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Retro or PeriBulbar Injection Techniques to Reverse Visual Loss After Filler Injections

Carruthers, Jean MD*; Fagien, Steven MD; Dolman, Peter MD*

doi: 10.1097/DSS.0000000000000558
Original Article
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BACKGROUND With the increasing popularity of three dimensional filler treatments, the tip of the injecting needle or cannula is subdermal, often adjacent to the facial vasculature. Inadvertent canalization of these vessels can rarely result in vascular occlusion with consequent blindness or stroke.

OBJECTIVE The goal was to demonstrate a technique of retro or peribulbar injection of hyaluronidase should such an emergency arise if no ophthalmologist was immediately available. The treatment is needed urgently because the retina can only withstand up to 90 minutes of hypoxia.

MATERIALS AND METHODS We present verbal and diagrammatic instructions for this treatment and videos of both the retrobulbar technique (courtesy of Dr. D. Maberley) and peribulbar technique (courtesy of Dr. S. Fagien).

RESULTS None of us have yet used this technique to treat iatrogenic filler induced blindness but we present the information for the benefit of patient safety, given the limited time the retina can survive vascular occlusion.

CONCLUSION Inadvertent canalization of facial vessels can cause embolic occlusion of retinal vasculature because of the anastomotic nature of the facial vasculature and the end artery morphology of the retinal circulation. Embolism from 3-dimensional hyaluronic acid filler use is potentially reversible if hyaluronidase is injected into the adjacent tissue.

*University of British Columbia, Department of Ophthalmology, Vancouver, Vancouver, British Columbia, Canada

Private Practice, Oculoplastic Surgery, Boca Raton, Florida

Address correspondence and reprint requests to: Jean Carruthers, MD, Suite820-943 West Broadway, Vancouver, British Columbia V5Z4E1, Canada, or e-mail: drjean@carruthers.net

The authors have indicated no significant interest with commercial supporters.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the full text and PDF versions of this article on the journal's Web site (www.dermatologicsurgery.org).

Blindness from injection of 3-dimensional fillers was first reported in 19061 and since then there have been 98 cases reported in the English literature.2 This is likely an underreported event as the reports are largely written by the physicians who have managed the vision loss and not by the physician injectors. From these publications, it seems that most of the case load is from the past 5 years when cosmetic filler injections have become increasingly popular. This concern has prompted the recent FDA Safety Communication (May 2015).3

Autologous fat injection alone accounts for almost half of the cases of blindness, and to date, these have been universally irreversible. Fortunately, some cases of vision loss from hyaluronic acid have been partially reversed.

It has been shown that embolic occlusion of arteries supplying the eye must be reversed within 90 minutes to avoid permanent visual loss.4 In cases where injectable hyaluronic acid gel is used in the periorbital region and acute visual loss is encountered from a presumed intravascular occlusive event, the authors propose the injection of high-dose hyaluronidase by the retrobulbar or peribulbar route5. In vitro investigation has shown that hyaluronidase will “dissolve” intravascular hyaluronic acid gel even if it is injected adjacent to the occluded vessel,6 suggesting that delivery of the enzyme adjacent to the blocked vessel (rather than within its lumen) may be sufficient to relieve the obstruction.

This article describes the relevant periocular anatomy and the techniques for retrobulbar and peribulbar injection of hyaluronidase for those physicians who encounter a case of visual loss during a hyaluronic filler injection and do not have an experienced ophthalmologist immediately available.7

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Material and Methods

Relevant Anatomy

The orbit is a conical structure with its wider end pointing anteriorly. The cone is 42 to 54 mm deep in adults. The globe sits in the anterior half of the orbit and its axial length in adults is 20 to 25 mm. The roof is composed of the frontal and sphenoid bones and the optic canal, and contains the optic nerve and ophthalmic artery. The lateral wall of the orbit is composed of zygomatic and sphenoid bones. The orbital floor is composed of the maxilla, zygomatic, and palatine bones.

The medial orbital wall (ethmoid, lacrimal, and frontal bones) is very thin and is composed mainly of the lamina papyracea of the ethmoid.

The retrobulbar space is thus approximately 25 + mm behind the anterior orbital margin. The 4 recti muscles extend from the orbital apex and merge with the sclera of the globe. The optic nerve passes within the muscle cone from the optic foramen to the back of the globe within this muscle cone (Figures 13). Thus the retrobulbar space is immediately posterior to the globe. The ophthalmic and central retinal arteries pass within the fascia of the optic nerve to the globe. Delivering hyaluronidase to the retrobulbar space will allow the enzyme to dissolve the intravascular hyaluronic acid embolus.

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

The internal carotid artery gives off the ophthalmic artery, which enters the orbital apex through the optic canal with the optic nerve. The central artery of the retina is an end artery that branches from the ophthalmic artery and runs forward within the dural sheath of the optic nerve.

Blood drains from the orbit through the superior and inferior orbital veins. The former drains into the cavernous sinus, whereas the latter drains into the inferior petrosal sinus.

The inferotemporal quadrant of the orbit is relatively less vascular than other quadrants and thus is the safest route for retrobulbar injection.

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Technique of Retrobulbar Injection

This outlines the steps in a retrobulbar injection in the event of an acute vision loss because of 3-dimensional filler injection, where an ophthalmologist is not immediately available (see Supplemental Digital Content 1, Video 1, http://links.lww.com/DSS/A25).

  • (1) Documentation of the loss of visual acuity including demonstration of relative afferent pupil defect.
  • (2) Informed consent.
  • (3) Topical anesthesia using tetracaine 0.5% or other topical anesthetic drops for transconjunctival injections.
  • (4) Injection of a bleb of 0.1–0.2 mL of lidocaine 1% in the lower eyelid skin midway between the central and lateral lower eyelid if the retrobulbar injection is to be performed from the skin surface.
  • (5) Use of a 25-gauge 1.5-inch long needle with syringe loaded with hyaluronidase, at least 500 units.
  • (6) Gentle advancement of the needle in the inferotemporal quadrant of the orbit, aiming the needle parallel to the orbital floor for the first half inch and then aiming it to the space immediately posterior to the globe. The needle can be gently wiggled in the horizontal plane while the patient looks slightly upward to ensure that the globe or optic nerve are not being engaged by the moving needle.
  • (7) Gentle depression of the plunger to deliver the hyaluronidase into the retrobulbar space. The white orbit is deeper than the Asian orbit, and the female orbit is shallower than the male. Between 3 and 8 mLs of enzyme is injected.
  • (8) Documentation of change in visual acuity. Possible reinjection if required.
  • (9) Urgent referral to an experienced ophthalmologist or oculoplastic surgeon for participation in ongoing management.
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Technique of Peribulbar Injection

  • (1) to (3) as above (see Supplemental Digital Content 2, Video 2, http://links.lww.com/DSS/A26).
  • (4) A short 1″ to 1.5″ 25-g needle is introduced by a transconjunctival approach as the nondominant hand stabilizes the patient's head and, at the same time, retracts the upper and lower eyelid.
  • (5) The needle is passed into the lower conjunctival fornix introducing the needle at the mid orbit while advancing the needle along the periosteum. This approach places the needle most distant from the globe.
  • (6) A 4-8 mL of at least 500 units of hyaluronidase is injected in a bolus fashion.
  • (7) to (9) as above.
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Discussion

Ideally catastrophic iatrogenic blindness from 3-dimensional fillers should never occur, but this complication is more likely with increasing the use of these agents by those less familiar with the periocular vascular anatomy. As the central retinal artery is an end artery, there are no communicating vessels, which could assist with retinal perfusion. Using hyaluronic acid fillers in the mid face and periocular region makes sense because they are potentially reversible with enzymatic degradation by Hyaluronidase. With some filling agents such as autologous fat, restoration of occluded retinal circulation has never been reported.

The authors recommend that dermatologists, plastic surgeons, ophthalmologists, and all cosmetic physicians who inject 3-dimensional fillers should be educated about the risk of sudden visual loss from intravascular occlusion from periorbital fillers. Immediate retrobulbar injection of hyaluronidase may partially reverse this. Ideally, the injecting physician should have a relationship with an ophthalmology colleague willing to assist immediately should a retrobulbar injection be needed. As well, the injecting physician should familiarize themselves with the variations in vascular anatomy8 and with a safe retrobulbar injection technique as outlined in this article, in case an ophthalmologist is not immediately available.

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Acknowledgment

With thanks to David Maberley, MD, for permitting the authors to videotape his injection technique.

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References

1. Brawley FE. Injury to the eyes after paraffin injection for saddle nose. Ophthalmic Record 1906;15:115–6.
2. Beleznay K, Carruthers J, Humphrey S, Jones D. Avoiding and treating blindness from fillers: a review of the world literature. Dermatol Surg 2015;41:1097–117.
3. FDA Safety Communication. Unintentional injection of soft tissue filler into blood vessels in the face. 2015. Available at: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm448255.htm. Accessed May 28, 2015.
4. Hayreh SS, Podhajsky PA, Zimmerman B. Nonarteritic anterior ischemic optic neuropathy: time of onset of visual loss. Am J Ophthalmol 1997;124:641–7.
5. Carruthers JD, Fagien S, Rohrich RJ, Weinkle S, et al.. Blindness caused by cosmetic filler injection: a review of cause and therapy. Plast Reconstr Surg 2014;134:1197–201.
6. DeLorenzi C. Complications of injectable fillers, part I. Aesthet Surg J 2013;33:561–78.
7. Almeida DR, Belliveau MJ, Enright T, Islam O, et al.. Anatomic distribution of gadolinium contrast medium by high-resolution magnetic resonance imaging after peribulbar and retrobulbar injections. Arch Ophthalmol 2012;130:743–8.
8. Kim YS, Choi DY, Gil YC, Hu KS, et al.. The anatomical origin and course of the angular artery regarding its clinical implications. Dermatol Surg 2014;40:1070–6.

Supplemental Digital Content

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© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.