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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E56 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 hyaluronidase has been shown to be ineffective at recanalizing the retinal artery occlusion or improving the visual outcome after four hours after onset of blindness. 3 SPECIALIST TREATMENT Once the patient has been transferred to the hospital setting, the aim is to further reduce intraocular pressure, remove/reverse central retinal ischaemia, and increase blood flow to the retina. The following treatment methods may be used: • Injection of 500mg IV acetazolamia, which should increase retinal blood flow and reduce intraocular pressure. • Use of enoxaparin subcutaneously or IV heparin for anticoagulation 7 —If the patient is having signs or symptoms of cerebral infarction, defer this step until a neurologist has assessed the patient. • Intravenous infusion of mannitol 20% (100mLover 30 minutes). 4,7 • Injection of hyaluronidase via the transorbital approach into the more prominent and tortuous postseptal ophthalmic artery. 21 OTHER SUPPORTIVE THERAPIES • Anterior chamber paracentesis 7,11 to immediately lower intraocular pressure • Steroid administration, 7 intravenous dexamethasone 4,14 • Judicious use of antibiotics for suspected infection 7 • Hyperbaric oxygen may salvage vulnerable retinal damage. 7,11,14 Practitioners should familiarise themselves with their nearest hyperbaric oxygen chamber. • Intravenous prostaglandin E14 to increase blood flow to the retina and decrease activation of thrombocytes and neutrophils. DISCLAIMER The ACE Group have produced a series of evidence based and peer reviewed guidelines to help practitioners prevent and manage complications that can occur in aesthetic practice. These guidelines are not intended to replace clinical judgement and it is important the practitioner makes the correct diagnosis and works within their scope of competency. Some complications may require prescription medicines to help in their management and if the practitioner is not familiar with the medication, the patient should be appropriately referred. Informing the patient's General Practitioner is considered good medical practice and patient consent should be sought. It may be appropriate to involve the General Practitioner or other Specialist for shared care management when the treating practitioner is not able or lacks experience to manage the complication themselves. Practitioners have a duty of care and are accountable to their professional bodies and must act honestly, ethically and professionally. REFERENCES 1. Lazzeri D, Agonstini T, Figus M, et al. Blindness following cosmetic injections of the face. Plastic Reconstructive Surgery, 2012 April; 129(4):995–1012. 2. von Bahr G. Multiple embolisms in the fundus of an eye after an injection in the scalp. Acta Ophthalmol (Copenh.) 963;41:85–91. 3. Zhu GZ, Sun ZS, Liao WX, et al. Efficacy of retrobulbar hyaluronidase injection for vision loss resulting from hyaluronic acid filler embolization. Aesthetic Surg J 2017;38(1):12–22. 4. Szantyr A, Orski M, Marchewka I, et al. Ocular complications following autologous fat injections into facial area: case report of a recovery from visual loss after ophthalmic artery ccclusion and a review of the literature. Aesthetic Plast Surg. 2017; 41(3):580–584. 5. Park KH, Kim YK, Woo SJ. Iatrogenic occlusion of the ophthalmic artery after cosmetic facial filler injections. JAMA Ophthalmol.2014;132(6):714–723. 6. Yujin M, Sangjun Y, Jeong JH, et al. The classification and prognosis of periocular complications related to blindness following cosmetic filler injection. Plastic and Recon Surg. 2017;140(1):61–64. 7. Loh KTD, Chua JJ. Prevention and management of vision loss relating to facial filler injections. Singapore Med J. 2016;57(8):438–443. 8. Tansatit T, Moon HJ, Apinuntrum P, Phetudom T. Verification of embolic channel causing blindness following filler injection. Aesthetic Plast Surg. 2015;39(1):154–161. 9. Khan TT, Colon-Acevedo B, Mettu P, et al. An anatomical analysis of the supratrochlear artery: considerations in facial filler injections and preventing vision loss. Aesthetic Surg J.2017;37(2):203–208. 10. Woo SJ, Park SW, Park KH, et al. Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections. Am J Ophthalmol. 2012;154(4):653–662. 11. Carle MV, Roe R, Novack R, Boyer DS. Cosmetic facial fillers and severe vision loss. JAMA Ophthalmol. Epub March 06, 2014. doi:10.1001/jamaophthalmol.2014.498. 12. Belezany K, Carruthers JDA, Humphrey S, Jones DJ. Avoiding and treating blindness from fillers: a review of the world literature. Dermatologic Surg. 2015;41: 1097–1117 13. Townshend A. Blindness after facial injection. J Clin Aesthet Dermatol. 2016;9(12):E5–E7. Epub 2016 Dec 1. 14. Hu XZ, Hu JY. Posterior ciliary artery occlusion caused by hyaluronic acid injections into the forehead. Medicine (Baltimore). 2016 Mar;95(11):e3124. doi: 10.1097/ MD.0000000000003124. 15. Hazani R, Yaremchuk MJ. Correction of posttraumatic enophthalmos. Arch Plast Surg. 2012;39:11–17. 16. Lohn JW, Penn JW, Norton J, Butler PE. The course and variation of the facial artery and vein: implications for facial transplantation and facial surgery. Ann Plast Surg. 2011 Aug;67(2):184–188. 17. Fraser SG, Adams W. Interventions for acute non-arteritic central retinal artery occlusion. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD001989. doi: 0.1002/14651858. CD001989.pub2. 18. Prado G, Rodriguez-Feliz J. Ocular pain and impending blindness during facial cosmetic injections: Is your office prepared? Aesth Plast Surg. 2017;41:199–203. 19. Baker DL. Gentle, prolonged ocular massage can restore vision after retinal artery occlusion. Healio.com website. Ocular Surgery News U.S. Edition. July 1, 2004. https:// www.healio.com/ophthalmology/retina-vitreous/ news/print/ocular-surgery-news/%7b39ac5b8e-e0c2- 4e4a-9df4-cf1b1a77f289%7d/gentle-prolonged- ocular-massage-can-restore-vision-after-retinal-artery- occlusion. Access date: 27 Apr 2018. 20. Chestnut C. Restoration of visual loss with retrobulbar hyaluronidase injection after hyaluronic acid filler. Dermatol Surg. 2018;44(3):435–437. 21. Tansatit T, Apinuntrum P, Phetudom T. An anatomic basis for treatment of retinal artery occlusions caused by hyaluronic acid injections: a cadaveric study. Aesthetic Plast Surg. 2014;38(6):1131–1137. EMERGENC Y KIT EXPERT GROUP: Martyn King, MD; Emma Davies, RN, NIP; Stephen Basset, MD; Sharon King, RN, NIP. EMERGENC Y KIT CONSENSUS GROUP: Sharon Bennet, RN, NIP; Ben Coyle, MD; David Eccleston, MD; Xavier Goodarzian, MD; Andrew Rankin, RN, NIP; Sam Robson, MD; Lou Sommereux; Askari Townshend, MD; Patrick Treacy, MD; Frances Turner-Trail, RN, NIP. Access the complete library of guidelines here.

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