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Selective angiogram of the ophthalmic artery after facial hyaluronic acid injection. (A) Occlusion and flow stagnation in the distal segment of the right ophthalmic artery (black arrowhead). Although some branches from the ophthalmic artery are visible, there is no choroidal flush. (B) Venous-phase external carotid angiography shows an occlusion at the peripheral portion of the facial (black arrow), infraorbital (double black arrows), and anterior deep temporal arteries (white arrow) surrounding the right orbit. (C) Angiography after hyaluronidase infusion into the ophthalmic artery showed partial recanalisation with visible branches of the ophthalmic artery (white arrowhead). The absence of a choroidal flush after hyaluronidase infusion was still noted. (D) In comparison with pre-injection angiography, external carotid angiography during the parenchymal phase revealed a slight improvement in branch runoff immediately after the injection of hyaluronidase, especially in the anterior deep temporal artery (open arrow).
Source publication
Although dermal/subcutaneous injection of filler into the face is a popular aesthetic surgery, severe complications related to arterial occlusion, including skin necrosis and visual loss, have been reported. Herein, we report a case of intra-arterial hyaluronidase infusion in the ophthalmic artery and other arteries supplying the facial skin follow...
Contexts in source publication
Context 1
... angiography was subsequently per- formed. Selective angiograms of the ophthalmic artery and the branches of the right external carotid artery (ECA) were obtained ( Figure 2A, B). As the ophthalmic artery and the branches of the right ECA were occluded by HA, we thought it would be impossible to restore retinal perfusion through the injection of urokinase alone. ...
Context 2
... performed after hyaluronidase infusion revealed partial recana- lisation of the ophthalmic artery and ECA, especially in the anterior deep temporal artery. However, angi- ography performed after the injection revealed no significant improvement in blood flow around the right orbit ( Figure 2C, D). ...
Citations
... El relleno que presentó mayor tasa de reacciones fue el CaHA y la rinoplastia quirúrgica previa aumentó el chance de evento adverso en un 51%. La embolia arterial oftálmica la reportaron Cohen y colaboradores (26) , Oh y colaboradores (27) y Kim y colaboradores (28) ; este último describió isquemia ocular con hipotonía y oftalmoplejía. Existen casos de oclusión vascular coroidea y neuropatía isquémica óptica, como los reportados por Chou y colaboradores (29) , donde se presentó alteración de la visión, síntoma que describieron Wibowo y colaboradores (30) , Jolly y colaboradores (31) y Kim y colaboradores (32) . ...
Introducción: Los rellenos en rinomodelación representan un importante nicho de innovación en medicina estética. Dentro de las principales sustancias se destacan el ácido hialurónico, el polimetilmetacrilato y la hidroxiapatita de calcio. Recientemente, los avances tecnológicos han permitido desarrollar rellenos dérmicos con menor inmunogenicidad, sin embargo, su uso no está exento de efectos adversos. Objetivo: Analizar los avances en los últimos 10 años en cuanto a estudios de investigación relacionados con rellenos en rinomodelación. Material y métodos: Se realizó una revisión bibliográfica consultando Medline, Web of Science, Google Scholar, Lilacs, ProQuest, PLOSONE, EMBASE, OVID, ScienceDirect, Pascal and Francis, Cochrane y Tripdatabase. Se utilizó combinación de términos MeSH, descriptores y términos libres. Dentro de los términos en inglés se incluyeron: nonsurgical rhinoplasty, nose, hyaluronic acid y fillers. En español se incluyeron, entre otros: rinomodelación, nariz, rellenos dérmicos y estudio de caso. Resultados: Se incluyeron 36 artículos. La mayoría correspondió a reportes de caso (58.3 %), seguidos de estudios prospectivos (22.2 %). Predominan artículos de Corea del Sur, China y EE. UU. El relleno descrito con mayor frecuencia fue el ácido hialurónico y el principal clúster temático correspondió a complicaciones. Conclusiones: Las complicaciones, en especial, oftálmicas, representan un elemento de gran trascendencia dentro del área de la rinomodelación. El especialista en medicina estética debe contar con gran entrenamiento y profundo conocimiento de la anatomía nasal. Asimismo, es relevante establecer consensos en relación con los métodos y tiempos de evaluación de satisfacción de los pacientes tanto con el procedimiento como con el relleno.
... This enzyme can be injected into the retrobulbar space using a cannula or directly into the incriminating vessel, although results of the limited cases reportedly treated with these two methods have been equivocal. (3,4,11,13,14) It is postulated that this enzyme may diffuse across the wall of the ophthalmic artery. However, this method is not useful for central retinal artery events. ...
... (4) If vascular compromise to the retina is suspected, the patient should be placed in a supine position and the following should be immediately administered: (a) one drop of topical timolol 0.5% and/or an acetazolamide 500 mg tablet (after excluding for sulfa allergy) (1,4,9) (Grade B); (b) an intravenous infusion of mannitol 20% (1,9,11) (100 mL over 30 minutes); and (c) nitroglycerin 2% paste. (5,13,14,18) (Grade D) Rapid infusion of mannitol may precipitate shrinkage of the cerebrospinal fluid space and stretching of the transdural veins, leading to slow cerebral haemorrhage in some patients. It is best to avoid this agent in the elderly and those with a past history of stroke or on blood thinning agents. ...
Aims
To describe the clinical features and outcomes of anti-NMDA receptor encephalitis (ANMDARE) in Southeast Asian (SEA) patients.
Method
SEA patients diagnosed and treated for ANMDARE at Singapore General Hospital between January 2010 and June 2020 were included in this observational study, in which their clinical features and outcomes were retrospectively analysed.
Results
We studied 20 patients: 11 Chinese, 3 Tagalogs, 2 Malays, 2 Indians, 1 Eurasian and 1 Javanese. Their median age was 28 years. 15 were females, amongst whom teratomas were demonstrated in 13 (12 ovarian, 1 mediastinal). Delirium and seizures were the two commonest events leading to their presentation at our facility. 1 male had biliary neuroendocrine tumour. Comparison between genders revealed a strong male predilection for early seizures and insomnia; females were four times likelier than males to develop movement disorders or have underlying neoplasms. Patients with dysautonomia required longer ICU stay beyond 14 days, but their outcomes at 1 year did not differ. When reviewed at 1 year, none had clinical relapses, and outcomes were favourable (mRS 0-2) in nearly two-thirds.
Conclusions
SEA patients with ANMDARE frequently present with delirium and seizures. Underlying neoplasms are very common in females. Differences in clinical characteristics may exist between the two genders. Recognition of these can facilitate diagnosis, and permit earlier initiation of appropriate treatment strategies, and thus improve outcomes of SEA patients.
... In several animal and human models of FIVO, this distribution typically consists of proximal intraluminal plugs with distally impacted filler microemboli (1-1000 μm), consistent with type III/IV vaso-dissemination ( Figure 13) [111,174,175]. These distal emboli can fully or partially obstruct any component of the arterial tree, including small arterial branches (~400-1000 μm), subcutaneous arterioles (~100-400 μm), terminal (dermal) arterioles (15-100 μm), and capillaries (5-15 μm) [148,[177][178][179][180][181]. Ultimately, the ischemic insult of FIVO results from the underperfusion of end-organ capillary beds and the amount of filler required to do so depends on the functional configuration of the affected angiosome; specifically, it depends on the presence of true anastomoses and choke vessels [182,183]. ...
... The presence of arteriovenous connections (AVCs) also influences the pattern of occlusion and dysperfusion in FIVO. AVCs may be useful in clearing filler particles from arterial These distal emboli can fully or partially obstruct any component of the arterial tree, including small arterial branches (~400-1000 µm), subcutaneous arterioles (~100-400 µm), terminal (dermal) arterioles (15-100 µm), and capillaries (5-15 µm) [148,[177][178][179][180][181]. Ultimately, the ischemic insult of FIVO results from the underperfusion of end-organ capillary beds and the amount of filler required to do so depends on the functional configuration of the affected angiosome; specifically, it depends on the presence of true anastomoses and choke vessels [182,183]. ...
... Fortunately, intra-arterial therapy has demonstrated a modest, but encouraging degree of success in the reversal of CRAO, especially when intervention is administered early and is combined with thrombolytic therapy [211,212]. Nonetheless, therapeutic success rates are still suboptimal, as evidenced by the poor outcomes reported in multiple animal and human interventional studies, likely due to delays in therapy [181,213,214]. Furthermore, cases of iatrogenic cerebral infarct occurring during super-selective angiography underscore the risks of intra-arterial therapy [215]. ...
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.
... Los otros 13 fueron casos o series de casos en los que se documenta un episodio isquémico orbitario u ocular con pérdida de visión y tratamiento posterior con hialuronidasa retroocular 9,10,19,[23][24][25][26][27][28][29][30][31][32]35 . Recogen datos de un total de 17 pacientes que, tras inyección de AH facial por motivos estéticos, presentaron una disminución brusca de la visión y en los que se inyectaron dosis variables de hialuronidasa retroocular. ...
Introduction:
Blindness after periocular cosmetic filler injection is a rare but devastating complication. Complication management protocols recommend injecting retrobulbar hyaluronidase if visual loss related to accidental intravascular injection of hyaluronic acid occurs. Given the dramatic increase in cosmetic filler injections and the variety of professionals that can deliver them, it is reasonable to assume that the incidence of complications will rise significantly.
Objective:
To evaluate if there is evidence-based efficacy of retrobulbar hyaluronidase injection in visual loss secondary to periocular cosmetic filler injection.
Material and methods:
The authors performed a search of English and Spanish language articles following the PRISMA statement published on the use of retrobulbar hyaluronidase to reverse vision loss precipitated by hyaluronic acid gel fillers. Articles reviewed included case reports/series and experimental investigations. We identified a total of 13 patients in this review following defined inclusion and exclusion criteria. Finally, we included 15 articles in the study, 12 of them were cases / case series. The 2 remaining articles are experimental studies in animals with a control group, in which after causing selective occlusion of the ophthalmic artery, serial injections of retroocular hyaluronidase are administered with control of visual function.
Results:
Of the 15 articles included in the study, we studied 17 patients treated with retrobulbar hyaluronidase for hyaluronic acid-induced blindness. Improvement was demonstrated in 3 cases. Animal studies demonstrate variable data are provided regarding the recovery of visual acuity.
Conclusions:
There is no confirmed evidence of retrobulbar hyaluronidase injection effectiveness in treating visual loss due to accidental intravascular injection of hyaluronic acid. More studies are needed to show the efficacy of hyaluronidase as a treatment for blindness caused by hyaluronic acid.
... Up to date, no standardized treatment is available for post-HA injection ischemia. 10 Topical nitroglycerin and oral medications such as salicylic acid or sildena l have shown limited e ectiveness. 11 Hyaluronidase, on the other hand, is perhaps the most e ective treatment for vascular complications, because it can degrade HA that causes external compression of the blood vessels. ...
... The two patients with more severe ischemia of the nasal ala were additionally treated with intravenous vasodilators, which is the established recommendation for critical ischemia of the limbs as well as the face. 10,13 A recent 2017 consensus on the prevention and treatment of dermal ller complications recommends the use of cannula and emphasized the importance of applying negative pressure during needle insertion in critical areas of the face. 14 Therefore, to minimize the risk of vascular complications with ller injections, areas with critical anatomic features should be avoided and continuous aspiration should be employed during insertion of the cannula or needle. ...
Facial injections with hyaluronic acid (HA) dermal fillers have become increasingly common. Hyaluronic acid is currently the most frequently used dermal filler. When compared to collagen for the treatment of nasolabial folds, HA not only produces similar cosmetic results with smaller doses but also lasts longer. Our objective was to evaluate the results of 10 patients with vascular complications associated with HA fillers treated with ultrasound-guided injection of hyaluronidase (HYAL) according to the Brazilian Society of Dermatology guidelines. Admission clinical evaluation revealed that the most frequent signs were: livedo reticularis (100% of the patients), hypoesthesia (50%) and local pain (20%). Although 80% of the patients complained of local pain during HYAL injection, none of them persisted with pain after the procedure ended. The total dose of injected HYAL per patient ranged from 300 to 750 IU (mean 500 IU). Post-HYAL treatment Doppler ultrasound showed pervious facial arteries and veins in 100% of the patients.
... adverse events can occur following injection even at the hands of experienced injectors. 6,7 Severe complications related to arterial occlusion have been reported, including skin necrosis, eye and eyelid movement disorder, ptosis, loss of visual field, and even blindness. 8,9 The most commonly affected areas were the frontal, glabellar area, nose, alar base, and nasolabial folds. ...
Background
Vascular embolism is a serious complication of hyaluronic acid (HA) filler cosmetic injection and hyaluronidase injection has been proposed as the treatment. Until now there is a lack of adequate clinical evidence regarding the benefits of treatment for HA filler-induced vascular embolism by percutaneous facial or supratrochlear arterial hyaluronidase injection.
Objectives
To evaluate the efficacy of percutaneous facial or supratrochlear arterial hyaluronidase injection as a rescue treatment for HA filler-induced vascular embolism.
Methods
We included 17 patients with vascular embolism after facial HA filler injection. Intraarterial injection of 1500 units hyaluronidase was performed via facial artery for thirteen cases with skin necrosis and via supratrochlear arterial for four cases with severe ptosis and skin necrosis but no visual impairment. Simultaneously, the general symptomatic treatment and nutritional therapy were performed.
Results
After hyaluronidase injection, the facial skin necrosis in all cases was restored and the ptosis in the four cases was also significantly relieved. Patients were subsequently followed for 1 month to 1 year. The skin necrosis in 16 patients were completely healed and only 1 patient had small, superficial scars.
Conclusions
It is effective to alleviate the skin necrosis and ptosis resulting from HA filler embolism via percutaneous facial or supratrochlear arterial hyaluronidase injection.
... Transient reactions included edema in 15% (n = 35), vesicle and blister formation in 5% (n = 12), subcutaneous nodules in 3% (n = 8), and filler dislocation in 0.5% (n = 1). 2,4,13,14,19,23,24,30,46,53 In contrast, severe complications were described as follows: skin necrosis in 13% (n = 31), immediate vision loss in 2% (n = 4), 16,27 oculomotor nerve palsy in 1% (n = 3), ischemic optic neuropathy in 0.5% (n = 1), and positivity to herpes simplex type 1 encephalitis with altered mental status and seizures in 0.5% (n = 1). Complications occurred both after injection of HA (87.5%) and CaHa (12.5%). ...
Background:. A variety of complications after injection of nonpermanent fillers for facial rejuvenation have been reported so far. However, to date, the overall complication rate is still a matter of debate. The aim of this study was to perform a systematic review of literature to assess the type and severity of associated complications following injections in different anatomical regions of the face.
Methods:. The entire PubMed/Medline database was screened to identify case reports and clinical studies describing complications that have occurred after injection of nonpermanent fillers in the face. These complications have been reviewed and analyzed according to their occurrence in different anatomical regions of the face.
Results:. Forty-six articles including a total of 164 patients reported on a total of 436 complications during the time period between January 2003 and February 2020. The majority of the complications were reported after injections to the nose and the nasolabial fold (n = 230), the forehead and the eyebrows (n = 53), and the glabellar region (n = 36). Out of 436 complications, 163 have been classified as severe or permanent including skin necrosis (n = 46), loss of vision (n = 35), or encephalitis (n = 1), whereas 273 complications were classified as mild or transient, such as local edema (n = 74), skin erythema (n = 69), and filler migration (n = 2). The most severe complications were observed in treatments of nose, glabella, and forehead.
Conclusions:. Nonpermanent facial fillers are associated with rare but potentially severe complications. Severity and impact of complications depend on the anatomical region of the face and eventually require profound knowledge of facial anatomy.
... At 3:50 hours post visual loss, APD persisted, but right VA had improved to count fingers (CF). Three injections of 1500 IU hyaluronidase were given at 4:00 hours as described above (#2, 3,4). The discomfort of the subcutaneous injection (#3) required further sedation. ...
... Our case did not receive specific intra-vascular hyaluronidase injections, as some studies have suggested, although the supraorbital and supratrochlear vessels were targeted. 4 The favorable visual result following extra-orbital and intra-orbital injections suggests that diffusion of hyaluronidase plays an important role despite in vivo cadaver studies suggesting otherwise. 5 The filler is thought to have entered the vasculature from the site it was injected into via highly anastomotic facial plexus. ...
Background
The rise of cosmetic injectables has seen new clinical scenarios related to complications. The scenario of hyaluronic acid (HA) aesthetic interventional induced visual loss (AIIVL) has become more recognized. While this complication is rare, there can be delayed recognition and treatment, with limited opportunity to evaluate potential treatments and establish best practice guidelines.
Objectives
We report a case of documented visual recovery with extra-orbital and intra-orbital hyaluronidase. Central retinal artery occlusion (CRAO) is an ischemic event requiring urgent intervention. We hope to assist protocols being developed for HA AIIVL.
Methods
Following loss of vision, 675 international units (IU) of hyaluronidase was given immediately to the injection site and extra-orbital area. Within four hours, 3,000 IU intra-orbital and 1,500 IU extra-orbital hyaluronidase was given in the Emergency Department (ED).
Results
Visual loss in a 38-year-old female, following ipsilateral glabella and nasal injection of 0.15 ml of hyaluronic acid filler Juvéderm Voluma via the nasal tip, was documented at no perception of light (NPL) with afferent pupil defect (APD), CRAO, fundoscopy showing a cherry red spot. This was associated with cerebral irritation and Magnetic Resonance Imaging (MRI) ischemia. Hyaluronidase was injected as described above. The following day, visual acuity (VA) in the affected eye recovered to 6/18 with a relative superior visual field scotoma. VA improved to 6/6 at one month.
Conclusions
We believe immediate injection, followed by high dose intra-orbital and extra-orbital injection of hyaluronidase, had a positive effect in this case. Recovery of vision was remarkable, from NPL to 6/6, documented at a tertiary referral eye hospital.
... Direct infusion in the ophthalmic artery using selective angiography has been reported, but it is practically not feasible in the emergency setting. 9,10 The other potential delivery option is retrobulbar injection. 3,4,11 Retrobulbar injection of 1500 to 3000 IU of hyaluronidase has failed to reverse the vascular occlusion in animal models or in humans treated for the same. ...
Purpose:
To determine if retrobulbar injection of hyaluronidase reaches the vitreous cavity, and to determine its concentration in the vitreous.
Methods:
Prospective case-control study. Patients undergoing evisceration with implant for noninfective blind eyes were enrolled in the study. Before the evisceration, a retrobulbar injection of 3,000 IU of hyaluronidase (2 ml) was injected. Time from injection to in vivo sampling of posterior vitreous was noted. Vitreous samples from controls were obtained from patients undergoing vitrectomy for retinal detachment or diabetic retinopathy. Concentration of hyaluronidase was assessed in all 30 samples. An ELISA-based microtiter-technique was used to evaluate the activity of hyaluronidase by an avidin-peroxidase-based procedure using an ELISA reader. Incubations were carried out at room temperature and at 37°C. All the samples were analyzed in duplicates, and the mean of each sample was plotted on a scatter plot.
Results:
Total of 30 vitreous samples were analyzed, of which 15 were controls and 15 were test samples. Of the 15 test samples, injection-to-sampling time was 0 to 20 minutes in 4 samples, 20 to 40 minutes in 6 samples, and 40 to 60 minutes in 5 samples. The highest concentration of hyaluronidase detected in control and test samples were 2.9 and 3.0 µg/ml, and the lowest concentration was 1.7 and 1.5 µg/ml (SD 0.3), respectively. There was no significant difference between control and test groups.
Conclusion:
Retrobulbar injection did not result in higher concentration of hyaluronidase in the posterior vitreous compared with controls when measured up to 60 minutes following injection.
... В США, Великобритании, ЕС используется в основном как вспомогательный компонент биологических лекарственных препаратов для подкожного введения, где способствует местному распространению действующего вещества в тканях, а также при лечении гематом [2-3]. Известно использование гиалуронидазы off -lable для экстренного лечения ятрогенной эмболии сосудов сетчатки при введении косметических препаратов гиалуроновой кислоты (филлеров) [4]. В инструкции по медицинскому применению [1] указаны следующие общие противопоказания: гиперчувствительность; острые инфекционно-воспалительные заболевания; недавние кровоизлияния; острые интеркуррентные заболевания; детский возраст до 18 лет. ...
Hyaluronidase is currently not included into Russian or foreign guidelines on the treatment of acute respiratory distress-syndrome in patients with COVID-19, and such treatment is not supported by evidence of clinical effectiveness. Hyaluronidase can only be used for COVID-19 within clinical trials.
