Patient 1

A healthy man in his late 30s presented 3 weeks after he noticed superior field visual loss in his left eye the day after an injection of a hyaluronic acid filler injection to his forehead. At the initial visit, his visual acuity was 20/20 OD and 20/30 OS. Dilated fundus examination of the left eye revealed retinal oedema and whitening in the inferotemporal macula consistent with a branch retinal artery occlusion. The whitening extended to the fovea, and a partial cherry-red spot was seen in the central macula, along with scattered intraretinal haemorrhage. Fluorescein angiography demonstrated blockage of the inferior branches of the retinal circulation in the left eye and areas of patchy choroidal nonperfusion.

One year later, the patient continued to experience a superior visual field defect in the left eye. His visual acuity was 20/25 OS. Optical coherence tomography demonstrated selective retinal thinning of the inferior macula.

Patient 2

A healthy woman in her early 60s presented the same day she experienced severe loss of vision, which occurred immediately after autologous fat injection into the high part of her forehead; the needle marks were visible just below the hairline. Her visual acuity was no light perception OD and 20/40 OS. Dilated fundus examination of the right eye revealed diffuse whitening of the retina, as well as lipid-filled arterioles. Fluorescein angiography demonstrated patchy choroidal filling and incomplete filling of the retinal arterioles in the later frames. A complete blood cell count was obtained, with differential count, erythrocyte sedimentation rate, and C-reactive protein level; all values were within normal limits. Carotid Doppler ultrasonography and cardiac echocardiography revealed no abnormalities.

Patient 3

A healthy woman in her mid-40s presented to the clinic after having received an injection of bovine collagen and polymethylmethacrylate microspheres (Artefill; Suneva) to her forehead creases that morning. After the injection was complete, she opened her eyes and could not see with her right eye. Her visual acuity was no light perception OD and 20/20 OS. A right afferent pupillary defect was demonstrated. Dilated fundus examination showed a cherry-red spot and retinal oedema, in keeping with a central retinal artery occlusion. Fluorescein angiography demonstrated delayed filling of some of the proximal arteries in the right eye, but the filling was patchy.

Because this was an acute presentation, we performed anterior chamber paracentesis and removed 0.1 mL of aqueous to rapidly lower the intraocular pressure. In the clinic, the patient received a litre of normal saline solution intravenously and underwent ocular massage; she was then transferred to receive hyperbaric oxygen therapy. Two days later, her right pupil was minimally reactive to light and her visual acuity was faint light perception OD

https://jamanetwork.com/journals/jamaophthalmology/fullarticle/1838342

In a 2015 review, 98 cases were analysed.

It’s apparent that there are many variables which correlate with the risk of blindness.

The only one which we are not in complete control of is the anatomy, as this is not precisely textbook for every single patient. Being aware and prepared to adjust everything possible to compensate will allow for risk.

We have already discussed high risk injection areas for visual disturbance, let’s see how the data and stats correlate:

39% of cases were as a result of injections in the glabella 25% in the nasal region
13% in the nasolabial fold and
12% in the forehead.

5% in the temple
6% in the periocular region

OTHER POINTS FOR CONSIDERATION IN RELATION TO THE ABOVE DATA

Anatomical structures of the face and how that relates to the eye area

Injection site

Injected product type

Amount of product injected