Ophthalmic complications of injectable facial fillers

Abstract

The recently published mini-review article by Miotti et al is an effort to clarify various aspects regarding the choice between fat grafts and fillers in facial aesthetic surgery. One of the complications associated with the administration of fillers is the possibility of vascular injury and spread of the dermal filler into the orbit, causing unexpected effects at a site distant from that of the initial injection, including ophthalmoplegia, ptosis and even visual compromise. Acute vision loss following filler injection is a devastating complication, occurring in up to 0.0008% of cases. The greatest risk of this complication occurs with nasal augmentation, followed by glabellar wrinkle treatment. While injected autologous fat predominantly occludes the proximal portion of the ophthalmic artery, hyaluronic acid fillers obstruct the ophthalmic artery comparatively distally. Treatment interventions include thrombolysis, hyperbaric oxygen therapy, oral aspirin, cobamamide and acetazolamide and administration of corticosteroids. However, most studies show a poor prognosis in the form of partial or no recovery of vision. Hence, prevention is of paramount importance. A high index of suspicion is also warranted on the part of both those administering as well as receiving injections of facial fillers to prevent potentially vision-threatening complications of this seemingly innocuous procedure.

Key Words: Adverse effects; Blindness; Cosmetic techniques; Dermal drug administration; Hyaluronic acid; Iatrogenic disease

Core Tip: The recently published mini-review article by Miotti et al is an effort to clarify various aspects regarding the choice between fat grafts and fillers in facial aesthetic surgery. One of the complications associated with the administration of fillers is the possibility of vascular injury and spread of the dermal filler into the orbit, causing unexpected effects at a site distant from that of the initial injection, including ophthalmoplegia, ptosis and even visual compromise. Acute vision loss following filler injection is a devastating complication, occurring in up to 0.0008% of cases.

TO THE EDITOR

We read with great interest the recently published mini-review article by Miotti et al[1] and congratulate the authors on their effort to clarify various aspects regarding the choice between fat grafts and fillers in facial aesthetic surgery. The authors have comprehensively reviewed the literature, presented the pros and cons of surgical grafting of dermal fat, and compared and contrasted them with those of injectable fat or dermal fillers[1].

One of the most important advantages of injectable fat or fillers, as correctly highlighted by the authors, is their ability to be administered in a minimally invasive manner, leading to their increasingly widespread use and acceptance in the modern era[1]. However, every such procedure comes with its risks. Given the level of treatment customization associated with aesthetic procedures, the onset and presentation of these complications may vary and must be recognized for early treatment[2]. The authors have presented a brief account of the complications encountered in patients undergoing filler injections[1]. We would like to add to the authors’ comments by highlighting the complications of facial filler injection from an ophthalmological point of view.

Signorini et al[3] have provided a consensus statement on the classification of soft-tissue filler complications based on the period of onset of the adverse event – either early or late. Most early complications are either related to cutaneous necrosis, inflammation, injection-related events or inappropriate, often superficial placement of the filler material[3]. Additionally, one of the complications is the possibility of vascular compromise and the spread of the dermal filler. Retrograde intravascular embolization of the injected filler material into the orbit may cause unexpected complications at a site distant from that of the initial injection including ophthalmoplegia, ptosis and even visual compromise[4]. Arterial occlusion presents with immediate or early symptoms and signs, while venous occlusion can present late[2,4,5].

Acute vision loss following filler injection is a devastating complication, occurring in up to 0.0008% of cases as per current literature[6]. This condition, termed ‘aesthetic interventional-induced visual loss’ (AIIVL), is usually associated with a poor visual prognosis[7,8]. A review of published case reports of filler-induced visual compromise has shown that the greatest risk of this complication occurs with nasal augmentation, followed by glabellar wrinkle treatment[2]. The periocular area is especially risky as branches of the ophthalmic artery anastomose with several superficial arteries of the face[8].

The most widely identified pathophysiologic change associated with vision loss due to filler injection is the diffuse occlusion of the ophthalmic artery and its branches, manifesting as diminished retino-choroidal blood flow demonstrable on fluorescein angiography. While injected autologous fat predominantly occludes the proximal portion of the ophthalmic artery, hyaluronic acid fillers obstruct the ophthalmic artery comparatively distally because of the difference in size of the injected particles. Administration of both may be also associated with acute multifocal cerebral embolic infarction independently[6].

Treatment interventions for AIIVL include high-dose pulse hyaluronidase (HDPH), gonio massage, thrombolysis, hyperbaric oxygen therapy, oral aspirin, cobamamide, acetazolamide and corticosteroids including intravenous dexamethasone, among other trial therapies. However, most studies show partial or no recovery of vision despite best efforts. Hence, the prevention of this devastating complication is of paramount importance[6,9].

Heydenrych et al[9] have presented a ten-point plan for the prevention of dermal filler complications based on consideration of factors related to patient, product and procedure. Briefly, the points to be remembered are the patient history and case selection, insightful assessment of the clinical condition and patient expectations, informed consent, consideration of reversibility of effect (e.g. by hyaluronidase), placement based on product properties (concentration and rheologic properties, and the manufacturing processes), layering of filler substances, complete and photographic documentation of the procedure, proper planning and aseptic technique, knowledge of facial anatomy as well as adopting a slow, careful, and methodical injection technique[3,9,10].

Specifically, the important prophylactic and precautionary measures include an emphasis on avoidance of the procedures in patients with tendency toward hypertrophic scarring or keloid formation. Any infection, bleeding break, and immunocompromise must be excluded. History of any previous injection(s) must be recorded[11,12].

Care should be taken to follow strict sterile aseptic techniques in preparing the filler injection and injecting it, as the tendency towards infection is heightened in the presence of a foreign body such as a filler. All overlying cosmetics should be removed prior to any injection. The overlying skin and appendages should be well-cleaned with an antiseptic-disinfectant such as chlorhexidine gluconate prior to and following the injection. Patients with a history of herpes simplex should be pretreated with oral acyclovir or valacyclovir to prevent reactivation of viral eruptions by the filler injection. Any active acne or skin infection should be treated prior to the injection, and injection into any such active lesion must be avoided[11,12].

Prior to the injection, patient identification should be verified with the clinical record and the plan. Documentation of the main reason for consultation and duration of the problem, family history, psychosocial history and proper counseling and consent with patient motivation, realistic patient expectations, level of education, nature of work, and hygiene conditions should be confirmed. Medical history regarding allergies, immunological diseases, herpes, current diseases and therapy, and surgical history regarding systemic, ocular, and aesthetic treatments, infections, dental history, active skin infections or inflammations must also be documented[11,12].

Well-focused pre- and post-treatment photographs help in assessment of treatment and adverse effects which are required for medicolegal purposes. Ultrasonography with Doppler delineates the tissue planes and blood vessels well and can guide filler choice and injection placement as well as monitor the injected area for complications[11,12].

Injection technique should be optimized with usage of smaller gauge needles or cannulas. Filler stacking and large volume filler injection have also been associated with an increased inflammatory response. Correct placement and correct plane of injection avoid complications like persistent hyperemia, skin necrosis or vascular compromise. The depth and course of the facial blood vessels should be considered before injection, with emphasis on watershed areas supplied by a single artery[11,12].

The post-injection period is crucial, as these injections are performed as outpatient procedures. There may be a considerable time gap between the initial procedure and the onset of orbital complications. Patients and aesthetic surgeons must be warned to immediately recognize the relationship between the injection of filler and any complication to avoid delays in diagnosis[4]. Clinical examination of patients presenting with vision loss with a history of facial filler injections must always direct treating physicians to urgently identify the filler and provide targeted therapy in addition to general measures[13].

In conclusion, a high index of suspicion is warranted on the part of both those administering as well as receiving injections of facial fillers to prevent potentially vision-threatening complications of this seemingly innocuous procedure. Apart from this, past history of filler-related complications, presence of any risk factor predisposing to complications, appropriate injection techniques, early diagnosis and management of complications and patient education are some important aspects of aesthetic procedures need to be considered by aesthetic surgeons practicing in this field.