Journal of Clinical and Aesthetic Dermatology

MAY 2018

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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E53 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY April 2018 • Volume 11 • Number 4 T H E E M E R G E N C Y K I T A n A e s t h e t i c Co m p l i ca t i o n s E x p e r t G ro u p Co n s e n s u s Pa p e r W elcome to the JCAD Aesthetic Complications Guidelines by The Aesthetic Complications Expert (ACE) Group. The ACE Group developed a series of evidence-based, peer-reviewed guidelines that cover complications that can occur in nonsurgical aesthetic practices. The objective of this series is to help dermatologists and other physicians performing aesthetic procedures identify and manage these potential complications. Each guideline was produced after a vast literature review by leading experts in the United Kingdom. We hope these guidelines help raise treatment standards within the medical community and ensure early diagnosis and appropriate management of complications, ultimately improving outcomes for our patients. This month's guideline Visual Loss Secondary to Cosmetic Filler Injection by Lee Walker, MD; Martyn King, MD JCAD A E S T H E T I C CO M P L I C AT I O N S G U I D E L I N E S DEFINITION Any impairment or loss of vision (temporary or permanent) secondary to central retinal or retinal branch artery occlusion occurring as a direct conse- quence of percutaneous injection for aesthetic treatment 1 INTRODUCTION Blindness after facial injection is extremely rare and was first reported by von Bahr 2 over 50 years ago after scalp injection of a hydrocortisone suspension to treat alopecia. The first cases after aesthetic filler treatments were reported in the 1980s (four cases) and rose to at least 16 reported cases between 2000 and 2010, presumably related to the increase in the number of treatments being performed. 1 Depending on which artery is occluded, vision loss can be classified into six subtypes: 3–5 • Ophthalmic artery occlusion (OAO) • Generalized posterior ciliary artery occlusion with relative central retinal artery sparing (PCAO) • Central retinal artery occlusion (CRAO) • Branch retinal artery occlusion (BRAO) • Anterior ischaemic optic neuropathy (AION) • Posterior ischaemic optic neuropathy (PION). There are also four subtypes of periocular complications associated with blindness following cosmetic filler injection: 6 • Type I –Blindness without ophthalmoplegia (paralysis or weakness of ocular muscles) and ptosis • Type II – Blindness with ptosis but without ophthalmoplegia • Type III – Blindness with ophthalmoplegia but without ptosis • Type IV – Blindness with ophthalmoplegia and ptosis. Based on previously reported case studies, improvement of visual acuity in patients with vascular occlusion after filler injection is extremely rare. By contrast, periocular symptoms such as ptosis and ophthalmoplegia recovered dramatically. 6 MECHANISM Terminal branches of the ophthalmic artery, namely the supraorbital and supratrochlear, supply the medial forehead, and anastomoses between these vessels and the terminal branches of the angular artery are well documented. 7 Similarly, anastomoses with the superficial temporal arteries and the orbit have also been demonstrated. 8 Injection of filler material into one of these vessels can lead to retrograde flow to beyond the point of the origin of the ophthalmic artery, and when pressure from the plunger is released, systolic pressure drives the product forward to enter the ophthalmic artery or central retinal artery, resulting in visual loss (Figure 1). In order for blindness to occur, there must be retrograde and subsequent anterograde passage of material, injection pressure exceeding systolic pressure, and sufficient amount of material within the lumen of the vessel. Findings indicate that the average entire volume of the supratrochlear artery from the glabella to the orbital apex is 0.085mL (range 0.04–0.12mL), 9 and injection volume should not exceed this volume in critical injection points. INCIDENCE Globally, at least 98 cases of vision loss after aesthetic facial injection have been reported prior to 2015. 1,10,11,12 A review of the world literature by - J Clin Aesthet Dermatol 2018;11(5):E53-E55 Seriousness of Complication Frequency of Complication Minor Complication Common Worrying Complication Occasional Moderate Complication Infrequent Serious, but not major Rare Major Complication X Very Rare X

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