Advertisement

Aesthetic Plastic Surgery

, Volume 43, Issue 4, pp 1054–1060 | Cite as

Clinical Observations and the Anatomical Basis of Blindness After Facial Hyaluronic Acid Injection

  • Lei Zhang
  • Lei Pan
  • Hong Xu
  • Sheng Yan
  • Yi Sun
  • Woffles T. L. Wu
  • Sufan WuEmail author
Original Article Non-Surgical Aesthetic
  • 191 Downloads

Abstract

Background

Blindness or visual loss is the most serious complication resulting from facial hyaluronic acid (HA) injection. In this study, three recent clinical cases were analyzed, and the relevant anatomy of cadavers was evaluated to investigate the mechanism behind visual impairment due to HA injection.

Methods

Three patients with different extents of visual loss after HA injection were studied. Ophthalmic testing and corresponding treatments were performed, and the clinical progress was observed. In addition, thirty-six fresh Asian cadaver hemifaces were anatomized to investigate the morphology of the ophthalmic artery and its branches. The minimum dose of HA for central retinal artery embolism was calculated based on the ophthalmic arterial volumes of cadavers.

Results

Visual impairment was more severe in central retinal artery occlusion and combined intraocular branch occlusion than in posterior ciliary artery occlusion. During follow-up, no improvement was observed in terms of visual impairment. Cadaver study reconfirmed that the ophthalmic artery included facial and intraocular branches. The ophthalmic arterial volumes running from the supraorbital artery and supratrochlear artery to the central retinal artery were 0.083 cm3 and 0.089 cm3, respectively.

Conclusions

The severity of blindness caused by HA injection may be associated with the occlusion site. Our clinical observations indicate that conventional treatments, such as retrobulbar hyaluronidase injection, are insufficient to relieve visual impairment. Injecting as little as 0.08 ml of HA into the facial branch is enough to cause central retinal artery embolism. Limiting the volume per injection could represent a simple prophylactic strategy.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Keywords

Blindness Hyaluronic acid Hyaluronidase Facial fillers Visual impairment Ophthalmic artery embolism Retrobulbar injection 

Notes

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflicts of interest to disclose.

Statement of Human and Animal Rights, or Ethical Approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed Consent

For this type of study informed consent is not required.

References

  1. 1.
    Hedén P, Sellman G, Wachenfeldt MV et al (2009) Body shaping and volume restoration: the role of hyaluronic acid. Aesthet Plast Surg 33(3):274–282CrossRefGoogle Scholar
  2. 2.
    Gottfried L, Rullan Peter P, Nelly G-H (2006) Avoiding and treating dermal filler complications. Plast Reconstr Surg 118:92S–107SCrossRefGoogle Scholar
  3. 3.
    Tae-Hwan P, Sang-Won S, June-Kyu K, Choong-Hyun C (2011) Clinical experience with hyaluronic acid-filler complications. J Plast Reconstr Aesthet Surg 64:892–896CrossRefGoogle Scholar
  4. 4.
    Kim DY, Eom JS, Kim JY (2015) Temporary blindness after an anterior chamber cosmetic filler injection. Aesthet Plast Surg 39:428–430CrossRefGoogle Scholar
  5. 5.
    Liew S, Wu WTL, Chan HH et al (2016) Consensus on changing trends, attitudes, and concepts of asian beauty. Aesthet Plast Surg 40(2):193–201CrossRefGoogle Scholar
  6. 6.
    Lazzeri D, Agostini T, Figus M et al (2015) Blindness following cosmetic injections of the face. Plast Reconstr Surg 129:995–1012CrossRefGoogle Scholar
  7. 7.
    Hayreh SS, Weingeist TA (1980) Experimental occlusion of the central artery of the retina. IV: Retinal tolerance time to acute ischaemia. Br J Ophthalmol 64:818–825CrossRefGoogle Scholar
  8. 8.
    Hayreh SS, Podhajsky PA, Zimmerman B (1997) Nonarteritic anterior ischemic optic neuropathy: time of onset of visual loss. Am J Ophthalmol 124:641–647CrossRefGoogle Scholar
  9. 9.
    Wu S, Pan L, Wu H et al (2017) Anatomic study of ophthalmic artery embolism following cosmetic injection. J Craniofac Surg 28:1578–1581CrossRefGoogle Scholar
  10. 10.
    Goodman GJ, Roberts S, Callan P (2016) Experience and management of intravascular injection with facial fillers: results of a multinational survey of experienced injectors. Aesthet Plast Surg 40(4):549–555CrossRefGoogle Scholar
  11. 11.
    Kim YS, Choi DY, Gil YC et al (2015) The anatomical origin and course of the angular artery regarding its clinical implications. Dermatol Surg 40:1070–1076CrossRefGoogle Scholar
  12. 12.
    Lang J, Kageyama I (1990) The ophthalmic artery and its branches, measurements and clinical importance. Surg Radiol Anat 12(2):83–90CrossRefGoogle Scholar
  13. 13.
    Hayreh SS (2006) Orbital vascular anatomy. Orbit 20(10):1130–1144Google Scholar
  14. 14.
    Perrini P, Cardia A, Fraser K et al (2007) A microsurgical study of the anatomy and course of the ophthalmic artery and its possibly dangerous anastomoses. J Neurosurg 106(1):142–150CrossRefGoogle Scholar
  15. 15.
    Khan TT, Colonacevedo B, Mettu P et al (2017) An anatomical analysis of the supratrochlear artery: considerations in facial filler injections and preventing visual impairment. Aesthet Surg J 37(2):203–208CrossRefGoogle Scholar
  16. 16.
    Scheuer JF 3rd, Sieber DA, Pezeshk RA et al (2017) Anatomy of the facial danger zones: maximizing safety during soft-tissue filler injections. Plast Reconstr Surg 139:50e–58eCrossRefGoogle Scholar
  17. 17.
    Carruthers JD, Fagien S, Rohrich RJ et al (2015) Blindness caused by cosmetic filler injection: a review of cause and therapy. Plast Reconstr Surg 134:1197–1201CrossRefGoogle Scholar
  18. 18.
    Carruthers J, Fagien S, Dolman P (2015) Retro or peribulbar injection techniques to reverse visual loss after filler injections. Dermatol Surg 41(Suppl 1):S354–S357CrossRefGoogle Scholar
  19. 19.
    Hwang CJ, Mustak H, Gupta AA et al (2018) Role of retrobulbar hyaluronidase in filler-associated blindness: evaluation of fundus perfusion and electroretinogram readings in an animal model. Ophthalm Plast Reconstr Surg 35:33–37CrossRefGoogle Scholar
  20. 20.
    Zhu GZ, Sun ZS, Liao WX et al (2015) Efficacy of retrobulbar hyaluronidase injection for visual impairment resulting from hyaluronic acid filler embolization. Aesthet Surg J 38:12–22CrossRefGoogle Scholar
  21. 21.
    Loh KTD, Chua JJ, Lee HM et al (2015) Prevention and management of visual impairment relating to facial filler injections. Singap Med J 57:438–443CrossRefGoogle Scholar
  22. 22.
    Signorini M, Liew S, Sundaram H et al (2016) Global aesthetics consensus: avoidance and management of complications from hyaluronic acid fillers-evidence and opinion-based review and consensus recommendations. Plast Reconstr Surg 137:961e–971eCrossRefGoogle Scholar
  23. 23.
    Carle MV, Roe R, Novack R et al (2014) Cosmetic facial fillers and severe visual impairment. JAMA Ophthalmol 132:637–639CrossRefGoogle Scholar
  24. 24.
    Chesnut C (2018) Restoration of visual loss with retrobulbar hyaluronidase injection after hyaluronic acid filler. Dermatol Surg 44:435–437CrossRefGoogle Scholar
  25. 25.
    Goodman GJ, Clague MD (2016) A rethink on hyaluronidase injection, intraarterial injection, and blindness: Is there another option for treatment of retinal artery embolism caused by intraarterial injection of hyaluronic acid? Dermatol Surg 42:547–549CrossRefGoogle Scholar
  26. 26.
    Foissac R, Kestemont P, Camuzard O (2016) Intravenous hyaluronidase with urokinase as treatment for arterial hyaluronic acid embolism. Plast Reconstr Surg 138:557e–558eCrossRefGoogle Scholar
  27. 27.
    Oh BL, Jung C, Park KH, Hong YJ, Woo SJ (2014) Therapeutic intra-arterial hyaluronidase infusion for ophthalmic artery occlusion following cosmetic facial filler (hyaluronic acid) injection. Neuro-Ophthalmology 38:39–43CrossRefGoogle Scholar
  28. 28.
    Katie B, Carruthers Jean DA, Shannon H, Derek J (2015) Avoiding and treating blindness from fillers: a review of the world literature. Dermatol Surg 41:1097–1117CrossRefGoogle Scholar
  29. 29.
    Narendra K, Eqram R (2017) Effectiveness of teaching facial anatomy through cadaver dissection on aesthetic physicians’ knowledge. Adv Med Educ Pract 8:475–480CrossRefGoogle Scholar
  30. 30.
    Narendra K, Eqram R, Adds Philip J (2018) An effective and novel method for teaching applied facial anatomy and related procedural skills to esthetic physicians. Adv Med Educ Pract 9:905–913CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2019

Authors and Affiliations

  1. 1.Department of Plastic and Reconstructive SurgeryZhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical CollegeHangzhouChina
  2. 2.Woffles Wu Aesthetic Surgery, Camden Medical CentreSingaporeSingapore

Personalised recommendations