Abstract
Purpose
Over the last decade, injectable soft tissue fillers have become an essential part of facial plastic surgery practice. We report here a tragic complication of hyaluronic acid filler injection in a young healthy woman, management offered, and the outcome.
Observations
A 32-year-old woman developed unilateral acute blindness, orbital pain, total ophthalmoplegia, and anterior and posterior segment ischemia immediately following hyaluronic acid injection. Urgent measures were taken including hyaluronidase enzyme injection, vigorous messaging, and systemic steroids. Eight weeks later, the extraocular motility has fully recovered; however, the consequences of ischemia on the anterior and posterior ocular segments persisted.
Conclusions and Importance
Describing a major refractory complication following injecting hyaluronic acid dermal filler. Prompt intervention including the use retro or peribulbar injection of hyaluronidase has a little impact when it comes to reversing ocular sequalae. Therefore, injectors should be aware of facial danger zones that could potentially lead to this devastating outcome.
1
Introduction
Filler rhinoplasty utilizing hyaluronic acid is becoming an increasingly popular procedure being simpler and cheaper option with fewer side effects and a shorter down time.
Occasionally, serious complications may occur. We describe a case with acute orbital infarction and facial skin necrosis following a hyaluronic acid injection. Urgent steps were followed; however, the visual effects of arterial occlusion by filler are devastating and irreversible.
2
Case report
At an aesthetic clinic, a 32-years-old woman was scheduled for a non-surgical filler rhinoplasty to correct a nasal hump deformity. A few seconds after injecting 0.5 mL of hyaluronic acid filler over the nasal bridge with a 30-gauge needle, she noted sudden complete loss of vison in her left eye. While still at the doctor’s office, she received hyaluronidase enzyme injections subcutaneously (40 Units/cm 2 ) in the area over the nose and around the left eye; however, a firm swelling with tenderness around the left eye started to develop. The patient rushed to the ED with worsening persistent dull, aching pain, and bluish discoloration of the facial skin. She was evaluated by an ophthalmologist on-call within less than one hour, her visual acuity was no light perception (NLP) in the left eye. The left globe was frozen with hypotropia, exotropia, and complete external ophthalmoplegia with blepharoptosis ( Fig. 1 A). Slit lamp biomicroscopy of the left eye showed conjunctival chemosis, and grade 4 corneal haze obscuring other intraocular structures ( Fig. 1 B). She was diagnosed with acute left orbital infarction secondary to hyaluronic acid filler injection. Then, an immediate peribulbar injection of 2 cc (total of 300 units) hyaluronidase enzyme was given followed by vigorous massage aiming to disburse the bulk of the filler material; however, no improvement in vision noted. A three-dimensional computed tomography angiogram (3D-CTA) of the head and neck showed patent arterial vasculature. A computed tomography (CT) of the head and the orbits showed normal brain parenchyma without focal lesion. The patient received intravenous methylprednisolone 1 gm daily for 5 days, in addition to broad spectrum antibiotic coverage, antibiotic creams, and oral aspirin. After 8 weeks from presentation, her visual acuity did not change. The skin necrosis resolved with residual scarring. Left extraocular movement and blepharoptosis improved ( Fig. 2 ). Slit lamp biomicroscope revealed clear cornea, with a dilated pupil and iris atrophy. Fundus exam indicated severe ischemia of the optic nerve and retina ( Fig. 3 A). Optical coherence tomography demonstrated diffuse retinal thinning of the inferior macula ( Fig. 3 B).
