6 Blindness with Blepharoplasty and Injectables

10.1055/b-0038-165839

6 Blindness with Blepharoplasty and Injectables

Francesco M. Egro and Foad Nahai

Summary

Blindness is fortunately a rare, yet devastating, complication that may occur following blepharoplasty or filler injections. Knowledge of the etiology and risk factors is key to preoperative preparation and adoption of appropriate measures to minimize risk and ensure patient safety. Avoidance strategies include: reduction in risk factors, optimization of the patient’s health, surgical technique in the operating room, and close postoperative monitoring. Early recognition and timely management are key for a successful resolution of blindness. A variety of medical and surgical techniques have been described and should be tailored to tackle the initial insult. This chapter explores the incidence, avoidance strategies, and management of blindness following blepharoplasty or filler injections.

6.1 Incidence

Blindness is fortunately a rare, yet devastating, complication that may occur following blepharoplasty or filler injections. Every physician operating on the eyelids or injecting fillers in the periorbital should be aware of this risk, take precautions to minimize it, and be prepared for emergency treatment.

The first report of blindness following blepharoplasty was published in 1962 by Hartmann et al, and since then, there have been several other publications discussing current strategies for prevention, diagnosis, and management of this complication (Table 6-1). The incidence of blindness following blepharoplasty was first published by DeMere et al in 1974. The authors surveyed 3,000 ophthalmologists and plastic surgeons in the United States, who reported 40 cases of blindness out of the 98,514 eyelid operations, an incidence of approximately 0.04%. Hass et al surveyed 237 members of the American Society of Ophthalmic Plastic and Reconstructive Surgery in 2004. The authors collected reports of 269,433 blepharoplasties, with 48 cases of orbital hemorrhage associated with temporary blindness and 12 cases of orbital hemorrhages associated with permanent blindness. The incidence of temporary blindness was 0.0425%, and that of permanent blindness was 0.0045%. In 2011, we published a large international study where we surveyed a total of 648 members of the American Society for Aesthetic Plastic Surgery (ASAPS) and 72 members of the British Association of Aesthetic Plastic Surgeons (BAAPS). Of the 752,816 blepharoplasties performed by the respondents, blindness was reported in 39 cases: 25 permanent and 14 temporary. The overall incidence of blindness following blepharoplasty was 0.0052% (5 in 100,000, or 1 in 20,000); the incidence of temporary blindness was 0.0019% (2 in 100,000, or 1 in 50,000) and that of permanent blindness was 0.0033% (3 in 100,000, or 1 in 30,000). A summary of the studies reporting the incidence of blindness following blepharoplasty is presented in Table 6-2.

Table 6.1 Published papers on blindness following blepharoplasty
Authors	Symptoms	Time of presentation	Time of LOV	Associated factors	Management	Diagnosis
Hartmann et al (1962)
(1) P V	Pain, LOV	24 h^a	36–48 h^a	Hyperthyroidism, Raynaud’s syndrome	Evacuation of hematoma, Novocain, vasodilator (Acecoline-Priscol)	Retinal ischemia caused by arterial spasm or occlusion
(2) P	Hematoma, chemosis	48 h	48 h	Congenital amblyopia	None	Retinal or optic nerve ischemia caused by arterial spasm or occlusion
(3) P V	LOV	24 h	24 h	–	Evacuation of hematoma	Optic nerve ischemia caused by arterial spasm or occlusion
(4) P	Pain, LOV	24 h	24 h	Transitory hyperthyroidism	Isotonic fluid, Novocain, heparin, vasodilators, vasoplegic	Retinal or optic nerve ischemia caused by arterial spasm or occlusion
Morax and Blanck (1969)
(1) T > P	LOV	0 h	0 h	–	Novocain, Priscol, Nicyl, Hydergine	–
Moser et al (1973)
(1) P	LOV	5 h	5 h	Hx PUD	Steroids	Retrobulbar optic neuritis
(2) P	Swelling	1 h	5 d	Hx phlebitis	ACTH	Retrobulbar optic neuritis
(3) P	LOV, hematoma, ecchymosis	18 h	18 h	Questionable HTN	Steroids, ACTH	Retrobulbar optic neuritis
(4) P	LOV	4 d	4 d	Arteriosclerosis, preexisting LOV	Diamox, O₂, CO₂	CRAT
(5) P	Hematoma, ecchymosis		7 d	Hx HTN	None	CRVT
(6) P V	Bleeding, ecchymosis, pain	6–7 h	55–60 h	Hx thrombocytopenia	Diamox, steroids, streptokinase, multivitamins, Arlidin	Optic nerve injury
(7) P	Swelling, pain	0–3 h	12–24 h	Cardiospasm, esophagus	–	–
Hartley et al (1973)
(1) None	Proptosis, edema, pain, reduced extraocular movements	Intra-op	No visual loss	–	Anterior chamber decompression	Retrobulbar hemorrhage
Jafek et al (1973)
(1) P V	Pain, bleeding, proptosis, ecchymosis, pupil dilation, no light perception	1.5 h	1.5 h	–	Lateral canthotomy, mannitol, Demerol, antibiotics	Retrobulbar hemorrhage
Putterman (1975)
(1) T	Pain, proptosis, no light perception, no ocular mobility	2 h	2 h	–	Incision and drainage	Retrobulbar hemorrhage and retinal artery occlusion
Hueston and Heinze (1974)
(1) T	Pressure, proptosis, ecchymosis	0–1 h	3 h	–	AC paracentesis, acetazolamide, hydrocortisone, chloramphenicol, atropine	Retrobulbar hemorrhage,^a central retinal artery occlusion
Hueston and Heinze (1977)
(1) T	LOV, pain, proptosis, dilated pupils, ecchymosis	3 h	3 h	–	Wound decompression, acetazolamide, mannitol	Retrobulbar hemorrhage,^a central retinal artery occlusion
Heinze and Hueston (1978)
(1) T	Pain, proptosis, tension	20–35 min	No visual impairment	–	Wound decompression, acetazolamide, ice packs	Retrobulbar hemorrhage^a
(2) P V	Pain, edema	1 h	7 d	–	Incision and drainage	Anterior ischemic optic neuropathy and partial central retinal artery occlusion
Waller (1978)
(1) P	Pain	0–12 h	12 h		Incision and drainage	Optic nerve injury
Gate et al (1979)
(1) P	Pain	2 h	12 h	–	Steroids, vasodilators, hyperbaric oxygen	Arterial spasm
Rafaty (1979)
(1) T	Swelling, pupil dilation, discoloration	Intra-op	Intra-op	Hx ZMC fx	Steroids, incision, and drainage	Reflex vasospasm of retinal vessels^a
Morgan (1979)
(1) P	Pain, swelling, “white spots” visual disturbance, proptosis, palsy, anesthesia	2–3 d	7 d	–	Opened wound and IV penicillin	Orbital cellulitis
Anderson and Edwards (1980)
(1) Right P and left T V	Pain, tension, proptosis, IOP, ecchymosis, hemorrhage	Intra-op	Right < 24 h; left 48 h	Hx HTN and HTN crisis intra-op	Bilateral orbital decompression, drainage	Optic nerve ischemia
Kelly and May (1980)
(1) T	Pain, swelling	2 h	3 h	–	Lateral canthotomy, incision and drainage, massage, acetazolamide, mannitol	Occlusion of central retinal artery or branches Venous stasis
Lloyd and Leone (1985)
(1) T	Swelling, ptosis, proptosis, mobility, LOV	7 h	7 h	ASA	Incision and drainage	Retrobulbar hemorrhage
Goldberg et al (1990)
(1) P	Swelling	Intra-op	4 h	Bleeding dyscrasia^a	Incision and drainage, acetazolamide, steroids. Lateral orbitotomy canthotomy, hyperbaric oxygen	Optic nerve injury
(2) P	Pain	6–12 h	48 h	–	Erythromycin, sulfa, steroids	Orbital hematoma
Brancato et al (1991)
(1) V P/T^a	Visual acuity	1 d	1 d	–	–	Occlusion of branches of the superotemporal and inferotemporal retinal arteries and revealed ischemia
Gayton and Ledford (1992)
(1) TV	Pain, visual acuity, fixed and dilated pupil, swollen lens, anterior chamber shallow, tension	2 d	2 d	–	Acetazolamide, mannitol, timolol, steroids, phacoemulsification, and IOL implant	Angle-closure glaucoma
Good et al (1999)
(1) P	Swelling, bruising	0–12 h	12–24 h	–	–	Retrobulbar hemorrhage
Cruz et al (2001)
(1) T V	Pain, proptosis, ecchymosis, extraocular motility, chemosis, conjunctival hemorrhage, visual acuity, IOP	7 d	7 d	–	Mannitol, acetazolamide, Beta-blocker eye drops	Retrobulbar hemorrhage
Oliva et al (2003)
(1) T V	Decrease vision and visual fields, dilated and fixed pupils, ocular motility	Intra-op	Intra-op	Hx of HTN, dyslipidemia, cerebrovascular accident	–	Hemorrhage, ischemia, anesthetic effect
Wride and Sanders (2004)
(1) P	Bleeding, red and painful eye, reduced vision, fixed and dilated pupil, IOP	Intra-op	24 h	Hx of hypermetropia	Acetazolamide, mannitol, pilocarpine, timolol, steroids, augmented trabeculectomy	Angle-closure glaucoma
Yachouh et al (2006)
(1) P	Edema, bleeding	6 h	11 h	Hx of HTN	Steroids, ice, surgical revision	Vascular spasm involving the retinal or the optic nerve circulation
Teng et al (2006)
(1) P V	Proptosis, extraocular movements, chemosis, subconjunctival hemorrhage, eyelid ecchymosis	9 d	9 d	–	Wound decompression, lateral canthotomy, cantholysis, cephalexin, Timoptic drops, Bacitracin	Retrobulbar hemorrhage
Chiu et al (2006)
(1) T	Edema, erythema	4 d	5 d	–	Unasyn, vancomycin, Zosyn, gentamicin, Timoptic, and Alphagan. Orbital decompression.	Orbital apex syndrome (orbital cellulitis)
Abbreviations: AC, anterior chamber; ACTH, adrenocorticotropic hormone; ASA, aspirin or nonsteroidal anti-inflammatory use; CRAT, central retinal artery thrombosis; CRVT, central retinal venous thrombosis; Fx, fracture; HTN, hypertension; Hx, history; IOL, intraocular lens implant; IOP, raised intraocular pressure; IV, intravenous; L, visual loss without hemorrhage; LOV, loss of vision; P, permanent visual loss; PUD, peptic ulcer disease; T, temporary visual loss; V, visual disturbance, including decreased visual acuity or field; ZMC, zygomatic-maxillary complex. Source: Adapted from Mejia JD, Egro FM, Nahai F. Visual loss after blepharoplasty: incidence, management, and preventive measures. Aesthet Surg J 2011;31(1):21–29. Refer to this article for full referencing of each case report and case series listed in this table. ^aUnclear data presented in the original article.

Table 6.2 Reported incidence of blindness following blepharoplasty
	DeMere et al (1974)	Hass et al (2004)	Mejia et al (2011)
Blepharoplasty cases	98,514	269,433	752,816
Blepharoplasty incidence: overall	0.04%	0.05%	0.0052%
Permanent	–	0.0045%	0.0033%
Temporary	–	0.0425%	0.0019%

Blindness is also seen following injection of fillers and adipose tissue. As yet, no incidence rate has been identified. However, a few studies summarized the current strategies for prevention, diagnosis, and management of this complication. Park et al in 2012 reported a consecutive series of 12 patients who suffered ophthalmic, central retinal, and branch retinal vascular occlusions following cosmetic filler injections: 7 patients following adipose tissue injections, 4 following hyaluronic acid, and 1 following collagen. Lazzeri et al published in 2012 a systematic review of 32 cases of blindness following cosmetic filler injections: 15 patients following adipose tissue injections and 17 patients following injections of hyaluronic acid, calcium hydroxyapatite, corticosteroids, silicone oil, paraffin, polymethylmethacrylate, and bovine collagen. Ozturk et al in 2013 published a review of 61 cases of facial vascular occlusion following cosmetic filler injections other than adipose tissue. They reported that 12 patients were complicated by blindness following injections with hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid, collagen, and dermal matrix. More recently in 2014, Park et al conducted a national survey of the members of the Korean Retina Society who reported a total of 44 cases of blindness following cosmetic filler injections: 22 patients following adipose tissue injections, 13 following hyaluronic acid, 4 following collagen, 2 following poly-L-lactic acid, 1 following calcium hydroxyl apatite, and 2 cases of unknown injections.

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Tags: General, Ophthalmology, Optometry, Plastic, Problems in Periorbital Surgery, Reconstructive and Cosmetic Surgery

May 17, 2020 | Posted by drzezo in OPHTHALMOLOGY | Comments Off

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6 Blindness with Blepharoplasty and Injectables