The aim of the present study was to review concomitant symptoms following cases of vision loss after hyaluronic acid filler injection and to classify patients on the basis of clinical manifestations, disease course, and prognosis.
PATIENTS AND METHODS
From September of 2012 to August of 2015, a total of nine patients with vascular occlusion were eligible for study enrollment. The eligibility criteria were as follows: (1) a history of receiving hyaluronic acid filler injection, (2) blindness and periocular symptoms occurring right after filler injection, and (3) symptoms limited to one eye, for comparison with the unaffected contralateral side.
All nine patients were female, ranging in age from 26 to 45 years (mean, 31.5 years). The types of injected hyaluronic acid fillers were Restylane (Galderma S.A., Lausanne, Switzerland) in four cases, Yvoire (LG LifeSciences, Seoul, Republic of Korea) in three cases, and Juvéderm (Allergan, Inc., Irvine, Calif.) and Neuramis (Medytox, Inc., Seoul, Republic of Korea) in one case each. All nine patients received injection directly by needle puncture, and injected quantities varied from 0.1 cc to over 1 cc, and in all cases hyaluronic acid fillers were injected by doctors, including board-certified plastic surgeons and dermatologists. Injection sites were the glabella (n = 5), nasolabial fold (n = 3), and nasal dorsum (n = 3), as two patients received injections to both the glabella and nasal dorsum area. The minimum follow-up period was 6 months.
Type I: Blindness without Ophthalmoplegia and Ptosis
Type I patients experienced vision loss from ophthalmic and central retinal artery occlusion. However, ptosis was absent because of preserved levator function, and eyeball movement was possible in every direction. In addition, no difference was noted in thalmometry, and no sign of enophthalmos was found (Fig. 1). Two of nine patients (22 percent) were classified as type I, and during the 6-month follow-up period there were no signs of ptosis, ophthalmoplegia, or enophthalmos.
Type II: Blindness with Ptosis but without Ophthalmoplegia
Type II patients experienced ptosis with blindness in the affected eye that was not accompanied by extraocular muscle weakness or eyeball movement limitation. Two patients were categorized as type II. On exophthalmometry, no difference between the two eyes (21/21 mm) was noted on the initial visit immediately after vascular occlusion injury, but after 6 months, the left eyeball demonstrated an average 1-mm posterior displacement compared with the uninvolved contralateral side (21/20 mm). By contrast, levator function of the patient showed dramatic improvement 6 months after injury, and eyeball movement remained normal during the follow-up period (Fig. 2).
Type III: Blindness with Ophthalmoplegia but without Ptosis
Patients with blindness and ophthalmoplegia but with preserved levator function were classified as type III. Although marginal retinal distance decreased because of corneal edema, there was no deficit in levator function, and normal voluntary lid opening was observed. However, eyeball movement was not possible on upward/downward gaze or lateral gaze. At 6 months after initial injury, ophthalmoplegia was improved, and no difference was apparent compared to the contralateral side. Two patients were categorized as type III. Enophthalmos assessed 6 months after injury indicated an average 1-mm posterior displacement, compared to symmetric eyeball position immediately after initial occlusion injury (Fig. 3).
Type IV: Blindness with Ophthalmoplegia and Ptosis
Type IV patients demonstrated the most severe presentation of extraocular manifestations, as severe ptosis and ophthalmoplegia were combined with blindness after arterial occlusion. Three patients were categorized as type IV. Photographs of the nine gaze positions taken 1 day after the injury showed weakened ocular movement in every direction, and the patients were also unable to open affected eyelids voluntarily. Exophthalmometry showed no difference (19/19 mm) compared to the contralateral side at the initial visit. Six months after the initial injury, levator function and extraocular muscle tone were recovered to normal levels, but enophthalmos (19/17 mm) of 2-mm posterior displacement was present in the injured left eye (Fig. 4).
This report reviews our experience of nine cases of severe blindness after hyaluronic acid filler injection in a single institution and, for the first time, presents a classification and prediction of the prognosis of periocular symptoms combined with vision loss after vascular occlusion. It is likely that the majority of retinal and ophthalmic artery occlusions are initiated from vessels located near the glabella.1
Occlusion of the central retinal artery leads to loss of vision, and ischemic injury to the posterior ciliary artery can lead to choroidal malfunction. In addition, on disturbed flow of the superior and inferior muscular branches, ophthalmoplegia and strabismus can arise because of malfunction of the extraocular muscles.2 Furthermore, various ocular symptoms can arise from vascular occlusion of different branches that supply the eyelid, conjunctiva, lacrimal gland, and orbital fat.3 There have been many trials to save vision in cases of vascular occlusion, but until now no effective therapeutic measure has been reported.4,5
On the basis of previously reported case series, improvement of visual acuity in patients with vascular occlusion after filler injection is extremely rare, and there has been no total recovery of vision after initial injury.5,6 By contrast, periocular symptoms such as ptosis and ophthalmoplegia recovered dramatically during the follow-up period, and almost all of the patients in this case series experienced total recovery of ptosis and ophthalmoplegia except for one type IV patient with persistent mild strabismus.
Although other periocular symptoms were relieved over time, the position of the involved eyeball continued to descend, and also enophthalmos that was not checked during the early stages of injury showed progression during the follow-up period. Enophthalmos did not develop in type I patients who had no ptosis or ophthalmoplegia, but type II and III patients who had ptosis or ophthalmoplegia combined with vision loss demonstrated average enophthalmos of 1 mm. Type IV patients (n = 3) suffered from enophthalmos with an average of 1.7-mm displacement developed during follow-up. Although the progression of enophthalmos changed gradually according to the severity of periorbital symptoms, there was no improvement of visual acuity. Hazani and Yaremchuk reported that if enophthalmos greater than 2 mm develops at any time within 6 weeks after injury, surgical correction should be considered.7 A more accurate understanding of symptom progression will be possible with the analysis of additional cases, and additional anatomical evidence should also be studied in the future.8
Patients provided written consent for the use of their images.
1. Gladstone HB, Cohen JL. Adverse effects when injecting facial fillers. Semin Cutan Med Surg. 2007;26:34–39.
2. Kwon SG, Hong JW, Roh TS, Kim YS, Rah DK, Kim SS. Ischemic oculomotor nerve palsy and skin necrosis caused by vascular embolization after hyaluronic acid filler injection: A case report. Ann Plast Surg. 2013;71:333–334.
3. Park KH, Kim YK, Woo SJ, et al; Korean Retina Society. Iatrogenic occlusion of the ophthalmic artery after cosmetic facial filler injections: A national survey by the Korean Retina Society. JAMA Ophthalmol. 2014;132:714–723.
4. Suga H, Eto H, Aoi N, et al. Adipose tissue remodeling under ischemia: Death of adipocytes and activation of stem/progenitor cells. Plast Reconstr Surg. 2010;126:1911–1923.
5. Li X, Du L, Lu JJ. A novel hypothesis of visual loss secondary to cosmetic facial filler injection. Ann Plast Surg. 2015;75:258–260.
6. Carle MV, Roe R, Novack R, Boyer DS. Cosmetic facial fillers and severe vision loss. JAMA Ophthalmol. 2014;132:637–639.
7. Hazani R, Yaremchuk MJ. Correction of posttraumatic enophthalmos. Arch Plast Surg. 2012;39:11–17.
8. Carruthers JD, Fagien S, Rohrich RJ, Weinkle S, Carruthers A. Blindness caused by cosmetic filler injection: A review of cause and therapy. Plast Reconstr Surg. 2014;134:1197–1201.