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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E54 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 Belezany 12 identified 98 cases of vision change. Reported high risk areas include glabella (38.8%), nasal region (25.5%), nasolabial fold (13.3%), and forehead (12.2%). Autologous fat was responsible for most of the complications (47.9%) followed by hyaluronic acid (23.5%), 12 and,in cases when autologous fat had been injected, 5,10 worse outcomes have been reported In 2012, the United Kingdom reported its first case (after injection to the temple with Poly-L-Lactic Acid, the first report with this product). 13 In 2013, the first two cases of bilateral blindness were reported (calcium hydroxyapatite to the nose and hyaluronic acid to the glabella, which also led to cerebral infarction). 11 The exact incidence of this devastating adverse event remains to be determined due to the heterogeneity of data. 7 Due to the seriousness of this complication, as part of the consent process, significant visual loss should be explained to the patient as a possible rare complication. 11 SIGNS AND SYMPTOMS • Pain (ocular, facial, headache or a combination) • Nausea • Vision loss • Paralysis or weakness of ocular muscles • Ptosis • Posterior displacement of the eye • Strabismus (misalignment of the eyes when looking at an object) • Corneal oedema • Pupillary abnormality • Iris atrophy • Anterior chamber inflammation • Phthisis bulbi (shrunken, non-functional eye) • Livedo reticularis (a mottled, reticulated vascular pattern of the skin). Visual loss following embolization of dermal filler typically occurs within seconds of injection, 7 although visual loss has been reported seven hours post-treatment in the case of a posterior ciliary artery occlusion. 14 Complete loss of vision is the normal presentation, although there might be visual field defects. Visual loss is often accompanied by sudden onset of severe pain (ocular, facial, and/or headache), although central retinal and retinal branch artery occlusions might present without ocular pain. Other symptoms include ophthalmoplegia (paralysis or weakness of ocular muscles), ptosis, enophthalmos (posterior displacement of the eye), and horizontal strabismus (abnormal alignment of the eyes). These symptoms accompany blindness due to disturbed flow to the superior and inferior branches, which supply the extraocular muscles. 6 Many cases with visual loss and periocular symptoms also subsequently develop enophthalmos, and surgery should be considered in patients demonstrating greater than 2mm descent within six weeks of the injury. 15 Other symptoms and signs include corneal edema, anterior chamber inflammation, nausea, headache, pupillary abnormality, iris atrophy, phthisis bulbi, and livedo reticularis. 7 Cerebral infarction can accompany retinal artery occlusion, and therefore signs and symptoms such as aphasia or even contralateral hemiparesis might also be present. Central nervous system complications were seen in 23.5 12 to 39 percent 5 of cases where vision was affected. An magnetic resonance imaging (MRI) scan should be performed in all patients who suffer visual loss or ocular pain as a result of filler injections. 10 AREAS OF CAUTION Injections into the nose and glabella form the vast majority of reported cases of blindness, 7 although moderate risk sites include the nasolabial folds, forehead, periocular region, temple, and cheek. Uncommon sites are the eyelid, lips ,and chin. Due to its complex vascularity, any region of the face is at risk for this complication. 4 MINIMIZING THE RISK The key preventative strategies are as follows: 6 1. Know the location and depth of facial vessels and the common variations. 7 Injectors should understand the appropriate depth and plane of injection at different sites. 2. Inject slowly and with minimal pressure. 1,4,11 3. Inject in small increments 1,7 so that any filler injected into the artery can be flushed peripherally before the next incremental injection. This prevents a column of filler traveling retrograde and subsequently anterograde. No more than 0.1mL of filler should be injected with each increment. 4. Move the needle tip while injecting 4 so as not to deliver a large deposit in one location. 5. Always aspirate before injection, 1,4,7 though

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