Filler blindness, rare but catastrophic

“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?

·  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

 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.