Case report
Central retinal artery occlusion and brain infarctions
after nasal filler injection
Y.-C. LIN1,2,3, W.-C. CHEN1,2,3, W.-C. LIAO1,2,3 and T.-C. HSIA1,2,3
From the 1Division of Pulmonary and Critical Care Medicine, Department of Internal
Medicine,
2Department
of Respiratory Therapy, and 3Hyperbaric Oxygen Therapy Center, China
Medical
University and China Medical University Hospital, Taichung 404, Taiwan
Address correspondence to T.-C. Hsia, No.2 Yu Der Road, Taichung, Taiwan. email:
D1914@mail.cmuh.org.tw
Learning Point for Clinicians
Facial filler injection has become more common
in cosmetic interventions. Severe adverse effects
like central retinal artery occlusion or brain infarction
can happen. This is a reminder of adverse
effects that not only have poor prognosis but also
severely impact on the quality of life, especially
in the healthy population.
A 25-year-old girl who had been previously healthy
consulted for right visual acuity loss after a nasal filler
injection of hyaluronic acid about 3 h prior to consult.
She felt severe ocular pain, nausea and dizziness
shortly after receiving the nasal injection. Physical
examination revealed clear consciousness, stable
vital signs, mild redness with ecchymosis over the
nasal and glabellar region, and right eye ptosis, with
no light reflex of the right eye. Examination of the
fundus showed right retinal attachment with diminished
blood vasculature, presence of cherry spot
and retinal edema, compatible with central retinal
artery occlusion (CRAO). However, her left upper
limb muscle power decreased and muscle power
score was 4 about 8 h later. Brain magnetic resonance
imaging showed multiple small acute infarcts over the
bilateral hemisphere but mainly in the middle cerebral
artery territory, with decreased right ophthalmic
artery flow (Figure 1).
An increasing number of people are pursuing aesthetic
enhancement and rejuvenation by means of
artificial procedures. Facial filler injections are
rapid, easy and relatively safe. They have become
popular in recent years and are considered acceptable
by the general population. The associated adverse
effects include both allergic and nonallergic
effects, although there is less risk of an allergic reaction
because hyaluronic acid has no species specificity.
Minimal nonallergic effects such as pain,
bruising or local swelling are frequently reported
but recovery is relatively easy and does not require
any treatment. Nonetheless, there are documented
cases of rare severe adverse effects, including blindness
and infarction1 that lead to devastating consequences
with only partial recovery despite invasive
treatment like intra-arterial thrombolysis and longterm
follow-up.2
The common risk factors of CRAO include thrombotic
embolus, calcified or cholesterol embolus, and
inflammatory reaction associated with vasculitis.
The incidence of CRAO is about 1:100 000.
Proper diagnosis relies on information obtained
from clinical history and ocular examination,
which includes fundoscopy and fluorescein angiography.
Fluorescein angiography showing delayed
filling or occlusion during the arterial phase, as
well as prolonged choroidal filling with the presence
of a cherry red spot, are warning signs of ophthalmic
artery occlusion.3 The face has abundant vessels
and, hence, it is possible for local subcutaneous injection
pressure to be increased enough to reverse
the flow of the filler into the ophthalmic
artery and then into the internal carotid artery.
Furthermore, functional anastomoses between the
! The Author 2014. Published by Oxford University Press on behalf of the Association of
Physicians.
QJM Advance Access published December 8, 2014
internal and external arteries make it possible for the
filler to form a brain infarction.4 Based on these
mechanisms, the present case can be explained as
the retrograde flow from the facial angular artery
and lateral nasal artery into the dorsal nasal artery
from the ophthalmic artery.
There are various available treatment options for
CRAO, including massaging the affected eye, reducing
the intraocular pressure using mannitol or acetazolamide,
and using thrombolytic agents. Park
et al. have demonstrated 44 cases of iatrogenic occlusion
of the ophthalmic artery and up to 60% of
those patients were diffuse occlusion-like ophthalmic
artery occlusion, generalized posterior ciliary
artery occlusion, and CRAO, which has the worst
visual prognosis.5 This case is a reminder for clinicians
of the care needed when performing facial
filler injections.
Conflict of interest: None declared.
References
1. Kwon SG, Hong JW, Roh TS, Kim YS, Rah DK, Kim SS.
Ischemic oculomotor nerve palsy and skin necrosis
caused by vascular embolization after hyaluronic
acid filler injection: a case report. Ann Plast Surg 2012;
71:333–4.
2. Park SJ, Woo SJ, Park KH, et al. Partial recovery after intraarterial
pharmaco-mechanical thrombolysis in ophthalmic
artery occlusion following nasal autologous fat injection.
J Vasc Interv Radiol 2011; 22:251–4.
3. Brown GC, Magargal LE, Sergott R. Acute obstruction of the
retinal and choroidal circulations. Ophthalmology 1986;
93:1373–82.
4. Egido JA, Arroyo R, Marcos A, Jimenez-Alfaro I. Middle
cerebral artery embolism and unilateral visual loss after
autologous fat injection into the glabellar area. Stroke 1993;
24:615–6.
5. Park KH, Kim YK, Woo SJ, et al. Iatrogenic occlusion of the
ophthalmic artery after cosmetic facial filler injections: a national
survey by the Korean retina society. JAMA Ophthalmol
2014; 132:714–23.
Figure 1. Brain magnetic resonance imaging demonstrated multiple small acute infarcts over the bilateral
hemispheres,
mainly in the middle cerebral artery territory and decreased right ophthalmic artery flow (arrow).