Ocular ischemia with hypotony after injection of hyaluronic acid gel

The authors experienced a case with ocular ischemia with hypotony following injection of a dermal filler for augmentation rhinoplasty. Immediately after injection, the patient demonstrated a permanent visual loss with typical fundus features of central retinal artery occlusion. Multiple crusted ulcerative patches around the nose and left periorbit developed, and the left eye became severely inflamed, ophthalmoplegic, and hypotonic. Signs of anterior and posterior segment ischemia were observed including severe cornea edema, iris atrophy, and chorioretinal swelling. The retrograde arterial embolization of hyaluronic acid gel from vascular branches of nasal tip to central retinal artery and long posterior ciliary artery was highly suspicious. After 6 months of follow up, skin lesions and eyeball movement became normalized, but progressive exudative and tractional retinal detachment was causing phthisis bulbi.     

Therapeutic Intra-arterial Hyaluronidase Infusion for Ophthalmic Artery Occlusion Following Cosmetic Facial Filler (Hyaluronic Acid) Injection

Although dermal/subcutaneous injection of filler into the face is a popular aesthetic surgery, severe complications related to arterial occlusion, including skin necrosis and visual loss, have been reported. Herein, we report a case of intra-arterial hyaluronidase infusion in the ophthalmic artery and other arteries supplying the facial skin following hyaluronic acid injection at the glabella and nasal ala. Despite direct hyaluronidase infusion into the ophthalmic artery, retinal arterial perfusion was not restored, but branches of the ophthalmic and facial arteries were recanalised. Skin discoloration was normalised, and partial recovery of retinal and choroidal perfusion and complete recovery of ocular movement were achieved.     

Severe ocular complications following facial calcium hydroxylapatite injections: Two case reports

Dermal soft-tissue augmentation using a filler is a technique widely used for facial cosmetic enhancement. However, potential complications following facial cosmetic injections have heightened the possibility of iatrogenic visual loss. We report two cases of severe ocular complications after nasal cosmetic enhancement. Both cases had poor visual outcomes in spite of emergency management. The second patient is a rare case with bilateral anterior ischemic optic neuropathy after dermal soft-tissue augmentation. The visual outcome was correlated with the location and the extent of the arterial embolization. Unfortunately, there is still no standard treatment protocol for vision-threatening complications. Clinicians should always keep in mind that embolic arterial occlusion may occur after augmentation.     

透明质酸面部微整形致视功能障碍的临床观察

目的　观察使用透明质酸进行面部微整形所致视功能障碍患者的临床表现、治疗效果等。方法　回顾性分析2013年1月至2017年12月我院眼科诊治的因面部微整形行透明质酸注射所致视功能障碍患者13例13眼的临床资料,包括一般情况、病史、临床检查结果、治疗效果及危险因素等。结果　13例患者全是女性,年龄21~40岁,平均26.7岁。注射部位位于眉间者7例、鼻部者4例、额部者2例。13例全是单眼发病,突然发病者10眼;严重视功能障碍者9眼,包括无光感4眼,光感2眼,手动1眼,数指2眼;另外4眼视力0.1。经眼底照相和荧光素眼底血管造影确诊为眼动脉阻塞者3眼、视网膜中央动脉阻塞者4眼、视网膜分支动脉阻塞者1眼、睫状后动脉阻塞者2眼、视网膜中央动脉阻塞合并睫状后动脉阻塞者1眼和眼底动脉血管痉挛者2眼。6例患者合并眼球运动障碍或面部外观异常。经治疗后,视力从0.1恢复到0.3、0.5、0.6者各1眼,光感恢复到手动者1眼,其他9眼视力未见改善。结论　透明质酸面部微整形所致视功能障碍多发生于年轻女性,多数突然发病,视功能障碍严重,主要是眼底动脉阻塞。治疗后多数患者视功能恢复效果不明显。     

Eficacia de la hialuronidasa retrobulbar en el tratamiento de la ceguera provocada por rellenos cosméticos. Revisión sistemática

IntroductionBlindness after periocular cosmetic filler injection is a rare but devastating complication. Complication management protocols recommend injecting retrobulbar hyaluronidase if visual loss related to accidental intravascular injection of hyaluronic acid occurs. Given the dramatic increase in cosmetic filler injections and the variety of professionals that can deliver them, it is reasonable to assume that the incidence of complications will rise significantly.ObjectiveTo evaluate if there is evidence-based efficacy of retrobulbar hyaluronidase injection in visual loss secondary to periocular cosmetic filler injection.Material and methodsThe authors performed a search of English and Spanish language articles following the PRISMA statement published on the use of retrobulbar hyaluronidase to reverse vision loss precipitated by hyaluronic acid gel fillers. Articles reviewed included case reports/series and experimental investigations. We identified a total of 13 patients in this review following defined inclusion and exclusion criteria.Finally, we included 15 articles in the study, 12 of them were cases / case series. The 2 remaining articles are experimental studies in animals with a control group, in which after causing selective occlusion of the ophthalmic artery, serial injections of retroocular hyaluronidase are administered with control of visual function.ResultsOf the 15 articles included in the study, we studied 17 patients treated with retrobulbar hyaluronidase for hyaluronic acid-induced blindness. Improvement was demonstrated in 3 cases. Animal studies demonstrate variable data are provided regarding the recovery of visual acuity.ConclusionsThere is no confirmed evidence of retrobulbar hyaluronidase injection effectiveness in treating visual loss due to accidental intravascular injection of hyaluronic acid. More studies are needed to show the efficacy of hyaluronidase as a treatment for blindness caused by hyaluronic acid.     

Iatrogenic ophthalmic artery occlusion and retinal artery occlusion

Iatrogenic ophthalmic artery occlusion (IOAO) is a rare but devastating ophthalmic disease that may cause sudden and permanent visual loss. Understanding the possible etiologic modalities and pathogenic mechanisms of IOAO may prevent its occurrence. There are numerous medical etiologies of IOAO, including cosmetic facial filler injection, intravascular procedures, intravitreal gas or drug injection, retrobulbar anesthesia, intraarterial chemotherapy in retinoblastoma. Non-ocular surgeries and vascular events in arteries that are not directly associated with the ophthalmic artery, can also cause IOAO. Since IOAO has a limited number of treatment modalities, which lead to poor final visual prognosis, it is imperative to acknowledge the information regarding medical procedures that are etiologically associated with IOAO. We accumulated all searchable and available IOAO case reports (our cases and previous reported cases from the literature), classified them according to their mechanisms of pathogenesis, and summarized treatment options and responses of each of the causes. Various sporadic cases of IOAO can be categorized into three mechanisms as follows: intravascular event, orbital compartment syndrome, and increased intraocular pressure. Embolic IOAO, which is considered the primary cause of the condition, was classified into three subgroups according to the pathway of embolic movement (retrograde pathway, anterograde pathway, pathway through collateral channels). Despite the practical limitations of treating spontaneous (non-iatrogenic) retinal artery occlusion, this article will contribute in predicting and improving the prognosis of IOAO by recognizing the treatable factors. Furthermore, it is expected to provide clues to future research associated with the treatment of retinal artery occlusion.     

Localized retinal detachment with combined central retinal artery and vein occlusion after retrobulbar anesthesia

The authors report a patient who was observed to have a localized retinal detachment with combined central retinal artery and vein occlusion after cataract surgery performed with retrobulbar anesthesia. The authors propose that this condition resulted from injection of the anesthetic mixture into the optic nerve. No acute neurologic symptoms occurred, but visual loss was severe and permanent. This case adds to the previously reported spectrum of complications from retrobulbar anesthesia.     

复方樟柳碱治疗视网膜中央动脉阻塞40例

目的比较复方樟柳碱球后注射联合颞浅动脉旁注射与单纯颞浅动脉旁注射治疗视网膜中央动脉阻塞对其视力、视野等影响的差别,评价其对视网膜中央动脉阻塞的疗效。方法观察2005年10月至2007年10月20例20眼采用复方樟柳碱球后注射联合颞浅动脉旁注射的治疗组与20例20眼单纯颞浅动脉旁注射治疗的对照组视网膜中央动脉阻塞患者的视力、视野变化,并进行对照分析。结果复方樟柳碱球后注射联合颞浅动脉旁注射与单纯颞浅动脉旁注射有效率进行比较分析,用药后7 d和用药后14 d治疗组与对照组比较,差异有统计学意义,在提高视力,改善视野上,2组差异有统计学意义。结论应用复方樟柳碱球后注射联合颞浅动脉旁注射治疗视网膜中央动脉阻塞是一种有效的治疗方法。     

Ocular complications associated with retrobulbar injections

The authors describe six complications, of retrobulbar injections documented by fundus photography and fluorescein angiography. These include (1) injection of corticosteroid into the posterior ciliary arterial circulation resulting in emboli in the vasculature of the choroid and the optic nerve head; (2) injection of corticosteroid into the ophthalmic artery resulting in emboli in both the choroidal and retinal circulations; (3) presumed injection of lidocaine and air into the optic nerve sheath adjacent to the globe with extension anteriorly into the subretinal space and the space between the posterior vitreous and the internal limiting membrane; (4) occlusion of the central retinal artery without an associated retrobulbar hemorrhage; (5) trauma to and partial injection of lidocaine in the central retinal artery with embolization into the retinal circulation; and (6) presumed injection of lidocaine into the optic nerve sheath producing a combined central retinal vein and artery occlusion. Alternative techniques that might decrease the incidence of complications associated with retrobulbar injections are discussed.     

Complete recovery of filler-induced visual loss following subcutaneous hyaluronidase injection

The rise in popularity of hyaluronic acid (HA) dermal filler injection has caused an exceptional increase in the number of cases of reported irreversible blindness. Here, we reported a case of ischemic optic neuropathy and ophthalmoplegia following subcutaneous HA filler injection with complete visual recovery. A 31-year-old Chinese woman presented with sudden onset of right monocular visual impairment associated with diplopia. Patient had received a hyaluronic acid-containing ?ller injection for nasal dorsum augmentation twelve hours prior to presentation. Visual acuity of the right eye was counting finger. A right relative afferent pupillary defect was demonstrated with ophthalmoplegia. Humphrey visual field test disclosed a right inferior altitudinal field defect with impairment of colour vision. Computed tomography of the orbit revealed mild enlargement of the right medial and inferior recti muscles. Our patient showed a tremendous improvement of vision after a subcutaneous hyaluronidase injection with complete visual recovery within 2 weeks.     

Thrombolysis of arterial retinal occlusion using urokinase]

The authors present an account on possible aimed thrombolytic treatment of occlusion of the retinal artery by urokinase. Aimed thrombolysis can be performed at ophthalmological departments with an available radiodiagnostic department, which performs angiographies of carotid arteries. The authors discuss the necessary dose of 200,000 to 300,000 i.u. of urokinase. One-hour infusion with an initial booster dose is best. Early administration of the preparation is considered most important by the authors. The authors present the case-history of a 34-year-old patient with complete occlusion of the central retinal artery with haemodynamically severe aortal stenosis with a congenital background. Urokinase was administered six hours after occlusion of the artery. Gradually reperfusion of the retina occurred and improvement of the visual acuity from 0.01 to 0.17 with a residual relative wedge-shaped loss of the visual field and paleness of the disc of the optic nerve.     

Retinal artery occlusions following carotid angiography (author's transl)]

The authors describe a case of retinal artery occlusion; succeeding to a carotid angiography. The ethiology could be a manifestation of an embolic phenomenas. The case is discussed in the light of simular and others reports of ocular complication following this procedure in the literature. Its appears that carotid artery disease was a precipitating factor in the ocular complication. It looks like a complication of injection of the contrast dye in some cases secondary to allergic, toxic or physical phenomenas.     

Deep-fill hyaluronic acid for the temporary treatment of the naso-jugal groove: a report of 303 consecutive treatments

PURPOSE: To report a 2-year experience of treating the naso-jugal groove with injectable hyaluronic acid gel, using a deep-fill method. METHODS: This was a consecutive, retrospective, nonrandomized case series of patients presenting with concerns involving dark circles, lower eyelid hollows, or other contour irregularities that make up the naso-jugal groove. One author performed all treatments, consisting of transcutaneous injection of hyaluronic acid gel filler, to address the naso-jugal groove. The filler was placed deep on the anterior lip of the orbital rim and molded to the desired shape. RESULTS: Between December 2003 and December 2005, 164 patients (34 male and 130 female) received hyaluronic acid gel filler in the face. Ninety-eight patients were treated just once and 66 had multiple treatment sessions. The mean dose of filler per session was 1.53 +/- 0.8 ml, with 0.84 +/- 0.38 ml divided between the two lower eyelids. The most common complication was localized swelling, followed by bruising, asymmetry, cellulitis (2 cases), and migraine (1 case). There were no cases of visual loss. CONCLUSIONS: Hyaluronic acid gel fillers have had an enormous impact on the practice of cosmetic surgery, and this series demonstrates the usefulness of these fillers for treatment of the lower eyelid and midface. The authors recommend the deep-fill method described as a reliable means of addressing the hollow created by the naso-jugal groove.     

Visual loss following intranasal anesthetic injection

Four patients had visual loss after nasal surgery. There was one instance each of branch retinal artery occlusion, central retinal artery occlusion, anterior ischemic optic neuropathy, and posterior ischemic optic neuropathy. The postulated mechanism is vasospasm. The submucosal injection, under pressure, of an anesthetic with epinephrine is deemed to be causative.     

Bilateral combined cilioretinal artery and central retinal vein occlusion

A rare case with bilateral combined cilioretinal artery and central retinal vein occlusion (CRVO) is reported in a 45-year-old man. Work-up was positive only for already-present type 2 diabetes. The patient first developed ischemic-type CRVO and cilioretinal artery occlusion in his right eye, and underwent successful trabeculectomy with mitomycin-C following panretinal and grid macular photocoagulation. The fellow eye developed a nonischemic type of CRVO and cilioretinal artery occlusion 4 years after the first episode with good visual outcome. The authors have stated that they do not have a significant financial interest or other relationship with any product manufacturer or provider of services discussed in this article. The authors also do not discuss the use of off-label products, which includes unlabeled, unapproved, or investigative products or devices.     

Eyelid mass secondary to injection of calcium hydroxylapatite facial filler

A 37-year-old woman presented with a 2-month history of fullness and ptosis of the left upper eyelid. Examination revealed a 6-cm x 2-cm mass in the left brow and upper eyelid, and a diffuse mass in the lower eyelid. Marked ptosis of the left upper eyelid and elevation of the left lower eyelid were noted. CT showed masses with a bone-like density in the left eyelid and periorbital soft tissue. A through history revealed that the patient had received calcium hydroxylapatite filler injection for nose augmentation 3 days prior to the development of the eyelid masses. The eyelid masses were excised and pathologically confirmed as calcium hydroxylapatite microspherules surrounded by collagen and histiocytes. Two months after surgery, the eyelid masses and ptosis of the left upper eyelid were completely resolved. To our knowledge, this is the first reported case of eyelid mass after injection of calcium hydroxylapatite facial filler for nose augmentation.     

Posterior ciliary-artery occlusion after subcutaneous silicone-oil injection

Visual loss occurred after subcutaneous silicone-oil injection for cosmetic purposes. To our knowledge, this is the first instance of amaurosis caused by a subcutaneous foreign-material injection that spared the central retinal artery and affected portions of the posterior ciliary-artery distribution, including a probable cilioretinal artery. The visual-field defects produced allow a rare opportunity to view the distribution of the human posterior ciliary-artery circulation by means of this in vivo pathologic embolic process. The facial arterial anatomy pertinent to ocular embolism is also discussed.     

Tear trough rejuvenation: A safety evaluation of the treatment by a semi-cross-linked hyaluronic acid filler

The aim of this study is to describe the experience of 33 physicians, dermatologists and surgeons, with the use of a semi-cross-linked hyaluronic acid (HA) gel as a tear trough deformity filler within one month following injection, and to assess patient satisfaction with the procedure. This study is a case series conducted between February 2012 and December 2012 with the use of semi-cross-linked HA to correct tear trough deformity. The filler was administered in the preperiosteal tissues. The study involved case note review and a patient satisfaction survey. A total of 302 eyes of 151 patients were treated by 33 physicians, with a mean follow-up of 3 weeks. Patients were mainly female (86%), and middle-aged (mean age 48 years old). The gel was placed preperiosteally, deep to the orbicularis, anterior to the inferior orbital rim, with a mean volume of 0.48 ml per eye to achieve correction. The injection procedure was performed without local anesthetic for 79% of the patients. No serious adverse event was recorded. Side effects reported by investigators immediately after injection included bruising (11%), swelling (12%), and redness (inflammation 12%). Very few transitional blue discolorations (2.6%) were observed. No patient required dissolution with hyaluronidase. According to our satisfaction survey, all patients had cosmetic improvement. Most patients (97%) described marked or moderate satisfaction with the treatment. At one month, 18% requested additional hyaluronic acid gel for a touch-up injection. This case series confirms the effective use of a semi-cross-linked HA gel in tear trough rejuvenation. It has excellent patient tolerability, minimal complications, and excellent patient satisfaction.     

Optic nerve enlargement and central retinal-artery occlusion secondary to retrobulbar anesthesia

Optic nerve injury after retrobulbar injection of anesthetic agents may damage the optic nerve and vascular supply to the eye. We describe a case of documented orbital optic nerve injury with central artery occlusion after retrobulbar injection before cataract surgery. Early computed tomography documentation of optic nerve injury associated with retrobulbar injection is suggested to allow early consideration of optic nerve sheath decompression.     

Intravitreal bevacizumab for neovascular glaucoma following central retinal artery occlusion

PURPOSE: To report a case of neovascular glaucoma due to central retinal artery occlusion treated with a single intravitreal injection of bevacizumab. METHODS: A 68-year-old patient with a 10-week history of central retinal artery occlusion presented with neovascularization of the iris and the angle and intraocular pressure of 30 mm Hg. The patient received a single injection of 1.25 mg bevacizumab in 0.1 mL intravitreally. RESULTS: Iris and angle neovascularization regressed within 48 hours of the injection. Intraocular pressure dropped from 30 to 15 mm Hg, and there was marked improvement in patient comfort. Panretinal photocoagulation was applied 4 weeks after the injection. CONCLUSIONS: Bevacizumab seems to be a useful adjunct to panretinal photocoagulation in the treatment of neovascular glaucoma.