We read with interest the recent article by Park and associates titled “Iatrogenic Retinal Artery Occlusion Caused by Cosmetic Facial Filler Injections.” The authors are to be commended for reporting the results of a retrospective noncomparative case series to evaluate the clinical manifestation and visual prognosis of retinal artery occlusion resulting from cosmetic facial filler injections. Herein, we discuss some key points about this serious eye injury that recently have heightened awareness.

In their article, Park and associates reported the clinical characteristics of 12 patients. Patient 6 (Table 1), affected by ophthalmic artery occlusion, had a follow-up duration of only 3 days after the treatment. In our opinion, this follow-up may be too short to consider as definitive for the final outcome of no light perception because a relative pupillary afferent defect may be predictive for a partial visual recovery.

With regard to Patients 1 through 4, Park and associates reported in Table 1 a superselective intra-arterial thrombolysis with urokinase as immediate treatment, whereas for the same patients in the Methods section, the interval between the occurrence of iatrogenic blindness and thrombolysis is reported as within 24 hours. This difference should be clarified by the authors because the interval between the onset of the symptoms of retinal artery occlusion and the therapy may affect the visual prognosis significantly. As a matter of fact, some authors have demonstrated that after 90 minutes, the damage caused by retinal ischemia becomes irreversible and retinal necrosis occurs. Moreover, in our experience, selective intra-arterial thrombolysis is a very ultraspecialized surgery that can be performed only in specialized ophthalmic units. Usually, patients undergo cosmetic injections in outpatient clinics, and transportation to the nearest unit may require time. Finally, this procedure is fraught with many important side effects, such as cerebral bleeding. Thus, it is reasonable to discuss further the benefits and drawbacks of intra-arterial thrombolysis to treat retinal embolism after cosmetic facial injections.

In our review of 32 cases of iatrogenic blindness after facial cosmetic injection, we presumed that incomplete treatment also could have contributed to failure of the treatment(s) in achieving visual recovery. In the European Assessment Group for Lysis in the Eye study, the 60% of patients with central retinal artery occlusion showing a significant improvement in best-corrected visual acuity underwent a 6-step therapy, whereas all of the treated patients in the study by Park and associates underwent a single-step therapy. This explains the lack of recovery of all cases of ophthalmic artery occlusion and central retinal artery occlusion except for Patient 8.

Finally, in Table 2, Park and associates reported a summary of 11 published cases of patients with filler-associated retinal arterial occlusion. We identified 15 cases diagnosed with blindness after cosmetic fat injection of the face and 17 cases diagnosed with transitory or permanent blindness after facial aesthetic injections of other materials. We strongly agree with Park and associates with regard to the retrograde embolic mechanism of the injected products from peripheral facial vessels into the ophthalmic arterial system because of the delivery of a sufficient amount of product into the vessel injected with a high injection pressure. As soon as the filler has reached the ophthalmic artery, it may cause occlusion or can be flushed anteriorly and can block the central retinal artery or its branches, depending on the variable particle size.