Injection of fillers is one of the most commonly sought-after and performed procedures in the fields of aesthetic and cosmetic practice. According to the latest Article "Update on Avoiding and Treating Blindness From Fillers: A Recent Review of the World Literature" published by Aesthetic Surgery Journal, between 2000 to 2017, the number of filler treatments performed globally has steadily grown by more than 300% with Hyaluronic Acid (HA) fillers injection procedures making up more than 77% of all injectable filler procedures in 2017.
In a 10-year retrospective review (2007–2017) conducted by the US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE), there has been a total of 47 reported cases of blindness and 42 reported cases of vision impairment caused by filler injections.
Based on an initial 2015 publication titled “Avoiding and Treating Blindness from Fillers: A Review of the World Literature”, it was reported that there were approximately 98 published cases of filler-related visual compromise in the world literature between 1906 and 2015. Adding the newly reported 48 cases of partial or complete vision loss related to filler injection, the latest publication released on 21 February 2019, brings the total count of cases up to 146. Although this number of reported incidence is still considered small, it is evident that the rate appears to be increasing.
Background & Objectives
While sudden loss of vision secondary to filler treatments is rare, it is considered to be a major catastrophic complication. In the latest publication released on 21 February 201916 May 2019, the authors' aim is to study and update the number of published cases of blindness after filler injection that have occurred since their last publication in 2015, while seeking to discuss prevention and management strategies.
Figure 1. The above illustration shows the number of cases per location of filler injection resulting in visual complication. The single black dot represents a case where the anatomic location of injection was not specified.
Based on the study, it shows that there were a total of 48 newly published cases of partial or complete vision loss after filler injection were identified. The sites that were of the highest risk were the nasal region (56.3%), glabella (27.1%), forehead (18.8%), and nasolabial fold (14.6%). Hyaluronic acid filler was the cause of such complication in 81.3% of cases. Ten cases (20.8%) experienced complete recovery of vision, whereas 8 cases (16.7%) reported only partial recovery. Management strategies varied greatly and there were no treatments that were shown to be consistently successful.
Figure 2. Number of cases of visual complications from each filler type.
Of the 48 newly reported cases, 54.2% (26 cases) were found to have complete vision loss. The remaining 45.8% (22 cases) cases had complete unilateral vision loss.
Among the 48 cases, there were 9 cases (18.8%) of central nervous system (CNS) complications, including stroke-like features such as unilateral weakness or evidence of brain infarction on imaging.
Ten cases (20.8%) reported complete recovery of vision, whereas 8 cases (16.7%) resulted in partial recovery of vision. Of the remaining cases, 25 (52%) had complete vision loss, 1 had worsened vision, vision remained the same in 2 cases, and the outcome was not reported in 2 cases. No deaths were reported.
Signs & Symptoms
It is reported that vision loss, pain, ophthalmoplegia, and ptosis were the most common symptoms with skin changes being seen in 43.8% of the cases and central nervous system complications observed in 18.8% of cases.
In 27 cases (56.3%) pain was reported as one of the initial symptoms (described as periorbital, ocular, periocular, orbital, eye pain, or headache). In 21 cases (43.8%), associated skin changes, commonly described as erythematous to violaceous mottling or skin necrosis, were reported.
Ophthalmoplegia (decreased extraocular movement) was reported in 26 cases (54.2%) and ptosis was seen in 25 cases (52.1%). Most commonly, the ophthalmoplegia and ptosis recovered completely. Nausea and/or vomiting were described as a presenting symptom in 8 cases (16.7%).
In this latest update, HA filler causes 81.3% of cases of visual complications compared to 2.1% due to autologous fat. This is in contrast to the 2015 publication where autologous fat was the leading cause (47.9%) of complications. The authors largely attribute the difference in the increase in the number of cases involving HA fillers to the growing popularity owing to the reported reversibility and favourable safety profile.
In addition, the 2019 update showed 10 cases (20.8%) with complete recovery of vision and 8 cases (16.7%) with partial recovery of vision. In the 2015 publication, there were only 2 cases out of 98 (2%) with complete vision recovery. This improvement is thought to reflect the fact that more cases were reported with HA filler, which has been shown to offer better outcomes than autologous fat. It is also possible that general preparedness, education, and early intervention may be responsible for the improved outcomes, but remains to be substantiated by a larger dataset.
Finally, in the latest update, it is observed that the nose has surpassed the glabella as the most common location for this complication at 56.3% of cases followed by the glabella (27.1%), forehead (18.8%), and NLF (14.6%). Whereas, in the previous publication, the highest-risk location was the glabella (38.8%), nasal region (25.5%), NLF (13.3%), and forehead (12.2%).
Lastly, visual compromise most commonly occurred immediately after injection. Ocular pain or headache occurred in the majority of cases (56.3%). Nausea and vomiting secondary to increased intraocular pressure occurred in 8.2% of cases. Obstruction of the blood supply to the extraocular muscles or innervating nerves caused ophthalmoplegia in 54.2% of cases.
Reduced blood supply to the levator palpebrae superioris muscle or its innervating nerves caused ptosis in 52.1% of cases. Although vision recovery was less common due to the permanence of retinal damage, ophthalmoplegia and ptosis more commonly recovered, likely because the nerves and muscle regenerate after vascular compromise.
Skin changes, including necrosis and subsequent scarring, were seen in 43.8% of cases. Central nervous system complications, including stroke-like features, were seen in 18.8% of cases.
In light of an absence of documented, validated, effective treatments for blindness arising from filler injections, the most rational strategy for avoiding blindness from fillers is prevention. While lacking in evidence, there are various strategies that have been proposed to avoid adverse events such as vision loss.
The following are the 10 Key Prevention Strategies:
1. Familiarise the anatomy, location, and depth of facial vessels:
Understand the common variations to better grasp a feel of the optimal depth and plane of injections at different sites.The safest plane to be injecting is likely deep and directly on bone or very superficially in the dermis. The subcutaneous plane, although frequently injected to achieve cosmetic improvement, is the highest-risk location as the vasculature most commonly courses through this region.
2. Inject slowly and with minimal pressure
3. Consider using a cannula: It is believed that a cannula is less likely to pierce blood vessel due to its blunt tip. However, there are cases of vascular compromise from cannulas of various sizes. It is recommended to use a 25G or larger cannula as smaller cannulas such as a 27G would more likely penetrate arterial walls.
4. Inject small increments at a time: This can aid in preventing a bolus of filler traveling retrogradely.
5. Move the needle tip while injecting: Moving the needle tip while injecting can help avoid depositing large amount of filler in one single location.
6. Aspirate before injection: While controversial because it may not be possible to retrieve flashback into a syringe through fine needles when thick gels are involved; and the small size as well as collapsibility of facial vessels may restrict the efficacy of aspiration, it is still recommended.
7. Exercise extreme caution, especially when injecting a patient who has undergone a previous surgical procedure in the area.
8. Consider mixing the filler with epinephrine: By doing so, it can help promote vasoconstriction because it is more difficult to cannulate a vasoconstricted artery.
9. Consider using targeted digital pressure: A cadaveric study showed that compressing the superior nasal corners with the fingers during cosmetic filler injections reduced the risk of filler traveling into the orbit as it can help to occlude major periorbital vessels and prevent inadvertent retrograde travel of filler. This technique may be particularly beneficial when injecting high-risk areas such as the nose.
10. Consider alternatives such as Use of Threads to improve NFL, Nose and Cheek area with natural results and no complications of blindness
In recent years, the aesthetic and cosmetic medical field has seen a shift in paradigm where PDO threads are much highly favoured to be used in non-surgical aesthetic and cosmetic procedures by both medical professionals and patients alike. This shift is likely attributed to the fact that PDO threads are not only able to produce similar, if not superior results that more natural and longer lasting, but is also able to potentially eliminate the risks, complications and adverse effects of fillers.
Learn the exclusive techniques on How to Deliver Results that are More Natural and Longer Lasting while avoiding the risks, complications and adverse effects of fillers by using PDO threads in your practice at our ever-popular Non-surgical Face Lifting Master Class happening globally!
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