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Rahman E, Philipp-Dormston WG, Webb WR, Rao P, Sayed K, Sharif AQMO, Yu N, Ioannidis S, Tam E, Rahman Z, Mosahebi A, Goodman GJ. "Filler-Associated Acute Stroke Syndrome": Classification, Predictive Modelling of Hyaluronidase Efficacy, and Updated Case Review on Neurological and Visual Complications. Aesthetic Plast Surg 2024:10.1007/s00266-024-04202-y. [PMID: 38971925 DOI: 10.1007/s00266-024-04202-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/09/2024] [Indexed: 07/08/2024]
Abstract
INTRODUCTION The rising use of soft tissue fillers for aesthetic procedures has seen an increase in complications, including vascular occlusions and neurological symptoms that resemble stroke. This study synthesizes information on central nervous system (CNS) complications post-filler injections and evaluates the effectiveness of hyaluronidase (HYAL) treatment. METHODS A thorough search of multiple databases, including PubMed, EMBASE, Scopus, Web of Science, Google Scholar, and Cochrane, focused on publications from January 2014 to January 2024. Criteria for inclusion covered reviews and case reports that documented CNS complications related to soft tissue fillers. Advanced statistical and computational techniques, including logistic regression, machine learning, and Bayesian analysis, were utilized to dissect the factors influencing therapeutic outcomes. RESULTS The analysis integrated findings from 20 reviews and systematic analyses, with 379 cases reported since 2018. Hyaluronic acid (HA) was the most commonly used filler, particularly in nasal region injections. The average age of patients was 38, with a notable increase in case reports in 2020. Initial presentation data revealed that 60.9% of patients experienced no light perception, while ptosis and ophthalmoplegia were present in 54.3 and 42.7% of cases, respectively. The statistical and machine learning analyses did not establish a significant linkage between the HYAL dosage and patient recovery; however, the injection site emerged as a critical determinant. CONCLUSION The study concludes that HYAL treatment, while vital for managing complications, varies in effectiveness based on the injection site and the timing of administration. The non-Newtonian characteristics of HA fillers may also affect the incidence of complications. The findings advocate for tailored treatment strategies incorporating individual patient variables, emphasizing prompt and precise intervention to mitigate the adverse effects of soft tissue fillers. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Eqram Rahman
- Research and Innovation Hub, Innovation Aesthetics, London, WC2H9JQ, UK.
| | | | | | - Parinitha Rao
- The Skin Address, Aesthetic Dermatology Practice, Bengaluru, India
| | - Karim Sayed
- Nomi Oslo, Oslo, Norway
- University of South-Eastern Norway, Drammen, Norway
| | - A Q M Omar Sharif
- Shaheed Suhrawardy Medical College, Sher e Bangla Nagar, Dhaka, Bangladesh
| | - Nanze Yu
- Peking Union Medical College Hospital, Beijing, China
| | | | | | - Zakia Rahman
- Stanford Dermatology, Stanford University School of Medicine, Redwood City, CA, USA
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Xiao H, Kou W, Yang Y, Dai E, Zhang X, Wen Y, Peng J, Fei P, Zhao P. Administration Method and Potential Efficacy of Hyaluronidase for Hyaluronic Acid Filler-Related Vision Loss: A Systematic Review. Aesthetic Plast Surg 2024; 48:709-718. [PMID: 36574028 DOI: 10.1007/s00266-022-03215-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/19/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND With the global increase in the use of injectable fillers, more cases with serious adverse events such vision loss are being reported. This article aims to review the cases of hyaluronic acid (HA) filler-related vision loss and to discuss the potential efficacy of hyaluronidase (HYASE) treatment via different given methods. METHODS A total of 29 articles presenting 144 cases of HA filler-related vision loss were included in this study. RESULTS Most cases of HA filler-related vision impairment were reported from China, followed by Korea. The majority of cases were seen in women. The nose, forehead and glabella were the most commonly injection sites. All cases had vision impairment and nearly all cases were unilateral with immediate onset of visual signs and symptoms. Ophthalmic artery occlusion (OAO) and central retinal artery occlusion (CRAO) were the two most commonly involved arterial obstruction patterns featured with a very poor prognosis followed by branch retinal artery occlusion (BRAO), the most favorable involved arterial pattern for a better prognosis. HYASE given subcutaneously and intra-arterially helped with visual recovery to different degrees, while retrobulbar HYASE seemed to be less helpful. CONCLUSION Complications after HA-based filler injection are extremely rare but can cause disastrous visual impairment. HYASE given subcutaneously and intra-arterially helped with visual recovery to different extents, and the efficacy might be reinforced when performed together, while retrobulbar HYASE seemed to be less helpful. However, to accurately access the efficacy of HYASE via different administration methods, further randomized controlled trials are needed. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Haodong Xiao
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China
| | - Wei Kou
- Ruijin Hospital Affiliated Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yuan Yang
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China
| | - Erkuan Dai
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China
| | - Xuerui Zhang
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China
| | - Yanjun Wen
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China
| | - Jie Peng
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China
| | - Ping Fei
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China.
| | - Peiquan Zhao
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China.
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Yue Y, Shi F, Wang J, Ning Q, Zhang Z, Lv H. Sulfated hyaluronic acid gel for the treatment of rheumatoid arthritis in rats. Int J Biol Macromol 2024; 256:128537. [PMID: 38043665 DOI: 10.1016/j.ijbiomac.2023.128537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/26/2023] [Accepted: 11/29/2023] [Indexed: 12/05/2023]
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease. NSAIDS, cyclophosphamide and glucocorticoid were commonly used to treat RA in clinical application, which long-term administration of these drugs caused serious adverse reactions. Therefore, sulfated hyaluronic acid (sHA) gel (SG) was prepared to firstly treat the RA and avoid the problem of toxic side effect caused by long-term application. In vitro evaluation showed that sHA inhibited the level of reactive oxygen species and TNF-α, IL-1β, and IL-6, and decreased the ratio of macrophage M1/M2 type, which exerted better anti-inflammatory capacity. In vivo studies showed that the injection of SG into the joint cavity of collagen-induced rheumatoid arthritis (CIA) rats could effectively treat joint swelling and reduce the level of inflammatory factors in the serum. Immunofluorescence showed that SG exerted its anti-inflammatory activity by decreasing the ratio of M1/M2 type macrophages in synovial tissue. Cartilage tissue sections showed that SG reduced bone erosion and elevated chondrocyte expression. These results confirmed that sHA is expected to be developed as a drug to treat or relieve RA, which could effectively regulate the level of macrophages in rat RA, alleviate the physiological state of inflammatory over-excitation, and improve its anti-inflammatory and antioxidant capacity.
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Affiliation(s)
- Yingxue Yue
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China; State Key Laboratory of Oral Drug Delivery Systems of Chinese Materia Medica, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing 210028, China
| | - FanLi Shi
- School of Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Jing Wang
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China; State Key Laboratory of Oral Drug Delivery Systems of Chinese Materia Medica, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing 210028, China
| | - Qing Ning
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China; State Key Laboratory of Oral Drug Delivery Systems of Chinese Materia Medica, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing 210028, China
| | - Zhenhai Zhang
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210028, China; State Key Laboratory of Oral Drug Delivery Systems of Chinese Materia Medica, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing 210028, China.
| | - Huixia Lv
- School of Pharmacy, China Pharmaceutical University, Nanjing 211198, China.
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Zhuang J, Zheng Q, Su X, Jiang L, Hu J. Clinical Manifestations and Prognosis of Embolism Caused by Filler Injection in Different Facial Regions. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5225. [PMID: 37650096 PMCID: PMC10465098 DOI: 10.1097/gox.0000000000005225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 07/12/2023] [Indexed: 09/01/2023]
Abstract
Background Embolism is a serious complication after facial filling, with a usually poor prognosis of the symptoms after embolism. The authors systematically reviewed reported cases of facial vascular embolism, explored the relationship between the location and material used for facial filling and occurrence of vascular embolism, and assessed the prognosis of complications after vascular embolism. Methods This study provides a systematic review of published cases of vascular embolism after facial filling. A summary of the filling materials and filling sites for each case, the adverse reactions and embolized blood vessels, a recording of the time when each patient experienced adverse reactions and started treatment, and a presentation of their prognosis are provided. Results The frontal, eyebrow, and nose are common filling sites causing facial embolism. The main clinical manifestations after embolism were visual impairment, skin necrosis, and ptosis. The prognosis of visual impairment after embolization was poor, whereas skin necrosis and ptosis generally improved after treatment. Conclusions This article aimed to review the clinical manifestations, therapies, and prognosis of embolism after facial filling. A better understanding of these complications can help clinicians to detect the occurrence of complications as early as possible and give patients timely treatment.
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Affiliation(s)
- Jun Zhuang
- From the Department of Ear Reconstruction, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiaoyuan Zheng
- College of Clinical Medicine, Fudan University, Xuhui District, Shanghai, China
| | - Xueshang Su
- Department of Cicatrix Minimally Invasive Treatment Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liya Jiang
- Department of Cosmetic Injection Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jintian Hu
- From the Department of Ear Reconstruction, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cosmetic Injection Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Paramaswaran Y, Subramanian A, Paramakrishnan N, Ramesh M, Muthuraman A. Therapeutic Investigation of Palm Oil Mill Effluent-Derived Beta-Carotene in Streptozotocin-Induced Diabetic Retinopathy via the Regulation of Blood-Retina Barrier Functions. Pharmaceuticals (Basel) 2023; 16:ph16050647. [PMID: 37242430 DOI: 10.3390/ph16050647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/17/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023] Open
Abstract
Diabetic retinopathy (DR) primarily progresses into retinal degeneration caused by microvascular dysfunction. The pathophysiology of DR progression is still uncertain. This study investigates the function of beta-carotene (PBC) originating from palm oil mill effluent in the treatment of diabetes in mice. An intraperitoneal injection of streptozotocin (35 mg/kg) was used to induce diabetes, which was then accelerated by an intravitreal (i.vit.) injection of STZ (20 µL on day 7). PBC (50 and 100 mg/kg) and dexamethasone (DEX: 10 mg/kg) were also administered orally (p.o.) for 21 days. At various time intervals, the optomotor response (OMR) and visual-cue function test (VCFT) responses were evaluated. Biomarkers, such as reduced glutathione (GSH), thiobarbituric acid reactive substances (TBARSs), and catalase activity were determined in retinal tissue samples. DR significantly lowers the spatial frequency threshold (SFT) and time spent in the target quadrant (TSTQ), increases the reaching time in the visual-cue platform (RVCP), lowers retinal GSH and catalase activity levels, and elevates TBARS levels. The treatments of PBC and DEX also ameliorate STZ-induced DR alterations. The potential ameliorative activity of PBC in DR is attributed to its anti-diabetic, anti-oxidative, and control of blood-retinal barrier layer properties.
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Affiliation(s)
- Yamunna Paramaswaran
- PG Research Scholar, Faculty of Pharmacy, AIMST University, Semeling, Bedong 08100, Kedah, Malaysia
| | | | - Nallupillai Paramakrishnan
- Department of Pharmacognosy, JSS College of Pharmacy, Mysore, JSS Academy of Higher Education and Research, Mysore 570015, Karnataka, India
| | - Muthusamy Ramesh
- Department of Pharmaceutical Analysis, Omega College of Pharmacy, Hyderabad 501301, Telangana, India
| | - Arunachalam Muthuraman
- Unit of Pharmacology, Faculty of Pharmacy, AIMST University, Bedong 08100, Kedah, Malaysia
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Reply: Investigation of the Orbital Arterial Distribution Using Image Superimposition to Determine Safe Zones for Retrobulbar Injection and to Prevent Filler Complications. Plast Reconstr Surg 2023; 151:168e-169e. [PMID: 36576836 DOI: 10.1097/prs.0000000000009793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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7
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Wang D, Chen B. Comment on: "Efficacy and Safety of Lyophilized Articular Cartilage Matrix as an Injectable Facial Filler". Aesthetic Plast Surg 2021; 45:1957-1958. [PMID: 33660015 DOI: 10.1007/s00266-021-02194-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Danying Wang
- Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 33 Ba-Da-Chu Road, Beijing, 100144, China
| | - Bo Chen
- Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 33 Ba-Da-Chu Road, Beijing, 100144, China.
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Rouanet C, Kestemont P, Winter C, Lerhe B, Savoldelli C. Management of vascular complications following facial hyaluronic acid injection: High-dose hyaluronidase protocol: A technical note. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2021; 123:262-265. [PMID: 34157447 DOI: 10.1016/j.jormas.2021.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 03/07/2021] [Accepted: 05/03/2021] [Indexed: 12/01/2022]
Abstract
Aesthetic medicine has experienced major developments in recent years, which is illustrated by the increasing number of hyaluronic acid injected in the area of facial rejuvenation. Although considered low risk, it can rarely result in arterial embolization with potentially major aesthetic and functional consequences. These vascular complications range from livedo to skin necrosis to permanent blindness. In such cases the management is urgent. Early care leads to a successful recovery but most of the time the diagnosis is delayed. Several treatments have been suggested and the use of hyaluronidase is decisive. There is no official guideline on the use of hyaluronidase. The aim of this article is to propose a protocol to clarify the management of vascular complications of HA with high doses of hyaluronidase based on the literature and our clinical experience of 35 patients treated.
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Affiliation(s)
- Cédric Rouanet
- Department of ENT and Maxillofacial surgery, Head and Neck Institute, University Hospital of Nice, France
| | - Philippe Kestemont
- Department of ENT and Maxillofacial surgery, Head and Neck Institute, University Hospital of Nice, France; Clinique Saint-George, Nice, France
| | | | - Barbara Lerhe
- Department of ENT and Maxillofacial surgery, Head and Neck Institute, University Hospital of Nice, France
| | - Charles Savoldelli
- Department of ENT and Maxillofacial surgery, Head and Neck Institute, University Hospital of Nice, France.
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9
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Investigation of the Orbital Arterial Distribution Using Image Superimposition to Determine Safe Zones for Retrobulbar Injection and to Prevent Filler Complications. Plast Reconstr Surg 2021; 147:1321-1328. [PMID: 34019502 DOI: 10.1097/prs.0000000000007944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Retrobulbar filler injection has recently been considered an ideal method for orbital volume enhancement due to its nontoxic, easily reversible, and noninvasive characteristics. This study determined the arterial distribution in the orbit with the aim of defining a safety zone for retrobulbar filler injections used to enhance the orbital volume. METHODS Twenty-seven orbits of 24 formalin-embalmed cadavers were dissected. The orbital arteries were identified after removal of the eyeball, extraocular muscles, and connective tissues. The course of each orbital artery was then recorded in each specimen, and all of the courses were then superimposed to determine the arterial distribution in the orbit. RESULTS The superimposition of lined images based on the orbital vasculature of each specimen revealed that the arterial density was highest in the superonasal region and lowest in the inferotemporal region. In particular, orbital arteries were scarce at 8 o'clock and 4 o'clock in the right and left orbits, respectively, and an artery-free zone was demonstrated in the outer part of those directions. CONCLUSIONS When performing a transcutaneous retrobulbar injection of filler for orbital volume enhancement, the relative safety zone could be considered to be located at 8 o'clock and 4 o'clock in the right and left orbits, respectively. The detailed topographic information about the arterial distribution in the orbit, provided by the present study, may help oculofacial surgeons to avoid injury to major vessels and decrease the risk of retrobulbar hemorrhage and vision-threatening complications.
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10
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Hwang CJ, Chon BH, Perry JD. Blindness After Filler Injection: Mechanism and Treatment. Facial Plast Surg Clin North Am 2021; 29:359-367. [PMID: 33906767 DOI: 10.1016/j.fsc.2021.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Dermal fillers remain popular for facial rejuvenation but with its increasing use, the potential for more complications including blindness is present. This article focuses on the mechanism of filler-associated blindness, possible treatments, and future directions. Unfortunately, to date there is no proven treatment to reverse filler-induced blindness or visual compromise. It is essential for all injectors to discuss the potential ocular risks including blindness with their patients and obtain informed consent before filler injection.
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Affiliation(s)
- Catherine J Hwang
- Oculofacial Plastic Surgery, Department of Ophthalmology, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - Brian H Chon
- Oculofacial Plastic Surgery, Department of Ophthalmology, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Julian D Perry
- Oculofacial Plastic Surgery, Department of Ophthalmology, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Philipp-Dormston WG. [Responsible application of hyaluronic acid fillers in aesthetic medicine : Prevention, diagnosis and therapy of adverse events and complications]. Hautarzt 2021; 72:408-420. [PMID: 33877378 DOI: 10.1007/s00105-021-04802-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
Injection treatments with hyaluronic acid-based fillers are a standard procedure in aesthetic medicine. Performed by an experienced and thoughtful physician, they lead to effective and natural treatment results. It is paramount to know and avoid adverse events and complications or to identify and treat them in a timely manner. They are classified and treated according to their cause, time of onset and severity.
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Affiliation(s)
- Wolfgang G Philipp-Dormston
- Hautzentrum Köln, Schillingsrotter Str. 39-41, 50996, Köln, Deutschland. .,Faculty of Health, Universität Witten/Herdecke, Alfred-Herrhausen-Straße 45, 58455, Witten, Deutschland.
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12
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Examining the Role of Retrobulbar Hyaluronidase in Reversing Filler-Induced Blindness: A Systematic Review. Ophthalmic Plast Reconstr Surg 2021; 36:231-238. [PMID: 31880685 DOI: 10.1097/iop.0000000000001568] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To provide a systematic review of the literature concerning retrobulbar hyaluronidase injections as a treatment for hyaluronic acid gel filler-induced blindness and evaluate the level of evidence for this proposed therapy. METHODS The authors performed a search of English language articles published on the use of retrobulbar hyaluronidase to reverse vision loss precipitated by hyaluronic acid gel fillers. Articles reviewed included case reports/series, experimental investigations, expert opinion commentaries, and major reviews. To date, there have been no case-control, cohort, or randomized control studies to evaluate this treatment. Five anecdotal descriptions of hyaluronic acid gel filler blindness treated specifically with retrobulbar hyaluronidase were identified, for a total of 9 patients. One hundred twelve articles in total on this treatment and related topics, including filler-induced blindness and alternative treatments, were identified and reviewed. RESULTS Of the 9 documented cases of patients treated with retrobulbar hyaluronidase for hyaluronic acid-induced blindness, visual improvement was demonstrated in 2 cases. The successes, however, are undermined by inconsistent pretreatment ophthalmic assessment and documentation. Animal studies demonstrate mixed results. Laboratory studies document the inability of hyaluronidase to cross the optic nerve sheath. CONCLUSIONS There is not currently enough evidence to support retrobulbar hyaluronidase as a treatment for filler-induced blindness. Additional studies are needed to further evaluate its efficacy and explore alternative treatments.
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Arlette JP, Ashenhurst M, Hill V, Jiang K. Prevention and Management of Filler Induced Iatrogenic Stroke of the Eye. J Cutan Med Surg 2021; 25:543-552. [PMID: 33653128 DOI: 10.1177/1203475421999340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In the past few decades, minimally-invasive esthetic treatments and the use of injectable Hyaluronic Acid Gels and other filling agents to treat facial esthetics have increased dramatically. Although extremely rare, a filler can cause ocular and orbital ischemia by retrograde flow from the ophthalmic artery when injected in any of the anastomosis of the face. Once filler reaches the central retinal artery, blindness is inevitable, and no treatment is effective. While the risk of blindness happening with any filler injection is rare, the life-altering irreversible consequence of a procedure that was anticipated to be simple and beautifying is a reality that each injector must be prepared for with every injection. The parameters associated with an iatrogenic stroke of the eye are the site of injection, the injection technique, patient characteristics, and the material injected. Understanding the interplay of each of these variables might help us reduce the possibility of blindness during the injection of a soft-tissue cosmetic filler. Here, we explore the causes of Hyaluronic Acid Gels Filler embolic phenomena, review the natural course of the process, and discuss appropriate immediate interventions. We also (1) propose an education plan for injectors and describe how to carry out a focused ophthalmologic examination and procedural activities for a referral to an ophthalmologist, (2) outline steps to prevent emboli during filler injection, and (3) how to manage and support a patient with a sudden loss of vision during or immediately after a Hyaluronic Acid Gels filler treatment.
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Affiliation(s)
- John P Arlette
- 70401 Department of Surgery, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Michael Ashenhurst
- Department of Surgery, Division of Ophthalmology, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Vivian Hill
- Department of Surgery, Division of Ophthalmology, University of Calgary, Alberta, Canada
| | - Kailun Jiang
- Department of Surgery, Division of Ophthalmology, Cumming School of Medicine, University of Calgary, Alberta, Canada
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Zhang L, Luo Z, Li J, Liu Z, Xu H, Wu M, Wu S. Endovascular Hyaluronidase Application Through Superselective Angiography to Rescue Blindness Caused by Hyaluronic Acid Injection. Aesthet Surg J 2021; 41:344-355. [PMID: 32401308 DOI: 10.1093/asj/sjaa036] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Blindness is a rare but catastrophic complication of facial hyaluronic acid (HA) injection. Although various means to rescue visual impairment have been employed, no consensus regarding effective treatment has yet been reached. We organized a multidisciplinary team to address this emergency situation by means of endovascular hyaluronidase application. OBJECTIVES The aim of this study was to investigate the direct delivery of hyaluronidase to ophthalmic artery occlusion through endovascular cannulation to resolve HA-induced blindness. METHODS Four patients with visual impairments caused by HA filler embolization were subjected to sequential treatments. Through superselective angiography, a microcatheter was introduced along a guidewire from the femoral artery to the ophthalmic artery to directly deliver hyaluronidase to the HA embolism. The safety and efficiency of this treatment were systematically analyzed. RESULTS Selective cerebral angiography demonstrated that the endovascular application of hyaluronidase significantly alleviated occlusion in 3 patients. One patient showed slight visual improvement, whereas the other patients showed no improvement in their visual function during a follow-up period of more than 3 months. One patient suffered from cerebral infarction in the left middle cerebral artery during the intervention surgery. Moreover, 2 patients showed multiple lacunar cerebral infarctions after the operation, whereas none exhibited symptoms of hemiplegia during follow-up. CONCLUSIONS Although the endovascular application of hyaluronidase could partially recanalize the occluded branches of the ophthalmic artery, it had limited effects on restoring vision. Considering the risks of vascular intervention surgery, this approach should be considered with caution. LEVEL OF EVIDENCE: 5
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Affiliation(s)
- Lei Zhang
- Zhejiang Provincial People’s Hospital, affiliated with Hangzhou Medical College, Hangzhou, Zhejiang Province, China
| | - Zuyan Luo
- Zhejiang Provincial People’s Hospital, affiliated with Hangzhou Medical College, Hangzhou, Zhejiang Province, China
| | - Jian Li
- Zhejiang Provincial People’s Hospital, affiliated with Hangzhou Medical College, Hangzhou, Zhejiang Province, China
| | - Zhe Liu
- Zhejiang Provincial People’s Hospital, affiliated with Hangzhou Medical College, Hangzhou, Zhejiang Province, China
| | - Hong Xu
- Zhejiang Provincial People’s Hospital, affiliated with Hangzhou Medical College, Hangzhou, Zhejiang Province, China
| | - Miaoqin Wu
- Zhejiang Provincial People’s Hospital, affiliated with Hangzhou Medical College, Hangzhou, Zhejiang Province, China
| | - Sufan Wu
- Zhejiang Provincial People’s Hospital, affiliated with Hangzhou Medical College, Hangzhou, Zhejiang Province, China
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Ocular Massage for Filler-Induced Blindness. Aesthetic Plast Surg 2021; 45:359-360. [PMID: 31263932 DOI: 10.1007/s00266-019-01432-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
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16
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Jones DH, Fitzgerald R, Cox SE, Butterwick K, Murad MH, Humphrey S, Carruthers J, Dayan SH, Donofrio L, Solish N, Yee GJ, Alam M. Preventing and Treating Adverse Events of Injectable Fillers: Evidence-Based Recommendations From the American Society for Dermatologic Surgery Multidisciplinary Task Force. Dermatol Surg 2021; 47:214-226. [PMID: 33543879 DOI: 10.1097/dss.0000000000002921] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Derek H Jones
- Skin Care and Laser Physicians of Beverly Hills, Los Angeles, California
| | | | - Sue Ellen Cox
- Aesthetic Solutions, Assoc Clinical Faculty, UNC Department of Dermatology, Consulting Associate, Duke University Department Dermatology, Chapel Hill, North Carolina
| | | | - M Hassan Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - Shannon Humphrey
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, Canada
| | - Jean Carruthers
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada
| | - Steven H Dayan
- Denova Research, Clinical Assistant Professor, University of Illinois, Chicago, Illinois
| | - Lisa Donofrio
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Nowell Solish
- Department of Dermatology, University of Toronto, Toronto, Canada
| | | | - Murad Alam
- Departments of Dermatology, Otolaryngology, and Surgery, Northwestern University, Chicago, Illinois
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17
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Lucet A, Ginoux L, Lecomte C. Cécité secondaire à l’injection d’acide hyaluronique à visée esthétique. ANNALES FRANCAISES DE MEDECINE D URGENCE 2020. [DOI: 10.3166/afmu-2020-0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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18
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Commentary On: "Examining the Role of Retrobulbar Hyaluronidase in Reversing Filler Induced Blindness: A Systematic Review," by Paap MK, Milman T, Ugradar S, Goldberg R, Silkiss RZ. Ophthalmic Plast Reconstr Surg 2020; 36:239-240. [PMID: 32379204 DOI: 10.1097/iop.0000000000001628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Effectiveness of Retrobulbar Hyaluronidase Injection in an Iatrogenic Blindness Rabbit Model Using Hyaluronic Acid Filler Injection. Plast Reconstr Surg 2020; 145:658e-660e. [PMID: 32097351 DOI: 10.1097/prs.0000000000006583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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