1
Choroid Vascular Occlusion and Ischemic Optic 1 Neuropathy after
2 Facial Calcium Hydroxyapatite Injection- A Case Report3
4 Chien-Chih Chou,a Hsin-Han Chen,b Yi-Yu Tsai,a
5 You-Ling Li,a Hui-Ju Lin,a, c, d *
6 7
8 a Department of Ophthalmology, China Medical University Hospital, Taichung,
9 Taiwan
10 b Department of Plastic and Reconstructive Surgery, China Medical University
11 Hospital, Taichung, Taiwan,
12 c Department of Medical Research, China Medical University Hospital, Taichung,
13 Taiwan,
14 d School of Chinese Medicine, College of Chinese Medicine, China Medical
15 University, Taichung, Taiwan, 16
17 18 19 20
21 *Corresponding author: Hui-Ju Lin, MD, PhD
22 Address: Department of Ophthalmology, China Medical University Hospital, No. 2
23 Yuh Der Road, Taichung 404, Taiwan 24 TEL: 886-4-22052121 ext. 1106 25 FAX: 886-4-22059265
26 E-mail: [email protected]
27 2
Chien-28 Chih Chou: [email protected]
29 Hsin-Han Chen: [email protected]
30 Yi-Yu Tsai: [email protected]
31 You-Ling Li: [email protected]
32 Hui-Ju Lin: [email protected]
33 3
35
36 Background:
37 We reported a case of sudden monocular vision loss after calcium hydroxyapatite 38 (CaHA) injection into the nasal tip and dorsum with detailed retina images. 39 Methods: A case report
40 Results:
41 A healthy, 35-year-old woman received CaHA filler injection for nose
42 augmentation. Ten minutes after the procedure, she developed nausea, vomiting, 43 headache, ptosis, and left periorbital pain. After 30 minutes, she complained of 44 progressively blurring vision in the left eye. The best-corrected visual acuity (BCVA)
45 in her left eye was 30 cm ahead of hand motion. Left exotropia was noted in primary
46 gaze. Limitations in adduction, supraduction, and infraduction of the left eye were 47 also observed. Slit lamp examination of the left eye revealed a pink conjunctiva, a 48 clear cornea, a mild anterior chamber reaction, a sluggish papillary light reflex, and a
49 semi-dilated pupil. A positive relative afferent pupillary defect was observed in the 50 left eye. Fundus examination revealed optic disc edema and some linear whitish 51 opacity over the superior and temporal sites in the left eye, suggesting multiple CaHA
52 emboli in the choroid vessels. 53 Conclusions:
54 Although the majority of adverse reactions are mild and transient, surgeons should 55 be alert about extremely rare serious adverse events such as visual loss.
56 57 58
59
Keywords
60 Calcium hydroxyapatite; Nose augmentation; Choroid vascular occlusion; Ischemic
61 optic neuropathy; Vision loss; Filler 62
63 4
64 Introduction
65 Facial plastic surgery reverses the signs of aging. Injectable facial fillers are 66 effective in ameliorating certain signs of aging [1], and calcium hydroxyapatite
67 (CaHA) is one of the most commonly used fillers for this purpose [2]. Serious adverse
68 events are rarely observed, and the majority of adverse reactions are mild and 69 transient [3]. Here we report the case of a 35-year-old woman who developed sudden
70 monocular vision loss after CaHA injection into the nasal tip and dorsum. 71
72 Case report
73 A healthy, 35-year-old woman without any history of ocular and systemic disease 74 received CaHA filler injections (RADIESSE® 1.5ml) for cosmetic nose
augmentation.
75 Multiple injections along midline of the nasal dorsum from nasal tip to glabella were
76 performed under local anesthesia. Ten minutes after the procedure, she developed 77 nausea, vomiting, headache, ptosis, and left periorbital pain. After 30 minutes, she 78 complained of progressively blurring vision in the left eye. The best-corrected visual
79 acuity (BCVA) in her left eye was 30 cm ahead of hand motion. Skin necrosis 80 developed over the nasal dorsum, glabellar region, and left forehead (Fig. 1a). Left 81 exotropia was noted in primary gaze. Limitations in adduction, supraduction, and 82 infraduction of the left eye were also observed (Fig. 1b). Slit lamp examination of the
83 left eye revealed a pink conjunctiva, a clear cornea, a mild anterior chamber reaction,
84 a sluggish pupillary light reflex, and a semi-dilated pupil. A positive relative afferent
85 pupillary defect was observed in the left eye. The intraocular pressure was normal in
86 both eyes. Fundus examination revealed optic disc edema and some linear whitish 87 opacities over the superior and temporal sites in the left eye, suggesting multiple 88 CaHA emboli in the choroid vessels (Fig. 2a, b). Optical coherence tomography (OCT)
89 revealed disc edema without macular edema in the left eye (Fig. 2c). Fluorescein 90 angiography revealed neither delayed filling nor hypofluroescence in the left eye. 91 Visual field testing revealed an inferior altitudinal visual field defect in the left eye.
92 Measurement of the visual evoked potential (VEP) showed a decreased amplitude and
93 marked delay in the appearance of peaks. Electroretinography (ERG) showed a 94 normal waveform. All examinations were normal in the right eye. Orbital computed
95 tomography (CT) demonstrated high-density deposits in the nose region and left 96 medial orbital cavity (Fig. 3). No evident lesion was noted on brain magnetic 97 resonance imaging (MRI).
98 Alprostadil and dextran were administered for improving blood supply. Moreover, 99 ten sessions of hyperbaric oxygen therapy were administered. One month later, the 100 visual acuity in her left eye improved to 6/60. A pale disc was observed, with 101 persistent plaque occlusions in the choroid vessels.
5
102 Discussion
103 There are few reports of vision loss following facial injection of autologous fat or 104 hyaluronic acid [4-6]. In a previous study, Lazzeri et al [7] reported 32 cases of 105 blindness caused by iatrogenic retinal embolism after cosmetic facial filler injections,
106 while Park et al [8] reported 12 cases of retinal artery occlusion caused by cosmetic
107 facial filler injections. Furthermore, Park et al [9] showed the clinical and 108 angiographic features of occlusion of the ophthalmic artery and its branches caused by
109 cosmetic facial filler injections. In these 44 cases, only one was attributed to CaHA,
110 and no CaHA emboli were clearly observed on fundus photography.
111 Sung et al [10] postulated that emboli may move in a retrograde fashion to the 112 ophthalmic artery under a high injection pressure. In the present case, multiple emboli
113 localized on the choroidal layer without retinal vessel occlusion, resulting in normal
114 ERG waveform. However, poor vision, a positive RAPD sign, and a pale, swollen 115 disc were present. Visual field testing showed an inferior altitudinal visual field defect.
116 We postulate that the CaHA emboli migrated via the dorsonasal artery back to the 117 main ciliary arteries and occluded the short posterior ciliary arteries, which supply the
118 superior nasal choroid and the optic nerve. Subsequently, ischemic optic neuropathy
119 developed and caused poor vision, a positive RAPD sign, a pale, swollen disc, and an
120 abnormal waveform on VEP. Furthermore, we first postulated that the occluded vessel
121 was Haller’s layer because the distribution pattern of affected vessels was consistent
122 with the Haller’s layer distribution pattern.
123 The emboli moved back to branches supplying the oculomotor nerve, causing 124 blepheroptosis and ophtalmoplegia. This is compatible with the CT findings (Fig. 3).
125 The ptosis and limitation in supraduction subsided gradually. We postulate that the
126 superior division of the oculomotor nerve innervating the levator and superior rectus
127 muscles recovered early.
128 In previously reported cases of CaHA injections and in this case, there was no 129 cerebral infarction, which is more frequently observed after autologous fat injections
130 [9]. This may be related to properties of the filler material, such as molecular weight
131 or size.
132 To decrease the risk of intravascular injection and retrograde occlusion, Park et al 133 suggested slow injection in a fractionated dose and the use of a blunt cannula [9]. We
134 suggest the use of a mixture of CaHA and epinephrine because epinephrine leads to
135 vasoconstriction and thus decreases the possibility of intravascular injection. Soft 136 tissue can be dissected to create a subcutaneous space for subsequent filler injection.
137 Furthermore, an injection device with a valve that can relieve excessive injection 138 pressure can be designed for this purpose.
139 Injectable facial fillers have become increasingly popular these days. Although the
6
majority of adverse reactions are mild and transient, s 140 urgeons should be alert about
141 extremely rare serious adverse events such as visual loss. Most cases of blindness are
142 caused by autologous fat and hyaluronic acid injections. To the best of our knowledge,
143 localized choroid vascular occlusion, ischemic optic neuropathy, and cranial nerve III
144 palsy without evidence of compromised retinal or choroidal circulation after CaHA
145 injection have not been reported.
146 In conclusion, we reported a case of sudden monocular vision loss after CaHA filler
147 injection into the nasal tip and dorsum. CaHA emboli were clearly observed in this
148 case, providing direct evidence to prove the mechanism underlying retrograde 149 occlusion after facial filler injection.
150 7
151 Consent statement:
152 Written informed consent was obtained from the patient for publication of this case
153 report and any accompanying images. A copy of the written consent is available for
154 review by the Editor of this journal. 8
155 Competing interests:
156 All authors certify that they have NO affiliations with or involvement in any 157 organization or entity with any financial interest (such as honoraria; educational 158 grants; participation in speakers’ bureaus; membership, employment,
consultancies,
159 stock ownership, or other equity interest; and expert testimony or patent-licensing 160 arrangements), or non-financial interest (such as personal or professional
161 relationships, affiliations, knowledge or beliefs) in the subject matter or materials 162 discussed in this manuscript.
163 9
164 Author's Contribution:
165 Chien-Chih Chou and You-Ling Li participated in the drafted the manuscript.
166 Hui-Ju Lin , Hsin-Han Chen, and Yi-Yu Tsai, participated in the design of the study
167 and helped to draft the manuscript. All authors read and approved the final manuscript.
168 10
169 Acknowledgments:
170 We do not have someone to acknowledge to.
171 172 173 11
174 References
175 1. Patricio F Jacovella (2008) Use of calcium hydroxylapatite (Radiesse®) for
facial
176 augmentation. Clin Interv Aging 3(1):161–74
177 2. Jurado JR, Lima LF, Olivetti IP, Arroyo HH, de Oliveira IH (2013) Innovations in
178 minimally invasive facial treatments. Facial Plast Surg 29(3):154–60
179 3. Funt D, Pavicic T (2013) Dermal fillers in aesthetics: an overview of adverse 180 events and treatment approaches. Clin Cosmet Investig Dermatol 6:295–316 181 4. Dreizen NG, Framm L (1989) Sudden visual loss after autulogous fat injection into
182 the glabellar area. Am J Ophthalmol 107:85–7
183 5. Danesh-Meyer HV, Savino PJ, Sergott RC (2011) Case reports and small case 184 series: ocular and cerebral ischemia following facial injection of autologous fat. Arch
185 Ophthalmol 119:777–8
186 6. Peter S, Mennel S (2006) Retinal branch artery occlusion following injection of
187 hyaluronic acid (Restylane). Clin Experiment Ophthalmol 34:363–4 188 7. Lazzeri D, Agostini T, FigusM, NardiM, PantaloniM, Lazzeri S (2012) Blindness
189 following cosmetic injections of the face. Plast Reconstr Surg 129(4):995–1012 190 8. Park SW, Woo SJ, Park KH, Huh JW, Jung C, Kwon OK (2012) Iatrogenic retinal
191 artery occlusion caused by cosmetic facial filler injections. Am Ophthalmol 192 154(4):653–66
193 9. Park KH, Kim YK, Woo SJ et al (2014) Iatrogenic retinal artery occlusion caused
194 by cosmetic facial filler injections: a national survey by the Korean Retina Society.
195 JAMA Ophthalmol 132(6):714-23
196 10. Sung MS, Kim HG, Woo KI, Kim YD (2010) Ocular Ischemia and Ischemic 197 Oculomotor Nerve Palsy After Vascular Embolization of Injectable Calcium 198 Hydroxylapatite Filler. Ophthal Plast Reconstr Surg 26:289–91
199 200 201 12
Figure 1. Skin necrosis developed at nasal dorsum, glabellar 202 region, and left forehead
203 (a). Left exotropia was noted in primary gaze, and limitations on adduction, 204 supraduction, and infraduction in left eye were also noted (b).
205
206 Figure 2. Fundus examination revealed optic disc edema and some linear whitish 207 opacities over the superior and temporal sites in the left eye, suggesting multiple 208 CaHA emboli in the choroid vessels (a). No macular edema in left eye was revealed
209 on fundus examination (b), or OCT (c). 210
211 Figure 3. Orbital CT demonstrates multiple radiopaque spots in the subcutaneous 212 layer of medial aspect of left periorbital region, suggesting CaHA deposition. 213 13 214 Figure 1. 215 216 217 218 219 Figure 2. 220 221 222 Figure 3. 223 Figure 1 Figure 2 Figure 3
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