“Sudden blindness
following filler treatment is rare but a catastrophic complication”
“The potential for vision loss, skin necrosis, and CNS complications
such as stroke should be included on consent forms ”
What are
complications caused by intravascular injection of fillers?
What are
complications caused by intravascular injection of fillers?
· Tissue
ischemia and loss,
· Blindness,
· Pulmonary embolization,
· Stroke
How fillers induced blindness occurs ?
Soft
tissue fillers induced blindness results from accidental injection
of filler materials into a blood vessel causing vascular occlusion of
ophthalmic artery.
The ophthalmic artery
The ophthalmic artery begins behind the eye, branching into vessels including the supraorbital, supratrochlear, and dorsal nasal artery
There are many
anastomoses between different arteries of the face and branches of the
ophthalmic artery system putting virtually any anatomic location of injection
at risk for ocular complications
The most common
locations of filler injection to result in vision changes
·
Nasal
region (high risk)
·
The
glabella (high risk)
·
The
forehead(high risk)
·
Nasolabial
fold
with
a needle or a cannula”
Recommendations to
treat blindness?
· Whenever possible, immediate evaluation by an ophthalmologist is best
· The patient should be asked about any pain, visual changes, weakness in
the extremities or other symptoms such as nausea, headache and dizziness
· Skin findings including any blanching, erythema, duskiness or
reticulate changes should be documented
·
Capillary refill tested in the
affected area.
· Early
supratrochlear/supraorbital hyaluronidase injection,
·
Ocular
massage
·
Rebreathing
into a plastic bag
·
Oral
aspirin
· Ophthalmologist ttt(acetazolamide, mannitol,
prostaglandins, \ anterior chamber paracentesis, \ sublingual glyceryl
trinitrate, \ hyperbaric oxygen, \ or direct intravascular or IV injection of
hyaluronidase with urokinase, Heparin, systemic steroids, and antibiotics)
Where to inject hyaluronidase ?
Not
necessary to inject into the affected Blood vessel, you may inject next to a
blood vessel clogged with HA, it catabolizes the HA without needing to canalize
the affected artery.
Where
to inject hyaluronidase in case of retinal artery embolization ?
Retrobulbar
injection of a large volume of hyaluronidase is essential to dissolve the intraorbital intravascular
hyaluronic acid in a time-sensitive manner.
When to inject hyaluronidase
?
Hyaluronidase
must be given within the window period of 60–90 min
Animal studies suggest that the retina is only able to
survive approximately 90 minutes without blood supply but it may be shorter as
12 -15 minutes if complete central retinal artery was occluded
Signs of vascular occlusion ?
·Pain (periorbital, ocular, periocular, orbital, eye pain or
headache)
·Ophthalmoplegia((decreased
extraocular movement)
·Ptosis
·Discomfort disproportionate
to what is typically experienced following filler treatments
·Blanching,
· Livedo pattern, Or violaceous discoloration
·Skin necrosis
· Nusea or vomiting
·Stroke like features such as unilateral
weakness or evidence of brain infarction on imaging
Factor that may affect the outcome ?
· Type of filler
· Volume of the filler injected,
· Pressure of injection
· The size of the syringe and gauge of the
needle/cannula
“Vascular complications can occur when injecting
with
a needle or a cannula”
Recommendations to
treat blindness?
· Whenever possible, immediate evaluation by an ophthalmologist is best
· The patient should be asked about any pain, visual changes, weakness in
the extremities or other symptoms such as nausea, headache and dizziness
· Skin findings including any blanching, erythema, duskiness or
reticulate changes should be documented
·
Capillary refill tested in the
affected area.
· Early
supratrochlear/supraorbital hyaluronidase injection,
·
Ocular
massage
·
Rebreathing
into a plastic bag
·
Oral
aspirin
· Ophthalmologist ttt(acetazolamide, mannitol,
prostaglandins, \ anterior chamber paracentesis, \ sublingual glyceryl
trinitrate, \ hyperbaric oxygen, \ or direct intravascular or IV injection of
hyaluronidase with urokinase, Heparin, systemic steroids, and antibiotics)
Where to inject hyaluronidase ?
Not
necessary to inject into the affected Blood vessel, you may inject next to a
blood vessel clogged with HA, it catabolizes the HA without needing to canalize
the affected artery.
Where
to inject hyaluronidase in case of retinal artery embolization ?
Retrobulbar
injection of a large volume of hyaluronidase is essential to dissolve the intraorbital intravascular
hyaluronic acid in a time-sensitive manner.
When to inject hyaluronidase
?
Hyaluronidase
must be given within the window period of 60–90 min
Animal studies suggest that the retina is only able to
survive approximately 90 minutes without blood supply but it may be shorter as
12 -15 minutes if complete central retinal artery was occluded
How to Avoid HA induced blindness?
“Key prevention strategies”
·
Be familiar with the anatomy, location and
depth of facial vessels and the common variations
·
Safest plane to be injecting is likely deep
directly on bone or very superficially in the dermis
·
The subcutaneous plane, is the most high-risk
location, as the vasculature most commonly courses through this region
·
Inject slowly and with minimal pressure.
·
Consider using a cannula cannula size 25 G or
greater in size is preferred
·
Inject small increments at one time to
prevent a bolus of filler traveling retrograde
·
Move the needle tip while injecting to avoid
depositing a large amount of filler in one location
·
Aspirate before injection
·
Exercise extreme caution when injecting a
patient who has undergone a previous surgical procedure in the area
·
Consider mixing the filler with epinephrine
to promote vasoconstriction
·
Consider using targeted digital pressure to
occlude major periorbital vessels and prevent inadvertent retrograde travel of
filler.
References :
1- Source of
arts image : Loh,
K. T. D., Chua, J. J., Lee, H. M., Lim, J. T. E., Chuah, G., Yim, B., & Puah,
B. K. (2016). Prevention and management of vision loss relating to facial
filler injections. Singapore medical journal, 57(8),
438.
2- Beleznay,
Katie, Jean DA Carruthers, Shannon Humphrey, Alastair Carruthers, and Derek
Jones. "Update on avoiding and treating blindness from Fillers: a recent
review of the world literature." Aesthetic surgery journal 39,
no. 6 (2019): 662-674.
3- Chatrath, V., Banerjee, P. S.,
Goodman, G. J., & Rahman, E. (2019). Soft-tissue filler–associated
blindness: a systematic review of case reports and case series. Plastic and Reconstructive
Surgery–Global Open, 7(4), e2173.
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