0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Brief Report |

Cosmetic Facial Fillers and Severe Vision Loss FREE

Michelle V. Carle, MD1; Richard Roe, MD, MHS1; Roger Novack, MD, PhD1; David S. Boyer, MD1
[+] Author Affiliations
1Retina-Vitreous Associates Medical Group, Los Angeles, California
JAMA Ophthalmol. 2014;132(5):637-639. doi:10.1001/jamaophthalmol.2014.498.
Text Size: A A A
Published online

Importance  Dermal injection of cosmetic fillers can lead to irreversible blindness when injected in the forehead, and this possible adverse effect is not typically mentioned to patients.

Observations  Vision loss from central retinal artery occlusion occurring, after cosmetic facial enhancement, was irreversible in 3 patients. However, 1 patient had a small amount of recovery with aggressive therapy.

Conclusions and Relevance  Cosmetic facial fillers are not approved for use in the forehead, but off-label use for enhancement in this region is common. To our knowledge, there have been no prior reports of blindness caused by filler injected into the forehead. We present findings of central retinal artery occlusion due to fillers in 3 patients shortly after their cosmetic procedures. The filler presumably enters the central retinal artery via the rich external-internal carotid anastomoses and becomes embedded in the retinal tissues, potentially leading to irreversible and severe vision loss. Physicians performing cosmetic enhancement procedures involving facial fillers need to be aware of this potential complication and should include significant vision loss as a possible rare complication.

Figures in this Article

Injection of dermal fillers for facial rejuvenation is a minimally invasive procedure frequently used in cosmetic procedures. Different types of dermal fillers injected include autologous fat, collagen, hyaluronic acid, polylactic acid, calcium hydroxylapatite, and polymethylmethacrylate. Complications from these procedures are rare but have been reported to include blindness, cerebral ischemic events, and even death. We describe 3 patients who presented with sudden loss of vision after injection of 3 different dermal fillers into the forehead area. In all 3, occlusions in the distal ophthalmic artery distribution were subsequently diagnosed.

Patient 1

A healthy man in his late 30s presented 3 weeks after he noticed superior field visual loss in his left eye the day after an injection of a hyaluronic acid filler injection to his forehead. At the initial visit, his visual acuity was 20/20 OD and 20/30 OS. Dilated fundus examination of the left eye revealed retinal edema and whitening in the inferotemporal macula consistent with a branch retinal artery occlusion. The whitening extended to the fovea, and a partial cherry-red spot was seen in the central macula, along with scattered intraretinal hemorrhage (Figure 1A). Fluorescein angiography demonstrated blockage of the inferior branches of the retinal circulation in the left eye and areas of patchy choroidal nonperfusion (Figure 1B).

Place holder to copy figure label and caption
Figure 1.
Early and Late Imaging Findings After Injection of a Hyaluronic Acid Filler to the Forehead in Patient 1

A, Color fundus photograph of the left eye demonstrates a partial cherry-red spot in the central macula and scattered intraretinal hemorrhage. B, Fluorescein angiography (FA) of the left eye demonstrates blockage of the inferior branches of the retinal arteries and patchy choroidal nonperfusion. ICG indicates indocyanine green. C, Ocular coherence tomography of the left eye, 1 year later, demonstrates retinal thinning starting just below the fovea. ILM indicates internal limiting membrane; RPE, retinal pigment epithelium.

Graphic Jump Location

One year later, the patient continued to experience a superior visual field defect in the left eye. His visual acuity was 20/25 OS. Optical coherence tomography demonstrated selective retinal thinning of the inferior macula (Figure 1C).

Patient 2

A healthy woman in her early 60s presented the same day she experienced severe loss of vision, which occurred immediately after autologous fat injection into the high part of her forehead; the needle marks were visible just below the hairline. Her visual acuity was no light perception OD and 20/40 OS. Dilated fundus examination of the right eye revealed diffuse whitening of the retina, as well as lipid-filled arterioles (Figure 2A). Fluorescein angiography demonstrated patchy choroidal filling and incomplete filling of the retinal arterioles in the later frames (Figure 2B and C). A complete blood cell count was obtained, with differential count, erythrocyte sedimentation rate, and C-reactive protein level; all values were within normal limits. Carotid Doppler ultrasonography and cardiac echocardiography revealed no abnormalities.

Place holder to copy figure label and caption
Figure 2.
Imaging Findings the Same Day as Injection of Autologous Fat to the Forehead in Patient 2

A, Color fundus photograph of the right eye reveals diffuse retinal whitening and lipid filled arterioles. B, Fluorescein angiography of the right eye in an early frame demonstrates delayed patchy choroidal filling. C, Later frame of the fluorescein angiogram demonstrates incomplete filling of the retinal arteries and patchy choroidal filling.

Graphic Jump Location
Patient 3

A healthy woman in her mid-40s presented to the clinic after having received an injection of bovine collagen and polymethylmethacrylate microspheres (Artefill; Suneva) to her forehead creases that morning. After the injection was complete, she opened her eyes and could not see with her right eye. Her visual acuity was no light perception OD and 20/20 OS. A right afferent pupillary defect was demonstrated. Dilated fundus examination showed a cherry-red spot and retinal edema, in keeping with a central retinal artery occlusion (Figure 3A). Fluorescein angiography demonstrated delayed filling of some of the proximal arteries in the right eye, but the filling was patchy (Figure 3B and C).

Place holder to copy figure label and caption
Figure 3.
Imaging Findings the Same Day as Injection of Bovine Collagen and Polymethylmethacrylate Microspheres in Patient 3

A, Color fundus photograph of the right eye shows retinal whitening and a cherry-red spot in the central macula. B, Fluorescein angiography of the right eye in an early frame demonstrates patchy choroidal filling and some delayed proximal filling of the arteries on the disc. C, Later frame of the fluorescein angiogram demonstrates incomplete filling of proximal arteries only.

Graphic Jump Location

Because this was an acute presentation, we performed anterior chamber paracentesis and removed 0.1 mL of aqueous to rapidly lower the intraocular pressure. In the clinic, the patient received a liter of normal saline solution intravenously and underwent ocular massage; she was then transferred to receive hyperbaric oxygen therapy. Two days later, her right pupil was minimally reactive to light and her visual acuity was faint light perception OD.

Owing to the rich extensive anastomotic network between the internal and external carotid circulations in and around the ocular area, any injection done in that anatomical area poses a risk of material entering the ophthalmic artery, presumably via retrograde flow from the supratrochlear, supraorbital, and dorsal nasal artery. This phenomenon of injectable material flowing from the external carotid circulation to the ophthalmic circulation via high-pressure retrograde flow has been identified several times when corticosteroid and autologous fat emboli entered into the retinal circulation.1,2 Hyaluronic acid–based filler has also been reported to enter the ophthalmic circulation via the external carotid circulation after high-pressure injection.3 Injected emboli have been reported to enter the ophthalmic circulation from the nasolabial folds4; from glabellar,2 intranasal,1 and periocular5 sites; and now, with our series, from the forehead.

Any substance injected at high pressure into the oculofacial area, including the forehead, can result in occlusion of the central or branch retinal artery or the posterior ciliary circulation, both of which branch from the ophthalmic artery. The presentation of central or branch retinal artery occlusion is distinct and classic, with sudden loss of vision, retinal whitening, and a cherry-red spot. In the case of solely posterior circulation occlusion, the fundus appears normal in the setting of sudden visual loss, but fluorescein angiography reveals choroidal filling defects. All 3 of our patients had both choroidal filling defects and retinal arterial involvement.

In the setting of sudden vision loss, one must consider the possibility of vasculitis (and giant cell arteritis in older patients) and carotid and cardiac embolic sources. A recent injection of cosmetic facial filler in an otherwise healthy individual can be considered causative when laboratory and cardiovascular examination findings are normal. Although uncommon, retrograde flow of foreign material into the ophthalmic artery from the external carotid circulation must be considered in this setting.

Our case series represents both retinal arterial and choroidal artery occlusions from a variety of fillers injected into the forehead region. The indication for fillers are limited to the nasolabial folds and lips by the manufacturers, yet they are often used in other areas. A review of the product and safety information from the manufacturers for many fillers indicates that safety has been established only in specific facial regions (varying by product, but generally the nasolabial folds or lips).

The visual effects of arterial occlusion by filler are devastating and irreversible in otherwise healthy patients. It is imperative that any physician considering injection of facial fillers carefully consider the location of the injection and respect the rich anastomotic vascular supply of the periocular region. Ocular arterial occlusion is an uncommon adverse effect of these treatments, but it can be a devastating consequence of injection into areas of rich anastomoses (much of the periocular region). We recommend that blindness or significant visual loss be added as a risk when discussing these procedures with patients, because these are devastating consequences.

Submitted for Publication: August 22, 2013; final revision received October 20, 2013; accepted November 4, 2013.

Corresponding Author: Richard Roe, MD, MHS, Retina-Vitreous Associates Medical Group, 1127 Wilshire Blvd, Ste 1620, Los Angeles, CA 90017 (roe.rick@laretina.com).

Published Online: March 6, 2014. doi:10.1001/jamaophthalmol.2014.498.

Author Contributions: Dr Carle had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Carle, Roe, Novack.

Acquisition of data: Roe, Novack, Boyer.

Analysis and interpretation of data: Carle, Roe, Novack.

Drafting of the manuscript: Carle, Novack.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: Boyer.

Study supervision: Roe, Novack.

Conflict of Interest Disclosures: None reported.

Whiteman  DW, Rosen  DA, Pinkerton  RM.  Retinal and choroidal microvascular embolism after intranasal corticosteroid injection. Am J Ophthalmol. 1980;89(6):851-853.
PubMed
Dreizen  NG, Framm  L.  Sudden unilateral visual loss after autologous fat injection into the glabellar area. Am J Ophthalmol. 1989;107(1):85-87.
PubMed
Peter  S, Mennel  S.  Retinal branch artery occlusion following injection of hyaluronic acid (Restylane). Clin Experiment Ophthalmol. 2006;34(4):363-364.
PubMed   |  Link to Article
Park  SH, Sun  HJ, Choi  KS.  Sudden unilateral visual loss after autologous fat injection into the nasolabial fold. Clin Ophthalmol. 2008;2(3):679-683.
PubMed
Lee  CM, Hong  IH, Park  SP.  Ophthalmic artery obstruction and cerebral infarction following periocular injection of autologous fat. Korean J Ophthalmol. 2011;25(5):358-361.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.
Early and Late Imaging Findings After Injection of a Hyaluronic Acid Filler to the Forehead in Patient 1

A, Color fundus photograph of the left eye demonstrates a partial cherry-red spot in the central macula and scattered intraretinal hemorrhage. B, Fluorescein angiography (FA) of the left eye demonstrates blockage of the inferior branches of the retinal arteries and patchy choroidal nonperfusion. ICG indicates indocyanine green. C, Ocular coherence tomography of the left eye, 1 year later, demonstrates retinal thinning starting just below the fovea. ILM indicates internal limiting membrane; RPE, retinal pigment epithelium.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Imaging Findings the Same Day as Injection of Autologous Fat to the Forehead in Patient 2

A, Color fundus photograph of the right eye reveals diffuse retinal whitening and lipid filled arterioles. B, Fluorescein angiography of the right eye in an early frame demonstrates delayed patchy choroidal filling. C, Later frame of the fluorescein angiogram demonstrates incomplete filling of the retinal arteries and patchy choroidal filling.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Imaging Findings the Same Day as Injection of Bovine Collagen and Polymethylmethacrylate Microspheres in Patient 3

A, Color fundus photograph of the right eye shows retinal whitening and a cherry-red spot in the central macula. B, Fluorescein angiography of the right eye in an early frame demonstrates patchy choroidal filling and some delayed proximal filling of the arteries on the disc. C, Later frame of the fluorescein angiogram demonstrates incomplete filling of proximal arteries only.

Graphic Jump Location

Tables

References

Whiteman  DW, Rosen  DA, Pinkerton  RM.  Retinal and choroidal microvascular embolism after intranasal corticosteroid injection. Am J Ophthalmol. 1980;89(6):851-853.
PubMed
Dreizen  NG, Framm  L.  Sudden unilateral visual loss after autologous fat injection into the glabellar area. Am J Ophthalmol. 1989;107(1):85-87.
PubMed
Peter  S, Mennel  S.  Retinal branch artery occlusion following injection of hyaluronic acid (Restylane). Clin Experiment Ophthalmol. 2006;34(4):363-364.
PubMed   |  Link to Article
Park  SH, Sun  HJ, Choi  KS.  Sudden unilateral visual loss after autologous fat injection into the nasolabial fold. Clin Ophthalmol. 2008;2(3):679-683.
PubMed
Lee  CM, Hong  IH, Park  SP.  Ophthalmic artery obstruction and cerebral infarction following periocular injection of autologous fat. Korean J Ophthalmol. 2011;25(5):358-361.
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

1,767 Views
3 Citations

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
Jobs
JAMAevidence.com

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Quick Reference

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Quick Reference

×