Vision-Threatening Complications of Soft Tissue Fillers: A Report by the American Academy of Ophthalmology.

Abstract

Purpose: To review evidence on ocular complications of injectable soft tissue fillers, identify features associated with risk for vision loss, and assess the efficacy and safety of reported treatments.

Methods: Literature search of the PubMed database was last conducted in May 2024. Articles were limited to English-language original research describing ocular complications of soft tissue fillers. Of 387 articles identified, 62 were selected for full-text review. Nineteen articles met the criteria for inclusion.

Results: All 19 articles were assigned a level III rating by the panel methodologist. This assessment identified 198 cases of vision loss caused by accidental intravascular injection of filler material, hyaluronic acid gel in 164 cases (83%), autologous fat in 29 cases (15%), collagen in 3 cases, poly-L lactic acid gel in 1 case, and calcium hydroxyapatite in 1 case. The 226 injection sites, sometimes multiple locations, when described, were nose in 90 cases (40%); forehead in 56 cases (25%); glabella in 26 cases (12%); temple in 21 cases (9%) frontal in 17 cases (7%); nasolabial fold in 9 cases (4%); face in 2 cases; periocular in 2 cases; and lip, eyebrow, cheek, and upper eyelid in 1 case each. The central and upper midface (nose, forehead, glabella, frontal) were the most common sites (189 cases, 84%). The most common therapeutic interventions included hyaluronidase injection (local, orbital, and intra-arterial), intra-arterial injection of thrombolytic agents and hyaluronidase, anterior chamber paracentesis, IV corticosteroid, IV mannitol, and hyperbaric oxygen. These interventions, although safe, were usually not effective in reversing vision loss. Vision after the occlusive event and final vision were described in 196 cases; it was unchanged in 137 patients (70%), improved in 56 patients (28%), and worsened in 3 patients (2%).

Conclusions: Inadvertent intravascular injection of soft tissue fillers is associated with cases of vision loss, with upper and central midface a common site of injection. This suggests zones of higher risk for vision loss compared with other facial areas. Hyaluronic acid gel was the most common material, although vison loss was also associated with a variety of other filler materials. No evidence-based protocol has been established for managing vision loss, but intra-arterial thrombolysis has had some success in recanalizing occluded arteries.

Financial disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.