Avoiding and Treating Blindness from Fillers - Belezany et al

The question of how to best avoid and treat blindness from a dermal filler injection remains controversial.  

This paper was a review of current published cases of blindness in 2015.  The autors discussed the cases and some ways to avoid and treat this catastrophic complication.

BELEZANY et al - October 2015

Derm Surg, 41:10:OCTOBER 2015

OBJECTIVE -

The authors reviewed published cases of blindness from dermal filler injection. They looked at the location of the injection when blindness occurred.  They also discussed prevention and management of blindness after a dermal filler.

METHODS AND MATERIALS -

They performed a literature review of all published cases of blindness from filler injection. Including all types of fillers.

RESULTS -

The most common sites for blindness were injection in the glabella (38.8%, n = 38), nasal region (25.5%, n = 25), nasolabial fold (NLF) (13.3%, n = 13), and forehead (12.2%, n = 12) (Figure 1).

The majority of the cases of blindness were from fat injection 47.9%, followed by HA dermal filler 23% then other fillers after that.

Though blindness is a catastrophic event from filler treatment, the risk is still very low. At the time of publication (2015), 98 cases of blindness from filler had been reported.  In 2014 alone there were over 5 million dermal filler treatments performed.

SUMMARY

Prevention of blindness from dermal fillers - the authors recommend -

• Understand the depth and location of facial vessels. Understand the plane at which vessels sit in each area of the face.
• Inject slowly with minimal pressure
• Inject small amounts (no more than 0.1ml)
• Move your needle tip while injecting
• Aspirate before injection. Although this is controversial as some studies have shown it could produce a false negative
• Use a smaller diameter needle
• Use a smaller syringe
• Consider using a cannula - (our comment, again since publication of this article smaller cannula's have been shown to act as needles and pierce vessel walls)
• Use extreme caution when injecting a patient who has undergone surgery in the area you are injecting
• Consider mixing the filler with epinephrine (adrenaline) to promote vasoconstriction.  (our comment - this may mean it is more difficult to recognise white blanching if you do occlude an artery while injecting).

The authors recommend strategies to treat blindess with a HA filler such as a retrobulbar injection of hyaluronidase approx 300 - 600 units in 2-4ml.  

We recommend you READ this article from Derm Surg and read it in full.  The link is below.

https://journals.lww.com/dermatologicsurgery/pages/default.aspx

OUR TAKE

If you are in Australia you should attend our 'Safety with Dermal Fillers Workshop' in 3 hours we cover all the latest published data on blindness and dermal fillers.  

You should keep current and read your clinical publications. Revise important anatomy. Know your limitations.

We teach in our classes (ASSOC PROF GOODMAN) -

• Keep your needle tip moving at all times
• Consider a large bore 22g cannula in areas that are risky
• Do not treat noses or glabellas with dermal fillers, it just isn't safe
• Inject slowly, gentle pressure on the plunger
• Inject small amounts less than 0.1ml, big boluses are bad medicine
• Aspirate if you want to but understand it has proven unreliable in 3 published studies.  If you aspirate and see blood then you wouldn't proceed. If you aspirate and don't see blood don't assume that means you can inject a large bolus of filler immediately after.
• Avoid semi-permanent and permanent fillers - if you can't take it out, don't put it in

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