Sudden vision loss and neurological deficits after facial hyaluronic acid filler injection

"Filler-Associated Acute Stroke Syndrome": Classification, Predictive Modelling of Hyaluronidase Efficacy, and Updated Case Review on Neurological and Visual Complications

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 .

Disastrous cerebral and ocular vascular complications after cosmetic facial filler injections: a retrospective case series study

Soft tissue filler injections are among the most popular facial rejuvenation methods. Cerebral infarction and ophthalmic artery occlusion are rare and catastrophic complications, especially when facial cosmetic fillers are injected by inexperienced doctors. Radiologists and plastic surgeons need to increase their awareness of the complications associated with fillers, which allows early diagnosis and intervention to improve patient prognosis. Regarding the mechanism by which vascular occlusion occurs after facial filler injections, a retrograde embolic mechanism is currently the predominant theory. Numerous case reports have been presented regarding complications associated with injections of facial aesthetics. However, the small sample sizes of these studies did not allow for an adequate assessment of the clinical and imaging manifestations based on the location of the occlusion and the type of filler, and detailed elaboration of multiple cerebral infarctions is also lacking. Therefore, this study aimed to investigate the clinical and radiological features of severe cerebral and ocular complications caused by cosmetic facial filler injections. In addition, we discuss the pathogenesis, treatment, and prognosis of these patients. The clinical, computed tomography (CT), magnetic resonance imaging (MRI), and digital subtraction angiography (DSA) findings were described and analysed. Radiological examinations are crucial for demonstrating severe complications, and brain MRI is especially strongly suggested for patients with cosmetic filler-induced vision loss to identify asymptomatic cerebral infarctions. Extreme caution and care should be taken during facial injections by plastic surgeons.

Dermal Filler Hypersensitivity Post-COVID-19 Illness: Case Series and Literature Review

OBJECTIVE

To report two cases of dermal filler hypersensitivity post-COVID-19 illness and review the literature.

METHODS

A literature review was performed. Data were extracted from the articles: the author, year of publication, age and sex of the patient, filler substance, injection site, symptoms and signs, onset time, diagnostic results, treatment, and prognosis.

RESULTS

Six cases from six literatures were included in the review. All of them were female and were confirmed infected with COVID-19. Five of them received hyaluronic acid injection and one patient received polyacrylamide. Time after injection ranged from 8 months to 9 years. Onset of symptoms ranged from two to four weeks post-infection. The clinical manifestations included swelling, edema, induration, erythema, and tenderness. The site where the symptoms appeared was the injection site, and symptoms appeared at each injection site at the same time, including cheeks, periocular area, and lips.

CONCLUSION

Dermal filler hypersensitivity may occur post-COVID-19 illness. A detailed history and clinical examination can help confirm the diagnosis.

LEVEL OF EVIDENCE V

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 .

Delayed Diagnosis of Septal Ulcer after Hyaluronic Acid Nasal Filler Injection

The utilization of fillers, notably hyaluronic acid, has increased due to their proven effectiveness, versatility, and generally favorable safety profile. In the field of rhinoplasty, hyaluronic acid dermal fillers have been employed for the correction of nasal deformities and surface irregularities. Nevertheless, the intricate vascular network of the nasal region, involving anastomoses between the external and internal carotid arteries, predisposes it to serious vascular complications. We report a case of a severe septal ulcer secondary to local ischemia following an injection of a hyaluronic acid nasal filler. The patient presented with immediate pain and nasal discomfort; however, there was an unfortunate delay in diagnosis and treatment. This report discusses the intricacies of the case and imparts crucial insights gleaned from the incident.

Clinical Manifestations and Prognosis of Embolism Caused by Filler Injection in Different Facial Regions

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.

Research hotspots and trends of oculomotor nerve palsy from 2001 to 2021 based on web of science: A bibliometric analysis

Background

Oculomotor nerve palsy (ONP) is a clinically occurring neurological disorder. Due to the complex anatomy and long travel distances of the oculomotor nerve, the causes of ONP vary and manifest in various ways. With continued interest in this area, it has become necessary to conduct a bibliometric study in ONP. This work aims to synthesize and visually identify current research themes and future trends in ONP through a literature-based analysis.

Method

Articles and reviews on ONP published from 2002 to 2021 were derived from the Web of Science Core Collection (WoSCC) database. We generated visual images and performed quantitative and qualitative analysis through an online bibliometric tool, Citespace and VOSviewer software.

Results

A total of 1,205 published articles were included in this analysis. The annual number of this area's publications is showing an overall upward trend, with the number of citations increasing every year, reaching 2,698 by 2021. The United States (367) and Japan (116) dominated the list with the most numerous articles published. The University of California Los Angeles in the USA is the institution that published the highest number of articles (47). Engle EC (23) and the JOURNAL OF NEUROSURGERY (46) are the most influential authors and journals in this field. The co-occurrence network analysis divided the keywords into five main research themes, which mainly include clinical manifestations of ONP, aneurysms, cerebral neurological symptoms, diseases with ONP as a complication, and other neurological disorders.

Conclusion

This study is the first comprehensive and systematic bibliometric analysis of the current state of global ONP research over the past 20 years. We organized current hotspots and expected trends and provided key information for exploring potential research frontiers in ONP.

Clinical Characteristics of Methanol-Induced Optic Neuropathy: Correlation between Aetiology and Clinical Findings

Purpose. To show the clinical characteristics, identify the magnetic resonance imaging (MRI) and optical coherence tomography (OCT) features, and observe the visual outcome of methanol-induced optic neuropathy. Methods. Clinical data were retrospectively collected from in-patients diagnosed with methanol-induced optic neuropathy in the Neuro-Ophthalmology Department of the Chinese People’s Liberation Army General Hospital from January 2016 to January 2021. Results. Eight patients were included in this study. The exposure time was 6–34 h for ingestion, 3-4 months for inhalation, and more than ten years for skin absorption. All patients demonstrated bilateral acute visual impairment. Seven of eight patients had other accompanying systemic symptoms. Seven of eight patients demonstrated optic nerve lesions in MRI, and five presented with a hyperintense T2 signal in a “central” type. OCT showed the macular ganglion cell layer and inner plexiform layer (mGCL-IPL) thinning before the peripapillary retinal nerve fiber layer (pRNFL) thinning. The visual improvement was achieved transiently for seven of eight patients after treatment. One patient with a mitochondrial DNA mutation maintained a bilateral no-light perception (NLP) from the onset to the last visit. All patients had poor visual prognoses, with either light perception or NLP. Conclusions. Methanol-induced optic neuropathy is a rare bilateral optic neuropathy with a poor visual outcome. A centrally hyperintense T2 signal of the optic nerve is common in methanol-induced optic neuropathy. The thinning of the mGCL-IPL is more sensitive than that of the pRNFL for early diagnosis. A mitochondrial genetic defect may be a predisposing factor for methanol-induced optic neuropathy.

Bridging a Century-Old Problem: The Pathophysiology and Molecular Mechanisms of HA Filler-Induced Vascular Occlusion (FIVO)—Implications for Therapeutic Interventions

Biocompatible hyaluronic acid (HA, hyaluronan) gel implants have altered the therapeutic landscape of surgery and medicine, fostering an array of innovative products that include viscosurgical aids, synovial supplements, and drug-eluting nanomaterials. However, it is perhaps the explosive growth in the cosmetic applications of injectable dermal fillers that has captured the brightest spotlight, emerging as the dominant modality in plastic surgery and aesthetic medicine. The popularity surge with which injectable HA fillers have risen to in vogue status has also brought a concomitant increase in the incidence of once-rare iatrogenic vaso-occlusive injuries ranging from disfiguring facial skin necrosis to disabling neuro-ophthalmological sequelae. As our understanding of the pathophysiology of these injuries has evolved, supplemented by more than a century of astute observations, the formulation of novel therapeutic and preventative strategies has permitted the amelioration of this burdensome complication. In this special issue article, we review the relevant mechanisms underlying HA filler-induced vascular occlusion (FIVO), with particular emphasis on the rheo-mechanical aspects of vascular blockade; the thromboembolic potential of HA mixtures; and the tissue-specific ischemic susceptibility of microvascular networks, which leads to underperfusion, hypoxia, and ultimate injury. In addition, recent therapeutic advances and novel considerations on the prevention and management of muco-cutaneous and neuro-ophthalmological complications are examined.