Journal of Clinical Neuroscience 21 (2014) 890–891
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Correspondence
Panophthalmoplegia and vision loss after cosmetic nasal dorsum injection
Dear Professor Kaye, We read with interest the recent review by Kim et al. entitled ‘‘Panophthalmoplegia and vision loss after cosmetic nasal dorsum injection’’ in the April 2014 issue of the Journal of Clinical Neuroscience [1]. The authors are to be commended for their detailed description of a new case of visual loss following facial cosmetic injection with filling materials. They discussed the sight-threatening and sometimes lifethreatening iatrogenic injuries directly related to injected substances. Here, we highlight some key points regarding the management and prevention of blindness following facial cosmetic injections, recount a serious eye injury that has recently heightened awareness [2,3] and propose ways to avoid such injuries [2]. Including the patients reported by Kim et al. [1], 25 patients diagnosed with transitory or permanent blindness or neurovascular injury following facial injections of cosmetic materials have been described in the literature to our knowledge [2–5]. The nose (root, dorsum or tip) was the injected site in nine patients [1,2,4]. Permanent visual loss without light perception combined with ophthalmoplegia and cerebral infarction persisted in almost all patients regardless of the type of material injected or the type of treatment attempted [2,3]. In one patient blindness and anterior segment ischemia occurred in both eyes after a filler injection for nose augmentation [4]. We agree with the authors regarding the presumed origin of the symptoms [2]. In all of these patients direct intra-arterial delivery of the product and its retrograde embolization via high pressure injection through a syringe has been suggested as the main cause of the retinal embolism. Some particles of the injected material were accidentally delivered in the lumen of an arteriole and pushed in a retrograde fashion from peripheral vessels into the ophthalmic arterial system proximal to the central retinal artery. Once the plunger of the syringe is released, the arterial systolic pressure propelled the resulting column of material into the ophthalmic artery and its branches. Once the filler reached the ophthalmic artery it can cause occlusion or be flushed anteriorly and block the central retinal artery or its branches, depending on the variable particle size. The same mechanism might explain cerebral infarction and stroke due to retrograde migration of the filling substance in the internal carotid artery system. Ophthalmic system embolization may occur only when a sufficient amount of material delivered into the vessel is pushed retrogradely with an injection pressure higher than the sum of the systolic arterial pressure and the frictional forces due to viscous flow pressure drops within the vessel [1]. The force of the injection used for the product delivery exerted on the plunger of a syringe
significantly expands the arterioles to many times their normal caliber and can cause retrograde flow. Currently no safe and curative treatment exists for iatrogenic retinal embolism. Some precautions should be kept in mind to decrease the occurrence of such complication following facial cosmetic injections [2,3]. Aspiration before injection may reveal the intravascular location of the needle. Small size needles and cannulas or blunt flexible needles and microcannulas should be preferred. Low injection pressure and the delivery of a limited amount of filler in every session should diminish the risk of retrograde ocular embolization. References [1] Kim SN, Byun DS, Park JH, et al. Panophthalmoplegia and vision loss after cosmetic nasal dorsum injection. J Clin Neurosci 2013 [Epub ahead of print]. [2] Lazzeri D, Agostini T, Figus M, et al. Blindness following cosmetic injections of the face. Plast Reconstr Surg 2012;129:995–1012. [3] Park SW, Woo SJ, Park KH, et al. Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections. Am J Ophthalmol 2012;154:653–62. [4] Kim YJ, Choi KS. Bilateral blindness after filler injection. Plast Reconstr Surg 2013;131:298e–9e. [5] Roberts SA, Arthurs BP. Severe visual loss and orbital infarction following periorbital aesthetic poly-(L)-lactic acid (PLLA) injection. Ophthal Plast Reconstr Surg 2012;28:e68–70.
Davide Lazzeri Plastic Reconstructive and Aesthetic Surgery Unit, Villa Salaria Clinic, Rome, Italy Giuseppe Spinelli Maxillofacial Unit, Hospital of Florence, Florence, Italy Yi Xin Zhang Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China Tel.: +86 21 2327 1699; fax: +86 21 6305 1858. E-mail address: [email protected] Marco Nardi Stefano Lazzeri Ophthalmology Unit, University Hospital of Pisa, Pisa, Italy
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Correspondence
Panophthalmoplegia and vision loss after cosmetic nasal dorsum injection
Dear Professor Kaye, We read with interest the recent review by Kim et al. entitled ‘‘Panophthalmoplegia and vision loss after cosmetic nasal dorsum injection’’ in the April 2014 issue of the Journal of Clinical Neuroscience [1]. The authors are to be commended for their detailed description of a new case of visual loss following facial cosmetic injection with filling materials. They discussed the sight-threatening and sometimes lifethreatening iatrogenic injuries directly related to injected substances. Here, we highlight some key points regarding the management and prevention of blindness following facial cosmetic injections, recount a serious eye injury that has recently heightened awareness [2,3] and propose ways to avoid such injuries [2]. Including the patients reported by Kim et al. [1], 25 patients diagnosed with transitory or permanent blindness or neurovascular injury following facial injections of cosmetic materials have been described in the literature to our knowledge [2–5]. The nose (root, dorsum or tip) was the injected site in nine patients [1,2,4]. Permanent visual loss without light perception combined with ophthalmoplegia and cerebral infarction persisted in almost all patients regardless of the type of material injected or the type of treatment attempted [2,3]. In one patient blindness and anterior segment ischemia occurred in both eyes after a filler injection for nose augmentation [4]. We agree with the authors regarding the presumed origin of the symptoms [2]. In all of these patients direct intra-arterial delivery of the product and its retrograde embolization via high pressure injection through a syringe has been suggested as the main cause of the retinal embolism. Some particles of the injected material were accidentally delivered in the lumen of an arteriole and pushed in a retrograde fashion from peripheral vessels into the ophthalmic arterial system proximal to the central retinal artery. Once the plunger of the syringe is released, the arterial systolic pressure propelled the resulting column of material into the ophthalmic artery and its branches. Once the filler reached the ophthalmic artery it can cause occlusion or be flushed anteriorly and block the central retinal artery or its branches, depending on the variable particle size. The same mechanism might explain cerebral infarction and stroke due to retrograde migration of the filling substance in the internal carotid artery system. Ophthalmic system embolization may occur only when a sufficient amount of material delivered into the vessel is pushed retrogradely with an injection pressure higher than the sum of the systolic arterial pressure and the frictional forces due to viscous flow pressure drops within the vessel [1]. The force of the injection used for the product delivery exerted on the plunger of a syringe
significantly expands the arterioles to many times their normal caliber and can cause retrograde flow. Currently no safe and curative treatment exists for iatrogenic retinal embolism. Some precautions should be kept in mind to decrease the occurrence of such complication following facial cosmetic injections [2,3]. Aspiration before injection may reveal the intravascular location of the needle. Small size needles and cannulas or blunt flexible needles and microcannulas should be preferred. Low injection pressure and the delivery of a limited amount of filler in every session should diminish the risk of retrograde ocular embolization. References [1] Kim SN, Byun DS, Park JH, et al. Panophthalmoplegia and vision loss after cosmetic nasal dorsum injection. J Clin Neurosci 2013 [Epub ahead of print]. [2] Lazzeri D, Agostini T, Figus M, et al. Blindness following cosmetic injections of the face. Plast Reconstr Surg 2012;129:995–1012. [3] Park SW, Woo SJ, Park KH, et al. Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections. Am J Ophthalmol 2012;154:653–62. [4] Kim YJ, Choi KS. Bilateral blindness after filler injection. Plast Reconstr Surg 2013;131:298e–9e. [5] Roberts SA, Arthurs BP. Severe visual loss and orbital infarction following periorbital aesthetic poly-(L)-lactic acid (PLLA) injection. Ophthal Plast Reconstr Surg 2012;28:e68–70.
Davide Lazzeri Plastic Reconstructive and Aesthetic Surgery Unit, Villa Salaria Clinic, Rome, Italy Giuseppe Spinelli Maxillofacial Unit, Hospital of Florence, Florence, Italy Yi Xin Zhang Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China Tel.: +86 21 2327 1699; fax: +86 21 6305 1858. E-mail address: [email protected] Marco Nardi Stefano Lazzeri Ophthalmology Unit, University Hospital of Pisa, Pisa, Italy
