13
Jun

Aesthetic induced visual loss

Visual Loss

Blindness following soft tissue augmentation is a serious complication caused by occlusion of the branches of the ophthalmic artery. A worldwide review of literature on all reported cases of vision changes attributed to fillers was conducted in 2015. The results showed 98 cases of vision changes, with 65 of those leading to unilateral vision loss and only two cases being reversible. The sites that were at highest risk of complications were the glabella (38.8%), nasal region (25.5%), nasolabial fold (13.3%), and forehead (12.2%). The authors concluded that, “although the risk of blindness from fillers is rare, it is critical for injecting physicians to have a firm knowledge of the vascular anatomy and to understand key prevention and management strategies.

Visual loss following the injection of soft tissue augmentation materials appears to be due to the obstruction of the ophthalmic artery and its branches. The proposed theory is that of retrograde pressure induced embolization of material through the vascular anastomosis of arterial vessels in the facial region with a final common pathway ending in the end arteries of the retinal artery.

The Aesthetic Interventional Induced Visual Loss (AIIVL) Consensus Group recently published consensus advice to aestheticians. They noted that there is no consistent management pathway for this very rare but life-changing complication and suggested the following guidance:

General Guidelines

  • Essential knowledge of facial anatomy in respect to vessels (layers of face and where vessels may be)
  • Potential for visual loss and skin necrosis on consent form and discussion with patient
  • Careful, aseptic skin preparation
  • For single-entry sites, care should be taken to minimise adjacent skin contact on cannula entry so as to avoid the introduction of skin commensals at each entry
  • Multiple injection points – consider further skin cleaning to reduce bacterial load and change needle for patient comfort
  • Injections should be delivered slowly with minimal pressure, to minimise trauma and also the potential for embolism if a vessel has unknowingly been breached
  • Inject small volumes - less than 0.1 ml per bolus
  • Cannula size 25G or greater bore (Smaller Needle diameter - 27 G or less - may enter vessels and also need high pressure to initiate flow – controversial point as smaller needle makes it difficult to deliver large volume in one bolus quickly so may make it less likely to cause visual loss)
  • Caution with injections especially with 27 G or smaller gauge needles/cannulas

Immediate visual loss

In the eventuality of a patient presenting with immediate visual loss, the first action of the practitioner should:

  • stop injecting immediately
  • Ask the patient to start to rebreathing into a paper bag to increase the carbon dioxide concentration in the bloodstream. This is in keeping with recommendations for CRAO. The principle of retinal artery vasodilatation was considered as a priority to encourage the movement of the emboli into the peripheral portions of the vascular system
  • Give oral aspirin immediately as an oral regimen of 2 pills of 325 mg daily to try to prevent further clot formation due to vascular compromise. The duration of aspirin treatment would depend on the clinical scenario and whether improvement is seen, but a one week course is recommended
  • Sublingual GTN may be administered of potentiate further vascular dilatation and encourage movement of the product toward the periphery of the retinal system
  • Commence ocular massage to theoretically cause the embolus to travel physically displace emboli toward the periphery of the retinal system. This should be instituted immediately in conjunction with the above maneuvers.

Without any additional delay, the patient should be transferred to a specialist facility (Eye Hospital/A&E). There is some evidence from the literature on CRAO to suggest that after 90 minutes there is irreversible loss of vision that is progressive. Specialist treatment at an appropriate facility should be instituted as soon as possible to optimize all possible treatment pathways and provide professional support to the patient

Delayed presentation—patient not in clinic

The group felt that the same management pathway as for immediate visual loss should be instituted: rebreathing, oral Aspirin, and ocular massage. The practitioner would need to give advice to the patient remotely to ensure that this protocol is instituted as soon as possible.

The practitioner will also need to coordinate the immediate transfer of the patient to the specialist center (Eye Hospital/A&E Department). The practitioner should also take full responsibility in terms of informing the facility of the impending arrival of the patient. It is important that the practitioner ensures the facility who know all details including interventions performed, time of injection—onset time—delay of transfer, and all relevant medical history.

About the author

Peter Charlesworth MSc MCOptom

Peter Charlesworth is an optometrist and Managing Director of Eyecare. He is a former examiner and councillor of the College of Optometrists, a former member of the GOC’s fitness to practise committee and holds an MSc in Investigative Ophthalmology and Vision Science from the University of Manchester. He was Boots Opticians Tutor Practitioner at the University of Bradford for 7 years. His duties there included teaching the Law and Management module to final year students and a clinical investigative techniques module to the second year.

View all posts by Peter Charlesworth MSc MCOptom

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