2 hr Ocular massage, AC On day 30: no light Relative afferent pupillary defect embolism into the paracentesis, and perception Diffuse retinal whitening, a central retinal oral acetazolamide cherry-red spot in the macula, artery vascular attenuation, and boxcar flow in arteries and veins None 8 hr hours later: PCAOs, choroidal After 8 hr Topical and After 3 mo BCVA RE: hand movement ischemia limited in intravenous BCVA RE: 20/20 with Pupil: fully dilated without the nasal area and antibiotics and pinhole reverse afferent pupillary occlusion of the topical steroids, No intraocular defect branch to the followed by low inflammation or Right exotropia oculomotor nerve dose of tapering oculomotor nerve palsy; Severe AC reaction, including oral corticosteroids still fixed dilated pupil hyphema, hypopyon, and corneal edema

None LE: no light perception, with Multiple BRAOs On day 3 Low-dose antiplatelet Blindness complete opacification of the agent and a calcium cornea and iris, complete channel blocker ophthalmoplegia, and ptosis of the LE Fundus photography: multiple BRAOs MRI: acute cerebral infarction of the superior frontal subcortex and subarachnoid hemorrhage of another part of the distal branch of the middle cerebral artery N/A Immediately: strong pain in the left CRAO On day 2 Intravenous At 6 mo: upper face methylprednisolone Complete recovery of the BCVA LE: no light perception at 1 g/day for 3 eyeball movement Funduscopy: retina pale and days and tapered Progressive exudative and swollen with a cherry-red spot high-dose oral tractional retinal On day 2, slit lamp examination: prednisolone and detachment at the severe chemosis, edematous aspirin at 100 mg; inferonasal retina caused cornea, Descemet folds, and iris daily Comfeel phthisis bulbi atrophy dressing Ultrasonography: severe chorioretinal swelling without detachment Left eyeball movement restricted at all gazes

1005 Plastic and Reconstructive Surgery • April 2012

Fig. 1. Schematic drawing that shows the anatomy, distribution, and connections between the ophthalmic and the facial arterial systems. The supratrochlear artery is the terminal branch of the ophthalmic artery and exits at the superior and medial corner of the bony orbit by piercing the orbital septum with the supratrochlear nerve. It runs superiorly into the forehead, where it supplies the integument, muscles, and pericranium and maintains numerous anastomoses with the supraorbital arteryandwiththecontralateralvessels.Thisisthevesselmostlikelytobeinvolved when intraarterial injection of fat and foreign material of the glabella and forehead is responsible for embolization. The supraorbital artery may occasionally be the route of embolization of injected material. It arises from the ophthalmic artery and divides into superficial and deep branches that nourish the integument, muscles, and pericranium of the forehead. Its terminal branches anastomose with the supratrochlear artery, the frontal branch of the superficial temporal artery, and the contralateral supraorbital artery. The second terminal branch of the ophthalmic artery, the dorsal nasal artery, may be responsible for transmission of emboli following injections low in the glabella or proximal to the nasal root. It anastomoses with the angular artery, the dorsal nasal artery of the opposite side, and the lateral nasal branch of the facial artery. The facial artery arises from the external carotid artery that supplies the structures of the face. The facial artery passes forward and upwardacrossthecheektotheangleofthemouth,whereitarborizesandgivesrise to the labial systems and, more distally, to the lateral nasal artery that supplies the ala and dorsum of the nose. It further forms anastomoses with its contralateral counterpart, with the septal and alar branches, with the dorsal nasal branch of the ophthalmic artery, and with the infraorbital branch of the internal maxillary. The facial artery then ascends along the side of the nose, ending at the medial canthus, where it is named the angular artery. After supplying the lacrimal sac and orbicu- laris oculi, it ends by anastomosing with the dorsal nasal branch of the ophthalmic artery. The angular artery on the cheek distributes branches that anastomose also with the infraorbital artery. The facial artery should be considered for embolization following injections of the cheek, nasolabial folds, and lips. tions (Pascal’s law71). However, beyond the fact that with large syringes can result anyway in pressures the surgeon’s control over the volume injected is greater than the systolic blood pressure.54 Even the severely impaired by the use of a large syringe for use of a small-gauge needle does not seem to prevent fine injection of filler materials and fat, injection retrograde flow. The decreased pressure resulting

1006 Volume 129, Number 4 • Blindness after Facial Cosmetic Injection from the use of a small-gauge needle or cannula does intraocular pressure and increase arteriolar flow, po- not decrease the injection pressure below the sys- tentially dislodging the embolus, but it has been temic arterial pressure.54 Furthermore, the initiation ineffective in all four of the cases included in this of an injection requires an order of magnitude more study.6,16,19,28 Intravenous administration of diuretics pressure than does maintenance of flow. Smaller such as acetazolamide81 may both increase retinal needle sizes require greater initial pressure to over- blood flow and immediately reduce intraocular pres- come resistance to flow and thus result in higher sure. This approach failed in two patients19,28 but was initial pressures transmitted to surrounding tissues.54 successful in one case.26 Retinal arteriolar dilation Obviously, in daily clinical practice, the most com- and oxygen delivery to ischemic tissues from oph- monly used devices for injecting cosmetic substances thalmic vessels may be encouraged by carbogen (5 into the face are 1-, 3-, and 10-ml syringes, in which percent carbon dioxide and 95 percent oxygen) the plunger has a manyfold smaller cross-sectional inhalation.82 The only patient6 who underwent car- area than the plungers of a 50-ml syringe and should bogen rebreathing had no substantial recovery of his therefore allow higher pressure injections to occur. sight. Although hyperbaric oxygen therapy may the- The use of a smaller syringe even with a small needle oretically be beneficial, transportation to the will increase the risk for the physician to exceed the nearest chamber may usurp precious time. Neither systolic arterial pressure. Thus, the force with which patient6,12 treated with oxygen therapy improved. the product is delivered becomes a really important Systemic and topical corticosteroids were success- variable to control. fully administrated in one case, with full recovery of sight but with a persistently dilated pupil.29 Systemic Treatment and local intraarterial fibrinolyses have failed to dis- solve cholesterol or heterologous materials83 as re- To optimize the possibility of fully or partially 11,12,15,30 regaining normal vision, early recognition and treat- ported in four cases. In the European Assessment Group for Lysis in ment are essential for treating ocular circulation 77 emboli. The goal of treatment is rapid restoration of the Eye study, a significant improvement in best perfusion to the retina and optic nerve head.48,54,72,73 corrected visual acuity in patients with an acute cen- After 90 minutes, the damage caused by retinal isch- tral retinal artery occlusion was obtained in 60 per- emia becomes irreversible and retinal necrosis oc- cent of patients at 1 month after a six-step therapy curs. Thus, limiting the length of ischemia may allow administered within 20 hours after the ischemic various degrees of recovery.54,74–77 Although current event. In the present review, improvement after therapy was achieved in only two cases (14 percent), both standard therapies have not been shown to alter the of which suffered ocular embolism following injec- natural course of the disease, it should be assumed that tion of heterologous material (hyaluronic acid26 and shortening the ischemic period increases the proba- calcium hydroxyapatite,29 respectively). In the first bility of residual visual function.54,74 The recovery pat- case, partial visual loss in the inferior visual field tern after branch retinal artery occlusion should be improved to a best corrected visual acuity of 6/6 similar, but remaining visual function is more likely. within 24 hours after immediate administration of 500 mg of acetazolamide,26 and in the second case, Nonsurgical Management a best corrected visual acuity of “hand movement” Current treatments may not satisfactorily treat improved to 20/20 at 3 months after topical antibi- arterial retinal occlusions caused by fat graft em- otics and steroids, including intravenous antibiotics, boli or foreign materials that are widely used as were initiated 8 hours after the occlusive event and facial cosmetic fillers or rejuvenating procedures. followed by a low-dose oral corticosteroid taper.29 In The currently available recommendations for retinal the first case,26 the recovery was attributable to both embolism54,78 attempt to rapidly reduce intraocular the natural history of a branch retinal artery pressure to dislodge the embolus to a downstream occlusion82 and to the therapy that could have dis- location to improve retinal perfusion. Because our lodged the embolus peripherally relative to the ret- review identified only two cases with improvement inal edema. Both effects would have allowed reso- following known treatments,26,29 we cannot recom- lution of the retinal edema and thus explained the mend any treatments as safe or effective. visual improvement. In the second case,29 the injury Anterior chamber decompression with a needle was a posterior ciliary artery occlusion, and the cho- or sharp cutting blade paracentesis results in an in- roidal ischemia was limited to the nasal area; thus, stantaneous decrease of intraocular pressure.79,80 the recovery was likely determined by resolution of However, this treatment failed in the case28 included the corneal edema and the severe anterior chamber in the present review. Ocular massage may lower reaction, which included hyphema and hypopyon,

1007 Plastic and Reconstructive Surgery • April 2012

Table 3. Tips and Techniques to Diminish the Risk of Intravascular Injection 1. Aspiration before injection. As mentioned previously, the small size and collapsibility of facial vessels limits the efficacy of preinjection aspiration for avoiding arteriolar injection*. Some authors* consider this precaution useless because, in several reported cases, aspiration did not identify intraarterial needle placement. It is our opinion, however, that aspiration will at least occasionally demonstrate intravascular placement of the needle and should thus be used. The needle should be withdrawn and repositioned if blood appears in the syringe during the aspiration. This precaution may not be applied easily during fat injection procedures because of the high viscosity of the product and the possible presence of residual blood within centrifuged fat. 2. Injections should be performed slowly and with the least amount of pressure possible. Thus, even if the tip of the needle has perforated the arterial wall, the column of filler will not be propelled retrograde in the artery. This may be the most important precaution for practitioners and has already been generally accepted by several authors†‡§. 3. The tip of the needle should be moved slightly to deliver the filler at different points along a line rather than as a single deposit. This precaution minimizes the chance of depositing a critical amount of material into an artery even if the needle has perforated the arterial wall by limiting the time during which the needle remains within the arteriole. 4. Incremental injections should be fractionated so that any filler injected into the artery can be flushed peripherally before the next incremental injection is performed. The surgeon should limit therefore to 0.1 ml of filler regardless of the filler type†‡§. This stepwise procedure minimizes the risk that a column of filler will extend proximally into the ophthalmic arterial system. 5. Although high injection pressures cannot be controlled by the size of the syringe or needle used during injection, small syringes should be preferred to larger ones. As already mentioned previously, a bolus injection technique is more likely to transmit a column of filler to the ophthalmic artery or the internal carotid system. The use of a high- volume syringe (Ն10 ml) may increase the probability of this complication because the surgeon cannot easily control the volume of the filler delivered. 6. Small needles should be preferred to larger ones. Although their initial pressure is higher and their drop pressure is insufficient, smaller needles slow injection speed and are less likely to occlude the vessel or block peripheral flow. 7. Repeated treatments with smaller volumes may be preferred to single-stage high-volume injections. Pretreatment with botulinum toxin type A may help reduce the volume of filler required for cosmesis. 8. When indicated, the use of recently introduced tools such as blunt, flexible microcannulas and nontraumatic flexible blunt tip needles should be preferred for filler injection¶. Both the microcannula and the blunt tip needle are inserted into the skin through a hole previously made with a sharp tip needle having the same diameter. These techniques allow facial injection with a limited number of insertion points for the whole face, thus reducing the risk of arterial entry. 9. Either the perforation of an arterial wall or the cannulation of an artery lumen will occur more frequently in a vasodilated artery. Thus, procedural risks should be reduced by application of a topical vasoconstrictor prior to filler delivery. Some authors†#** recommend local anesthesia with epinephrine to promote vasoconstriction. It can be combined with topical anesthesia or regional nerve block before injection to avoid excessive tissue distortion. 10. When performing autologous fat tissue transfer, sharp cannulas and small cannulas are much more likely to perforate the wall of an artery and cannulate the artery lumen than are larger, blunt cannulas†. 11. Extensive gentle pretunneling (e.g., moving of the cannula without applying vacuum or pressure) is usually advocated because the delivery of small fat parcels into multiple soft-tissue tunnels allows better revascularization and results in more predictable and more persistent results. This method may cause a hidden vascular lesion. Thus, it becomes extremely important to allow a low-pressure microdroplet injection technique with blunt cannulas to avoid a dramatically high injection pressure for a highly viscous substance such as fat tissue. The injection should be accomplished by delivering very small, noncontinuous amounts of 0.1 ml per pass†. Some authors emphasize the use of 0.025 to 0.05 ml per tunnel or even less for the periorbital region††. 12. When surgical procedures of the head and neck, such as face lifts and liposuction, are combined with local autologous fat grafting, the risk of ocular arterial system embolism increases, because intravascular delivery of fat tissue is easier in pretraumatized soft tissue.‡‡ This condition should be prevented. *McCleve DE, Goldstein JC. Blindness secondary to injections in the nose, mouth, and face: Cause and prevention. Ear Nose Throat J. 1995;74:182–188. †Coleman SR. Avoidance of arterial occlusion from injection of soft tissue fillers. Aesthet Surg J. 2002;22:555–557. ‡Matsuo T, Fujiwara H, Gobara H, Mimura H, Kanazawa S. Central retinal and posterior ciliary artery occlusion after intralesional injection of sclerosant to glabellar subcutaneous hemangioma. Cardiovasc Intervent Radiol. 2009;32:341–346. §Egbert JE, Paul S, Engel WK, Summers CG. High injection pressure during intralesional injection of corticosteroids into capillary hemangiomas. Arch Ophthalmol. 2001;119:677–683. Thomas EL, Laborde RP. Retinal and choroidal vascular occlusion following intralesional corticosteroid injection of a chalazion. Ophthalmology 1986;93:405–407. ¶Niamtu J III. Filler injection with micro-cannula instead of needles. Dermatol Surg. 2009;35:2005–2008. #Coleman SR. Structural fat grafting: More than a permanent filler. Plast Reconstr Surg. 2006;118(Suppl):108S–120S. **Berlin A, Cohen JL, Goldberg DJ. Calcium hydroxylapatite for facial rejuvenation. Semin Cutan Med Surg. 2006;25:132–137. ††Tzikas TL. Facial fat injection. In: Thomas JR, ed. Advanced Therapy in Facial Plastic and Reconstructive Surgery. Shelton, Conn: People’s Medical Publishing House; 2010:573–580. ‡‡Feinendegen DL, Baumgartner RW, Vuadens P, et al. Autologous fat injection for soft tissue augmentation in the face: A safe procedure? Aesthetic Plast Surg. 1998;22:163–167.

1008 Volume 129, Number 4 • Blindness after Facial Cosmetic Injection

Fig. 2. A useful algorithm approach is presented to minimize the occurrence of ophthalmic arterial system embolization during facial cosmetic injections. rather than by the resolution of the choroidal isch- therapy: topical (a single eye drop of timolol 0.5%) emia. In the other 12 cases in which the therapy was and systemic (intravenous injection of 500 mg of administered, no improvement was achieved regard- acetazolamide) lowering of intraocular pressure, iso- less of the nature of the embolus (fat6,11–15 or heter- volemic hemodilution in patients with a hematocrit ologous material16,19,21,28,30,31). The time between the greater than 40 percent (500 ml of blood was with- occlusive event and the onset of the therapy could drawn and 500 ml of 10% hydroxyethyl starch was have contributed to these failures, however. In the simultaneously infused within 15 to 30 minutes), European Assessment Group for Lysis in the Eye globe massage (repeated increased pressure was ap- study,77 the authors suggested that the visual prog- plied to the globe for 10 to 15 seconds, followed by nosis in patients with acute central retinal artery a sudden release with an in-and-out movement using occlusion depends in part on the duration of symp- a three-mirror contact lens for 3 to 5 minutes), and toms, with a shorter duration associated with better anticoagulation with heparin and acetylsalicylic visual outcome. In five cases described in this review, acid. In our review, all of the treated patients the therapy was administered after more than 20 underwent at most a three-step therapy, which hours11,13,14,30,31; in two cases,6,12 the timing was not included other treatment options, such as carbon specified; and in five cases, it was administered dioxide,6 oxygen therapy,6,12 oral or intravenous within 20 hours.15,16,19,21,28 corticosteroids,11–14,31 pharmacologic or pharma- Incomplete treatment could also have contrib- comechanical thrombolysis,12,15 vasodilators,19 an- uted to failure. In the European Assessment Group terior chamber paracentesis,28 and calcium chan- for Lysis in the Eye study,77 the standard treatment nel blockers.30 Monotherapy was administered of central retinal artery occlusion included a six-step in four cases,13–16 dual therapy was administered in

1009 Plastic and Reconstructive Surgery • April 2012 two cases,11,30 and triple therapy was administered Davide Lazzeri, M.D. in five cases6,12,19,28,31; in one case, an unspecified Plastic and Reconstructive Surgery Unit Hospital of Pisa routine treatment for vascular occlusion of the Via Paradisa 2 bulb was administered.21 Cisanello, 56100 Pisa, Italy [email protected] ACKNOWLEDGMENTS Surgical Management The authors thank Dr.ssa Ilaria Bondi (MEDICAL Contrasting opinions about the feasibility and ILLUSTRATOR, Via Carlo Lugli, Carpi, Modena, efficacy of reperfusion of the occluded retinal artery Italy) for help with Figure 1. through surgical removal of the emboli have been expressed.84,85 No data support the assumption that REFERENCES surgical embolectomy of the iatrogenically injected 1. Eppley BL, Dadvand B. Injectable soft-tissue fillers: Clinical materials within the retinal circulation is a safe overview. Plast Reconstr Surg. 2006;118:98e–106e. method for restoring ophthalmic system circulation 2. Coleman SR. Structural fat grafting: More than a permanent filler. Plast Reconstr Surg. 2006;118(Suppl):108S–120S. after embolization from cosmetic facial injections. 3. Teimourian B. Blindness following fat injections. Plast Re- The same caution applies to transluminal neodym- constr Surg. 1988;82:361. ium:yttrium-aluminum-garnet laser embolysis.86 Sur- 4. Dreizen NG, Framm L. Sudden unilateral visual loss after gical treatment has not been used or proposed by autologous fat injection into the glabellar area. Am J Oph- thalmol. 1989;107:85–87. any of the articles reviewed. 5. Egido JA, Arroyo R, Marcos A, Jime´nez-Alfaro I. Middle cerebral artery embolism and unilateral visual loss after autologous fat injection into the glabellar area. Stroke 1993;24: Tips and Techniques to Diminish the Risk of 615–616. 6. Lee DH, Yang HN, Kim JC, Shyn KH. Sudden unilateral visual Intravascular Injection loss and brain infarction after autologous fat injection into Although no rule can completely prevent the nasolabial groove. Br J Ophthalmol. 1996;80:1026–1027. occurrence of ocular circulation embolization, some 7. Feinendegen DL, Baumgartner RW, Vuadens P, et al. Au- reasonable precautions that may decrease the risk of tologous fat injection for soft tissue augmentation in the face: A safe procedure? Aesthetic Plast Surg. 1998;22:163–167. vascular occlusion during facial cosmetic injections 8. Danesh-Meyer HV, Savino PJ, Sergott RC. Case reports and are discussed in Table 3.2,7,9,51,52,54,78,87–89 A useful al- small case series: Ocular and cerebral ischemia following gorithm approach is also presented in Figure 2. facial injection of autologous fat. Arch Ophthalmol. 2001;119: 777–778. 9. Coleman SR. Avoidance of arterial occlusion from injection of soft tissue fillers. Aesthet Surg J. 2002;22:555–557. CONCLUSIONS 10. Yoon SS, Chang DI, Chung KC. Acute fatal stroke immedi- Some steps may minimize the risk of emboliza- ately following autologous fat injection into the face. tion of filler into the ophthalmic artery following Neurology 2003;61:1151–1152. 11. Allali J, Bernard A, Assaraf E, Bourges JL, Renard G. Multiple facial cosmetic injections. Intravascular placement embolizations of the branches of the ophthalmic artery: An of the needle or cannula should be demonstrated by unknown serious complication of facial surgeries (in aspiration before injection and should be further French). J Fr Ophtalmol. 2006;29:51–57. prevented by application of local vasoconstrictor. 12. Mori K, Ohta K, Nagano S, Toshinori M, Yago T, Ichinose Y. A case of ophthalmic artery obstruction following autologous Needles, syringes, and cannulas of small size should fat injection in the glabellar area (in Japanese). Nippon Ganka be preferred to larger ones and be replaced with Gakkai Zasshi 2007;111:22–25. blunt flexible needles and microcannulas when pos- 13. Park SH, Sun HJ, Choi KS. Sudden unilateral visual loss after sible. Low-pressure injections with the release of the autologous fat injection into the nasolabial fold. Clin Oph- thalmol. 2008;2:679–683. least amount of substance possible should be con- 14. Lee YJ, Kim HJ, Choi KD, Choi HY. MRI restricted diffusion sidered safer than bolus injections. The total volume in optic nerve infarction after autologous fat transplantation. of filler injected during the entire treatment session J Neuroophthalmol. 2010;30:216–218. should be limited, and injections into pretrauma- 15. Park SJ, Woo SJ, Park KH, et al. Partial recovery after intraarterial pharmacomechanical thrombolysis in ophthalmic tized tissues should be avoided. Actually, no safe, artery occlusion following nasal autologous fat injection. feasible, and reliable treatment exists for iatrogenic J Vasc Interv Radiol. 2011;22:251–254. retinal embolism. Nonetheless, therapy should the- 16. von Bahr G. Multiple embolisms in the fundus of an eye after oretically be directed to lowering intraocular pres- an injection in the scalp. Acta Ophthalmol (Copenh.) 1963;41: 85–91. sure to dislodge the embolus into more peripheral 17. Lee JH, Lee KH, Moon HJ. A case of unilateral blindness after vessels of the retinal circulation, increasing retinal paraffin injection on the forehead. J Korean Ophthalmol Soc. perfusion and oxygen delivery to hypoxic tissues. 1969;10:49–51.

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18. Selmanowitz VJ, Orentreich N. Cutaneous corticosteroid in- 40. Meythaler FH, Naumann GO. Intraocular ischemic infarcts jection and amaurosis: Analysis for cause and prevention. in injections into the lid and parabulbar region (without Arch Dermatol. 1974;110:729–734. perforation of the eye) (in German). Klin Monbl Augenheilkd. 19. Shin H, Lemke BN, Stevens TS, Lim MJ. Posterior ciliary- 1987;190:474–477. artery occlusion after subcutaneous silicone-oil injection. 41. Rishiraj B, Epstein JB, Fine D, Nabi S, Wade NK. Permanent Ann Ophthalmol. 1988;20:342–344. vision loss in one eye following administration of local an- 20. Castillo GD. Management of blindness in the practice of esthesia for a dental extraction. Int J Oral Maxillofac Surg. cosmetic surgery. Otolaryngol Head Neck Surg. 1989;100:559– 2005;34:220–223. 562. 42. Ellis PP. Visual loss following tonsillectomy; possible associ- 21. Shafir R, Cohen M, Gur E. Blindness as a complication of ation with injections in tonsillar fossae. Arch Otolaryngol. 1968; subcutaneous nasal steroid injection. Plast Reconstr Surg. 87:436–438. 1999;104:1180–1182; discussion 1183–1184. 43. McGrew RN, Wilson RS, Havener WH. Sudden blindness 22. Jee DH, Lee KI. A case of left ophthalmic artery occlusion secondary to injections of common drugs in the head and and right carotid cavernous fistula after illegal rhinoplasty. neck: I. Clinical experiences. Otolaryngology 1978;86:147– J Korean Ophthalmol Soc. 2002;43:898–904. 151. 23. Apte RS, Solomon SD, Gehlbach P. Acute choroidal infarc- 44. Fivgas GD, Newman NJ. Anterior ischemic optic neuropathy tion following subcutaneous injection of micronized dermal following the use of a nasal decongestant. Am J Ophthalmol. matrix in the forehead region. Retina 2003;23:552–554. 1999;127:104–106. 24. Silva MT, Curi AL. Blindness and total ophthalmoplegia after 45. Chamot L, Zografos L, Micheli JL. Ocular and orbital com- aesthetic polymethylmethacrylate injection: Case report. Arq plications after sclerosing injections in a case of a frontal Neuropsiquiatr. 2004;62:873–874. cutaneous angioma. Ophthalmologica 1981;182:193–198. 25. Kubota T, Hirose H. Permanent loss of vision following cos- 46. Shorr N, Seiff SR. Central retinal artery occlusion associated metic rhinoplastic surgery. Jpn J Ophthalmol. 2005;49:535– with periocular corticosteroid injection for juvenile heman- 536. gioma. Ophthalmic Surg. 1986;17:229–231. 26. Peter S, Mennel S. Retinal branch artery occlusion following 47. Ruttum MS, Abrams GW, Harris GJ, Ellis MK. Bilateral retinal injection of hyaluronic acid (Restylane). Clin Experiment Oph- embolization associated with intralesional corticosteroid in- thalmol. 2006;34:363–364. jection for capillary hemangioma of infancy. J Pediatr Oph- 27. Kang YS, Kim JW, Choi WS, Park HS, Jang SJ, Chio JC. A case thalmol Strabismus 1993;30:4–7. of sudden unilateral visual loss following injection of filler 48. Egbert JE, Schwartz GS, Walsh AW. Diagnosis and treatment into the glabella. Korean J Dermatol. 2007;45:381–383. of an ophthalmic artery occlusion during an intralesional 28. Tangsirichaipong A. Blindness after facial contour augmen- injection of corticosteroid into an eyelid capillary hemangi- tation with injectable silicone. J Med Assoc Thai. 2009; oma. Am J Ophthalmol. 1996;121:638–642. 92(Suppl 3):S85–S87. 49. Gupta V, Sharma SC, Gupta A, Dogra MR. Retinal and cho- 29. Sung MS, Kim HG, Woo KI, Kim YD. Ocular ischemia and roidal microvascular embolization with methylprednisolone. ischemic oculomotor nerve palsy after vascular embolization Retina 2002;22:382–386. of injectable calcium hydroxyapatite filler. Ophthal Plast Re- 50. Edwards AO. Central retinal artery occlusion following fore- constr Surg. 2010;26:289–291. head injection with a corticosteroid suspension. Pediatr Der- 30. Kwon DY, Park MH, Koh SB, et al. Multiple arterial embolism matol. 2008;25:460–461. after illicit intranasal injection of collagenous material. Der- matol Surg. 2010;36:1196–1199. 51. Matsuo T, Fujiwara H, Gobara H, Mimura H, Kanazawa S. 31. Kim YJ, Kim SS, Song WK, Lee SY, Yoon JS. Ocular ischemia Central retinal and posterior ciliary artery occlusion after in- with hypotony after injection of hyaluronic acid gel. Ophthal tralesional injection of sclerosant to glabellar subcutaneous Plast Reconstr Surg. 2011;27:e152–e155. hemangioma. Cardiovasc Intervent Radiol. 2009;32:341–346. 32. Byers B. Blindness secondary to steroid injections into the 52. Thomas EL, Laborde RP. Retinal and choroidal vascular nasal turbinates. Arch Ophthalmol. 1979;97:79–80. occlusion following intralesional corticosteroid injection of 33. Mabry RL. Visual loss after intranasal corticosteroid injec- a chalazion. Ophthalmology 1986;93:405–407. tion: Incidence, causes, and prevention. Arch Otolaryngol. 53. Yag˘ci A, Palamar M, Eg˘rilmez S, Sahbazov C, Ozbek SS. 1981;107:484–486. Anterior segment ischemia and retinochoroidal vascular oc- 34. Mabry RL. Intranasal corticosteroid injection: Indications, clusion after intralesional steroid injection. Ophthal Plast Re- technique, and complications. Otolaryngol Head Neck Surg. constr Surg. 2008;24:55–57. 1979;87:207–211. 54. Egbert JE, Paul S, Engel WK, Summers CG. High injection 35. Whiteman DW, Rosen DA, Pinkerton RM. Retinal and cho- pressure during intralesional injection of corticosteroids roidal microvascular embolism after intranasal corticoste- into capillary hemangiomas. Arch Ophthalmol. 2001;119: roid injection. Am J Ophthalmol. 1980;89:851–853. 677–683. 36. Wilkinson WS, Morgan CM, Baruh E, Gitter KA. Retinal and 55. Bachmann F, Erdmann R, Hartmann V, Wiest L, Rzany B. choroidal vascular occlusion secondary to corticosteroid em- The spectrum of adverse reactions after treatment with in- bolisation. Br J Ophthalmol. 1989;73:32–34. jectable fillers in the glabellar region: Results from the In- 37. Savino PJ, Burde RM, Mills RP. Visual loss following intra- jectable Filler Safety Study. Dermatol Surg. 2009;35(Suppl 2): nasal anesthetic injection. J Clin Neuroophthalmol. 1990;10: 1629–1634. 140–144. 56. Bellman B. Complication following suspected intra-arterial 38. Cheney ML, Blair PA. Blindness as a complication of rhino- injection of Restylane. Aesthet Surg J. 2006;26:304–305. plasty. Arch Otolaryngol Head Neck Surg. 1987;113:768–769. 57. Georgescu D, Jones Y, McCann JD, Anderson RL. Skin ne- 39. Rettinger G, Christ P, Meythaler FH. Blindness caused by crosis after calcium hydroxyapatite injection into the glabel- central artery occlusion following nasal septum correction lar and nasolabial folds. Ophthal Plast Reconstr Surg. 2009;25: (in German). HNO. 1990;38:105–109. 498–499.

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58. Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the 74. Hayreh SS, Weingeist TA. Experimental occlusion of the glabella: Protocol for prevention and treatment after use of central artery of the retina: IV. Retinal tolerance time to dermal fillers. Dermatol Surg. 2006;32:276–281. acute ischaemia. Br J Ophthalmol. 1980;64:818–825. 59. Hanke CW, Higley HR, Jolivette DM, Swanson NA, Stegman 75. Selle´s-Navarro I, Villegas-Pe´rez MP, Salvador-Silva M, Ruiz- SJ. Abscess formation and local necrosis after treatment with Go´mez JM, Vidal-Sanz M. Retinal ganglion cell death after Zyderm or Zyplast collagen implant. J Am Acad Dermatol. different transient periods of pressure-induced ischemia and 1991;25:319–326. survival intervals: A quantitative in vivo study. Invest Ophthal- 60. Inoue K, Sato K, Matsumoto D, Gonda K, Yoshimura K. mol Vis Sci. 1996;37:2002–2014. Arterial embolization and skin necrosis of the nasal ala fol- 76. Roth S, Li B, Rosenbaum PS, et al. Preconditioning provides lowing injection of dermal fillers. Plast Reconstr Surg. 2008; complete protection against retinal ischemic injury in rats. 21:127e–128e. Invest Ophthalmol Vis Sci. 1998;39:775–785. 61. Hirsch RJ, Lupo M, Cohen JL, Duffy D. Delayed presentation 77. Schumacher M, Schmidt D, Jurklies B, et al. Central retinal of impending necrosis following soft tissue augmentation artery occlusion: Local intra-arterial fibrinolysis versus con- with hyaluronic acid and successful management with hyal- servative treatment, a multicenter randomized trial. Ophthal- uronidase. J Drugs Dermatol. 2007;6:325–328. 62. Park TH, Seo SW, Kim JK, Chang CH. Clinical experience mology 2010;117:1367–1375.e1. with hyaluronic acid-filler complications. J Plast Reconstr Aes- 78. McCleve DE, Goldstein JC. Blindness secondary to injections thet Surg. 2011;64:892–896. in the nose, mouth, and face: Cause and prevention. Ear Nose 63. Schanz S, Schippert W, Ulmer A, Rassner G, Fierlbeck G. Throat J. 1995;74:182–188. Arterial embolization caused by injection of hyaluronic acid 79. Ffytche TJ. A rationalization of treatment of central retinal (Restylane). Br J Dermatol. 2002;146:928–929. artery occlusion. Trans Ophthalmol Soc UK. 1974;94:468– 64. Lowe NJ. Arterial embolization caused by injection of hyal- 479. uronic acid (Restylane). Br J Dermatol. 2003;148:379; author 80. Augsburger JJ, Magargal LE. Visual prognosis following treat- reply 379–380. ment of acute central retinal artery obstruction. Br J Oph- 65. Paul S, Egbert JE, Walsh AW, Hoey MF. Pressure measure- thalmol. 1980;64:913–917. ments during injection of corticosteroids. Med Biol Eng Com- 81. McGrew RN, Wilson RS, Havener WH. Sudden blindness put. 1998;36:729–733. secondary to injections of common drugs in the head and 66. Paul S, Hoey MF, Egbert JE. Pressure measurements during neck: II. Animal studies. Otolaryngology 1978;86:152–157. injection of corticosteroids: In vivo studies. Med Biol Eng 82. Alm A, Bill A. Ocular circulation. In: Alder FH, Moses RA, Comput. 1999;37:645–651. Hart WM, eds. Adler’s Physiology of the Eye. 8th ed. St. Louis: 67. Dutton JJ. Arterial supply to the orbit. In: Clinical and Surgical Mosby; 1987:183–203. Orbital Anatomy. Philadelphia, Pa: Saunders; 1994:68–71. 83. Hayreh SS. Prevalent misconceptions about acute retinal 68. Badeer H. Hemodynamics for medical students. Adv Physiol vascular occlusive disorders. Prog Retin Eye Res. 2005;24:493– Educ. 2001;25:44–52. 519. 69. Zweifach BW. Quantitative studies of microcirculatory struc- 84. Garcı´a-Arumı´ J, Martinez-Castillo V, Boixadera A, Fonollosa ture and function: I. Analysis of pressure distribution in the A, Corcostegui B. Surgical embolus removal in retinal artery terminal vascular bed in cat mesentery. Circ Res. 1974;34: occlusion. Br J Ophthalmol. 2006;90:1252–1255. 843–857. 85. Hayreh SS. Surgical embolus removal in retinal artery oc- 70. Zweifach BW. Quantitative studies of microcirculatory struc- ture and function: II. Direct measurement of capillary pres- clusion. Br J Ophthalmol. 2007;91:1096–1097. sure in splanchnic mesenteric vessels. Circ Res. 1974;34:858– 86. Opremcak EM, Benner JD. Translumenal Nd:YAG laser em- 866. bolysis for branch retinal artery occlusion. Retina 2002;22: 71. Bullock JD, Warwar RE, Green WR. Ocular explosion during 213–216. cataract surgery: A clinical, histopathological, experimental, 87. Tzikas TL. Facial fat injection. In: Thomas JR, ed. Advanced and biophysical study. Trans Am Ophthalmol Soc. 1998;96:243– Therapy in Facial Plastic and Reconstructive Surgery. Shelton, 276; discussion 276–281. Conn: People’s Medical Publishing House; 2010:573–580. 72. Hayreh SS. Vascular disorders in neuro-ophthalmology. Curr 88. Niamtu J III. Filler injection with micro-cannula instead of Opin Neurol. 2011;24:6–11. needles. Dermatol Surg. 2009;35:2005–2008. 73. Chen CS, Lee AW. Management of acute central retinal 89. Berlin A, Cohen JL, Goldberg DJ. Calcium hydroxylapatite for artery occlusion. Nat Clin Pract Neurol. 2008;4:376–383. facial rejuvenation. Semin Cutan Med Surg. 2006;25:132–137.

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