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995
RESULTS
996
DISCUSSION
Pathophysiology
Central retinal artery embolization is related
to the retrograde arterial displacement of the injected products from peripheral vessels into the
ophthalmic arterial system proximal to the central
retinal artery and follows the subsequent anterior
movement of the injected substance (Fig. 1). This
may occur when the wall of a distal branch is
accidentally perforated by the injecting needle or
cannula. In this case, the force of the injection
used for the product delivery exerted on the
plunger of a syringe can significantly expand these
arterioles many times their normal caliber and can
cause retrograde flow. Once an injection pressure
higher than systolic arterial pressure is applied,33,54
the injected material displaces the arterial blood
and travels proximally past the origin of the retinal
artery. When the plunger is released, the arterial
systolic pressure then propels the resulting column of material into the ophthalmic artery and its
branches. Although larger particles can block
larger and more consequential vessels, ophthalmic artery and central retinal artery blockage can
follow wedging of a very small amount of material
in the retinal artery.
Just as the pressure exerted during injection
may push a column of filler into the ophthalmic
artery, a higher injection pressure may cause the
retrograde migration of the column in the internal carotid artery, permitting cerebrovascular embolization and stroke.30,50 Discoloration and necrosis of the facial skin and cerebral ischemia after
997
Reference
Age
(yr)
Sex
Aesthetic
Procedure(s)
Injecting
Physician
Diameter/Size of
the Cannula/Needle
(Gauge or mm)
Complaint of Symptoms
Procedure/Symptoms
Interval
Teimourian, 19883
45
Plastic surgeon
N/A
44
Several milliliters of
autologous fat injection into
the forehead to remove
facial wrinkles
Plastic surgeon
N/A
47
N/A
N/A
42
Plastic surgeon
N/A
Feinendengen et al.,
19987
45
N/A
47
N/A
N/A
43
N/A
N/A
N/A
N/A
Unspecified
operating
surgeon
N/A
N/A
Injection of 3 ml of
autologous fat into the
cheek to fill a small
deficiency
Fat injection of 0.5 ml in each
oral commissure and lateral
canthal area, 0.25 ml in
each nasojugal trough, and
1.5 ml into a transverse scar
and wrinkle in the forehead
Unspecified
operating
surgeon
Danesh-Meyer et al.,
20018
Coleman, 20029
998
Risk
Factors
N/A
N/A
N/A
N/A
No cardiovascular
risk factor
N/A
Concomitant
bilateral neck and
face rhytidectomy
and liposuction of
the cheeks; high
level of TG and
low level of HDL
Excision of a Bakers
cyst, removal of
femoral varices,
cosmetic
correction of the
inframammary
folds, and
liposuction of the
thighs 4 days
prior; patent
foramen ovale
N/A
N/A
N/A
Pathogenesis/
Diagnosis
Retinal arterial occlusion
probably secondary to
fat particle embolism
Multiple fat emboli
occlusions of distal
branches of the
ophthalmic artery
Time When
Therapy
Started
Therapy
Outcomes
N/A
N/A
N/A
N/A
N/A
N/A
Not specified
Not specified
Not specified
Pupils: symmetrical
Left pupil: weakly reactive to
direct light stimulation
Few hours later, areactive and
mydriatic pupil
Fundus: papilledema and
ischemia of the retina
Not specified
Not specified
On day 3:
Fundus: no evidence of
multiple fat embolisms
in the retinal and
choroidal arterioles
10-mo follow-up: no
report about ocular
situation
On day 1, CT: large
hypodensities in the
left frontotemporal
area the next day
After several weeks: no
restoration of LE vision
N/A
N/A
Not specified
Not specified
N/A
N/A
N/A
N/A
CRAO
(Continued)
999
Injecting
Physician
Diameter/Size of
the Cannula/Needle
(Gauge or mm)
Complaint of Symptoms
Procedure/Symptoms
Interval
Reference
Age
(yr)
Sex
39
5 ml of autologous fat
injection into the glabella to
correct frown lines
N/A
N/A
49
N/A
N/A
30
N/A
N/A
Immediately: nausea,
pain, and visual loss
in RE
27
Unspecified
surgeon
operating in
a plastic
surgery clinic
N/A
Within 10 minutes:
sudden visual loss
24
N/A
N/A
39
Plastic surgeon
N/A
F, female; RE, right eye; N/A, not available; BCVA, best corrected visual acuity; ONH, optic nerve head; MCA, middle cerebral artery; LE, left eye; FA,
fluorescein angiography; CRAO, central retinal artery occlusion; VA, visual acuity; M, male; CT, computed tomography; MRI, magnetic resonance imaging;
TG, triglyceride; HDL, high-density lipoprotein; VEP, visual evoked potentials; OAO, ophthalmic artery occlusion; IOP, intraocular pressure.
1000
None
N/A
None
None
None
Immediate
Ocular
Situation
30 minutes later:
LE: midline fixed
Pupil: dilated and unresponsive to
direct light stimulation
Corneal opacity
IOP: 0 mmHg
Pupil: fixed mid dilated
Fundus: retinal ischemic edema with
segmentary occlusions of multiple
branches of the central retinal
artery by yellow emboli, serous
macular detachment, absence of
cherry-red macular spot
ONH: pale and edematous
Ptosis. FA: choroidal and retinal
unilateral occlusion
BCVA RE: no light perception
Funduscopy: widespread retinal
whitening and obstruction of the
retinal vessels of the fundus with
remarkable edema of the entire
retina
FA: no filling of the retinal arterioles
BCVA RE: hand motion
Right upper eyelid: slight ptosis
Pupil: fixed and mid-dilated
FA: multiple whitish patchy lesions
with macular and ONH edema
and deterioration of choroidal
circulation with patchy choroidal
filling
Fundus: absence of a cherry-red spot
Flash VEP: no response
Swelling and redness of the
eyelids
Pathogenesis/
Diagnosis
Occlusion of the ocular
and facial vessels and
branches of the external
carotid arteries
Time When
Therapy
Started
Therapy
Outcomes
None
After more
than 24 hr
Intravenous
corticosteroids and
antiplatelet therapy
No visual recovery
OAO
Not specified
No improvement
Choroidal infarctions
caused by multiple
occlusions of the short
posterior ciliary artery
On day 5
Drip infusion of
urokinase and
hyperbaric oxygen
therapy
Subsequent
administration of
corticosteroid
Methylprednisolone 1
g/day intravenously
for 3 days and dose
tapering with oral
administration
1001
Reference
Sex
Aesthetic Procedure(s)
25
Dermatologist
N/A
50
Subcutaneous injection of
paraffin on the forehead
N/A
N/A
Baran, 1964*
24
N/A
N/A
N/A
Baran, 1965*
31
N/A
N/A
Immediately: transitory
blindness
30
Injection of hydrocortisone
suspension for alopecia areata
Injection of methylprednisolone
acetate suspension for
alopecia areata
Injection of silicone oil
subcutaneously at the root of
her nose
N/A
N/A
Castillo, 198920
34
N/A
N/A
37
Unspecified
surgeon
25-gauge needle
44
N/A
N/A
48
N/A
N/A
52
Plastic surgeon
N/A
Immediately after
injection: severe RE
pain and visual loss
1002
Injecting
Physician
Diameter/Size of the
Cannula/Needle (Gauge
or mm)
Age
(yr)
Risk Factors
Three previous
treatments with the
same substance
Pathogenesis/
Diagnosis
Time When
Therapy
Started
Therapy
Outcomes
N/A
CRAO
Few minutes
later
On day 9, BCVA:
perception of hand
movements in the
temporal VF only
LE pupil: moderately
reactive
ONH: slightly pale
Retina: white and opaque
in the macular region
Fovea: brownish and
surrounded by a yellow
zone
4 mo later: unchanged
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Persistent impairment of
sight
After 5 minutes: return of
vision
N/A
N/A
N/A
N/A
N/A
N/A
Immediately
Digital massage,
vasodilators, and
acetazolamide
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Central retinal
embolus and
choroidal occlusion
Immediately
N/A
N/A
CRAO
N/A
N/A
Concomitant injection of
1.0 ml of Cymetra to
the bilateral nasolabial
regions and 0.5 ml of
Cymetra to the
bilateral oral
commissure regions
under a local
anesthetic without
incident
N/A
N/A
None
N/A
N/A
On day 9, BCVA: no
improvement
Fundus: retinal hemorrhage
FA: no dye filling of the
white vessel, ONH dye
leakage, zones of retinal
ischemia
VF examination: inferior
altitudinal defect, central
scotoma, RNFL defect in
the superior temporal
region
N/A
1003
Sex
29
Cosmetic
surgeon
N/A
48
N/A
N/A
65
N/A
N/A
Tangsirichaipong,
200928
36
N/A
N/A
Immediately: RE sudden
painful visual loss and
headache
25
Dermatologist
N/A
Immediately:
blepharoptosis and
orbital pain on the
right side
Some hours later: central
necrosis and
surrounding reddish
reticular pattern
affecting the right
eyelid
39
An acquaintance
performed
this
procedure
illegally at a
beauty salon
A self-manufactured
syringe
Immediately: complete
loss of vision in her left
eye and a headache
30
N/A
N/A
Reference
Aesthetic Procedure(s)
Injecting
Physician
Diameter/Size of the
Cannula/Needle (Gauge
or mm)
Age
(yr)
F, female; LE, left eye; N/A, not available; BCVA, best corrected visual acuity; ONH, optic nerve head; CRAO, central retinal artery occlusion;
VF, visual field; RE, right eye; RNFL, retinal nerve fiber layer; PCAO, posterior ciliary artery occlusion; FA, fluorescein angiography; RPE, retinal
pigment epithelium; PMMA, polymethylmethacrylate; AC, anterior chamber; MRI, magnetic resonance imaging; M, male; BRAO, branch
retinal artery occlusion.
*Selmanowitz VJ, Orentreich N. Cutaneous corticosteroid injection and amaurosis: Analysis for cause and prevention. Arch Dermatol. 1974;
110:729 734.
1004
Risk Factors
N/A
Tobacco abuse; no
previously systemic
embolic episodes
N/A
No medical problem
None
None
N/A
Pathogenesis/
Diagnosis
Time When
Therapy
Started
Therapy
Outcomes
N/A
N/A
4-mo follow-up,
BCVA RE: no light
perception; full ocular
motility and no
blepharoptosis; clear
cornea
Fundus: ONH atrophy
Immediately
500 mg of
acetazolamide
N/A
N/A
N/A
After 2 hr
Ocular massage, AC
paracentesis, and
oral acetazolamide
PCAOs, choroidal
ischemia limited in
the nasal area and
occlusion of the
branch to the
oculomotor nerve
After 8 hr
Topical and
intravenous
antibiotics and
topical steroids,
followed by low
dose of tapering
oral corticosteroids
After 3 mo
BCVA RE: 20/20 with
pinhole
No intraocular
inflammation or
oculomotor nerve palsy;
still fixed dilated pupil
Multiple BRAOs
On day 3
Low-dose antiplatelet
agent and a calcium
channel blocker
Blindness
CRAO
On day 2
Intravenous
methylprednisolone
at 1 g/day for 3
days and tapered
high-dose oral
prednisolone and
aspirin at 100 mg;
daily Comfeel
dressing
At 6 mo:
Complete recovery of the
eyeball movement
Progressive exudative and
tractional retinal
detachment at the
inferonasal retina caused
phthisis bulbi
1005
Fig. 1. Schematic drawing that shows the anatomy, distribution, and connections
between the ophthalmic and the facial arterial systems. The supratrochlear artery
is the terminal branch of the ophthalmic artery and exits at the superior and medial
corner of the bony orbit by piercing the orbital septum with the supratrochlear
nerve. It runs superiorly into the forehead, where it supplies the integument, muscles, and pericranium and maintains numerous anastomoses with the supraorbital
artery and with the contralateral vessels. This is the vessel most likely to be involved
when intraarterial injection of fat and foreign material of the glabella and forehead
is responsible for embolization. The supraorbital artery may occasionally be the
route of embolization of injected material. It arises from the ophthalmic artery and
divides into superficial and deep branches that nourish the integument, muscles,
and pericranium of the forehead. Its terminal branches anastomose with the supratrochlear artery, the frontal branch of the superficial temporal artery, and the
contralateral supraorbital artery. The second terminal branch of the ophthalmic
artery, the dorsal nasal artery, may be responsible for transmission of emboli following injections low in the glabella or proximal to the nasal root. It anastomoses
with the angular artery, the dorsal nasal artery of the opposite side, and the lateral
nasal branch of the facial artery. The facial artery arises from the external carotid
artery that supplies the structures of the face. The facial artery passes forward and
upward across the cheek to the angle of the mouth, where it arborizes and gives rise
to the labial systems and, more distally, to the lateral nasal artery that supplies the
ala and dorsum of the nose. It further forms anastomoses with its contralateral
counterpart, with the septal and alar branches, with the dorsal nasal branch of the
ophthalmic artery, and with the infraorbital branch of the internal maxillary. The
facial artery then ascends along the side of the nose, ending at the medial canthus,
where it is named the angular artery. After supplying the lacrimal sac and orbicularis oculi, it ends by anastomosing with the dorsal nasal branch of the ophthalmic
artery. The angular artery on the cheek distributes branches that anastomose also
with the infraorbital artery. The facial artery should be considered for embolization
following injections of the cheek, nasolabial folds, and lips.
1006
intraocular pressure and increase arteriolar flow, potentially dislodging the embolus, but it has been
ineffective in all four of the cases included in this
study.6,16,19,28 Intravenous administration of diuretics
such as acetazolamide81 may both increase retinal
blood flow and immediately reduce intraocular pressure. This approach failed in two patients19,28 but was
successful in one case.26 Retinal arteriolar dilation
and oxygen delivery to ischemic tissues from ophthalmic vessels may be encouraged by carbogen (5
percent carbon dioxide and 95 percent oxygen)
inhalation.82 The only patient6 who underwent carbogen rebreathing had no substantial recovery of his
sight. Although hyperbaric oxygen therapy may theoretically be beneficial, transportation to the
nearest chamber may usurp precious time. Neither
patient6,12 treated with oxygen therapy improved.
Systemic and topical corticosteroids were successfully administrated in one case, with full recovery of
sight but with a persistently dilated pupil.29 Systemic
and local intraarterial fibrinolyses have failed to dissolve cholesterol or heterologous materials83 as reported in four cases.11,12,15,30
In the European Assessment Group for Lysis in
the Eye study,77 a significant improvement in best
corrected visual acuity in patients with an acute central retinal artery occlusion was obtained in 60 percent of patients at 1 month after a six-step therapy
administered within 20 hours after the ischemic
event. In the present review, improvement after therapy was achieved in only two cases (14 percent), both
of which suffered ocular embolism following injection of heterologous material (hyaluronic acid26 and
calcium hydroxyapatite,29 respectively). In the first
case, partial visual loss in the inferior visual field
improved to a best corrected visual acuity of 6/6
within 24 hours after immediate administration of
500 mg of acetazolamide,26 and in the second case,
a best corrected visual acuity of hand movement
improved to 20/20 at 3 months after topical antibiotics and steroids, including intravenous antibiotics,
were initiated 8 hours after the occlusive event and
followed by a low-dose oral corticosteroid taper.29 In
the first case,26 the recovery was attributable to both
the natural history of a branch retinal artery
occlusion82 and to the therapy that could have dislodged the embolus peripherally relative to the retinal edema. Both effects would have allowed resolution of the retinal edema and thus explained the
visual improvement. In the second case,29 the injury
was a posterior ciliary artery occlusion, and the choroidal ischemia was limited to the nasal area; thus,
the recovery was likely determined by resolution of
the corneal edema and the severe anterior chamber
reaction, which included hyphema and hypopyon,
1007
1008
Fig. 2. A useful algorithm approach is presented to minimize the occurrence of ophthalmic arterial system embolization during
facial cosmetic injections.
rather than by the resolution of the choroidal ischemia. In the other 12 cases in which the therapy was
administered, no improvement was achieved regardless of the nature of the embolus (fat6,1115 or heterologous material16,19,21,28,30,31). The time between the
occlusive event and the onset of the therapy could
have contributed to these failures, however. In the
European Assessment Group for Lysis in the Eye
study,77 the authors suggested that the visual prognosis in patients with acute central retinal artery
occlusion depends in part on the duration of symptoms, with a shorter duration associated with better
visual outcome. In five cases described in this review,
the therapy was administered after more than 20
hours11,13,14,30,31; in two cases,6,12 the timing was not
specified; and in five cases, it was administered
within 20 hours.15,16,19,21,28
Incomplete treatment could also have contributed to failure. In the European Assessment Group
for Lysis in the Eye study,77 the standard treatment
of central retinal artery occlusion included a six-step
1009
CONCLUSIONS
Some steps may minimize the risk of embolization of filler into the ophthalmic artery following
facial cosmetic injections. Intravascular placement
of the needle or cannula should be demonstrated by
aspiration before injection and should be further
prevented by application of local vasoconstrictor.
Needles, syringes, and cannulas of small size should
be preferred to larger ones and be replaced with
blunt flexible needles and microcannulas when possible. Low-pressure injections with the release of the
least amount of substance possible should be considered safer than bolus injections. The total volume
of filler injected during the entire treatment session
should be limited, and injections into pretraumatized tissues should be avoided. Actually, no safe,
feasible, and reliable treatment exists for iatrogenic
retinal embolism. Nonetheless, therapy should theoretically be directed to lowering intraocular pressure to dislodge the embolus into more peripheral
vessels of the retinal circulation, increasing retinal
perfusion and oxygen delivery to hypoxic tissues.
1010
ACKNOWLEDGMENTS
1011
1012