Dermal fillers are widely used in aesthetic medicine for rejuvenation, wrinkle smoothing, contouring and soft tissue augmentation of the face. Despite the high safety profile of products based on hyaluronic acid, failure to properly inject the product can lead to serious and sometimes irreversible consequences, such as vision loss. In this article estet-portal.com Dr. Xiu Zhuo Hu et al. present a case of occlusion of the posterior ciliary artery after injections of a hyaluronic acid filler into the forehead area.
- Clinical case: occlusion of the posterior ciliary artery after HA injections
- Discussion of the problem of vascular complications after the administration of gialuronic acid
Clinical case: occlusion of the posterior ciliary artery after HA injections
A woman, 41 years, was admitted to the authors' clinic with a complaint of sudden loss of vision in her right eye. Seven hours earlier, the patient had a correction of the forehead area with a hyaluronic acid filler. The procedure was carried out in a beauty salon.
The patient's medical history is not burdened by ophthalmic, systemic diseases, allergic reactions to drugs and other substances.
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Sudden loss of vision during filler injections was accompanied by severe pain in the eye area. According to the information provided by the injector, the correction was performed with a HA filler with lidocaine and adrenaline for local anesthesia. 2 ml of HA was injected into the right side of the forehead with a 23-gauge blunt cannula.
In order to achieve hemostasis and give the gel the desired shape, the treated area was subjected to external compression, during which the patient developed a sharp pain in her right eye, followed by loss of vision.
Photo 1: patient after HA filler injections in the forehead area
Photo 2: patient 2 weeks after therapy
During the inspection it was found that:
- several areas of darkening have formed on the right side of the forehead, the size of the largest of them – about 8 x 5cm;
- Injection points were well visualized;
- the skin of the back of the nose has acquired a black-violet hue, a slight swelling has appeared;
- Visual acuity at the time of examination: OD – lack of photosensitivity, OS – 20/20;
- edema and ptosis of the right upper eyelid;
- afferent pupillary defect of the right eye;
- optic nerve edema;
- The fundus of the right eye has acquired a pink tint.
Read also: Vascular anatomy of the periorbital zone
Fluorescein angiography results:
- normal perfusion of the central retinal artery;
- several filling defects in the choroidal circulation;
- late choroid hyperfluorescence (T = 11 minutes after fluorescein injection);
- lengthening of the visual evoked potential by P100.
Optical coherence tomography showed thickening of the optic disc.
Despite the high safety of HA-based fillers, in rare cases, irreversible complications may occur after contouring.
The patient was diagnosed with occlusion of the right posterior ciliary artery.
Therapy:
- Injections of hyaluronidase in the total number of 1500 units. in the forehead, between the eyebrows, nose and retrobulbar region;
- aspirin oral;
- acetazolamide, oral;
- dexamethasone intravenously;
- hyperbaric oxygen therapy 2 hours daily.
After 2 weeks the condition of the skin of the forehead and nose improved significantly, visual acuity of the right eye began to recover. During the examination of the fundus, a decrease in edema of the optic nerve head was recorded. A month after the restoration, vision remained unchanged.
Discussion of the problem of vascular complications after the introduction of hyaluronic acid
In the case presented, the patient underwent the procedure in a non-medical institution, however, it was not possible to confirm that the injector had no medical education.
The risk of intravascular injection remains when working with any material, including autologous material.
Vascular occlusion of any type is a medical emergency. Vascular complications that develop after soft tissue fillers are a serious problem, as immediate intervention is required to restore blood circulation in the eye area.
In a retrograde way, the embolus can migrate to the ophthalmic, central retinal artery, or posterior ciliary arteries. This leads to retinal ischemia and necrosis, severe pain in the eye area, loss of vision and other terrifying consequences.
This article presents the first known case of occlusion of the posterior retinal artery after HA filler injections in the forehead, between the eyebrows and nose. Branches of the supraorbital, supratrochlear and dorsal nasal arteries pass through these zones.
Read also: A new method of using hyaluronidase for vision loss after hyaluronic acid injections
The risk of vision loss is associated with 3 factors:
- retrograde material movement;
- high pressure during injection;
- large amount of material in the vessel lumen.
The force applied during the administration of the product may cause dilation of the arterioles. When the pressure during injection exceeds the systolic pressure, the embolus begins to move retrograde. In this case, this resulted in occlusion of the posterior ciliary artery. It is unlikely that the migration of the embolus was caused by pressure on the treated area after the injection.
Fig. 1: arteries of the periorbital zone – 1) supratrochlear, 2) supraorbital; 3) continuation of the ophthalmic artery; 4) dorsal artery of the nose; 5) posterior deep temporal artery; 6) anterior deep temporal artery; 7) lacrimal artery; 8) superficial temporal; 9) back ciliary; 10) central retinal artery.
Injectable fillers can be used in any anatomical area, however, work in some of them is associated with a high risk of complications. Interbrow – the most dangerous area in terms of risk of loss of vision, followed by the nose, forehead and periorbital area.
This is why it is important to observe safety rules during injections:
- inject the filler slowly;
- inject the minimum amount of product while withdrawing the cannula;
- take all measures aimed at preventing intravascular administration of the drug.
You may also be interested in: First aid for central retinal artery occlusion after fillers
Remember that blindness – a very rare, but extremely dangerous and in most cases irreversible complication of filler injections, including hyaluronic acid. Therefore, the practitioner should be aware of the risk of arterial occlusion, symptoms and diagnostic methods, as well as recommendations for the management of this complication.
Adapted from Medicine.
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