Bilateral Blindness after Filler Injection

Abstract

Sir:FigureThere are various complications, including hypersensitivity reaction, ecchymosis, contour abnormalities, inflammation, and necrosis, that occur after filler injection.1 Among other things, blindness is a rare but devastating complication of cosmetic injection of the face. There are several reports of blindness following injections of various materials, including corticosteroids, paraffin, silicone oil, hyaluronic acid, and calcium hydroxyapatite.2 However, to the best of our knowledge, bilateral blindness has not been previously reported with cosmetic injection. A healthy 30-year-old man who received calcium hydroxyapatite filler injection for nose augmentation was presented with blindness in both eyes. Initial visual acuity of both eyes was no light perception. Both pupils were fully dilated, and light reflex was not present. Inspection revealed a blepharoptosis and total ophthalmoplegia on both sides, and central skin necrosis, along with surrounding reddish reticular pattern affecting the bridge of the nose and frontal area. The patient had conjunctival injection and multiple emboli along the conjunctival vessels in both eyes. Retinal edema was noticeable, and multiple emboli were visible and located in the choroidal vessels and retinal arteries (Fig. 1). Fluorescein and indocyanine green angiography revealed disturbances of the choroidal circulations and delayed retinal vascular filling caused by calcium hydroxyapatite emboli. Hyperreflective foci corresponding to deposits of calcium hydroxyapatite along the choroidal vessels and retinal arteries were detected by optical coherence tomography. Computed tomography also showed linear deposits of calcium hydroxyapatite on the bridge of the nose. He was diagnosed with bilateral anterior segment ischemia, total ophthalmoplegia, ophthalmic artery obstruction, skin necrosis, and bilateral blindness after filler injection.Fig. 1: Fundus photographs of both eyes. The multiple emboli were visible and located in choroidal vessels (white arrowheads) and retinal arteries (white arrows).Vascular supply to the eyeball and periorbital area is derived from the ophthalmic artery. Filler material, which is injected into the terminal branch of the ophthalmic artery, can enter the ocular circulation by high-pressure injection and subsequently leads to peripheral vascular obstruction.3 Therefore, blindness, ophthalmoplegia, and periorbital skin necrosis can occur, also bilaterally. This is the first reported case of bilateral blindness and anterior segment ischemia after filler injection. To avoid such complications, some techniques, including aspiration before injection and low-pressure injection, should be kept in mind to diminish the risk of vascular embolization.2–4 Yong Joon Kim, M.D. Kyung Seek Choi, M.D. Soonchunhyang University Hospital, Seoul, Korea DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this article.