This topic was covered in this month's JAMA Ophthalmology (https://archopht.jamanetwork.com/article.aspx?articleid=1838342) and reported by Medscape.
Blindness secondary to fillers used in the face is a recognized complication; it has been debated for a few years - certainly, I raised it at a meeting in London in 2012. The paper in JAMA Ophthal refers to (off-label) use in the glabellar area, and, correctly in my opinion, attributes the complication to the anastomoses between branches of the E.C.A. and I.C.A..
Unfortunately, most doctors are oblivious to this risk, and nurses even more so. In fact, I have met, even recently, 'nurse injectors' representing manufacturing companies that had no idea about this potential problem.
My advice to colleagues/ my team is as follows (which I have cut-and-pasted from my comments on Medscape):
1) Certain areas have a higher risk: malar area (medial infraorbital zone) and inferior glabellar area;
2) There can be aberrant vessels and high pressure injecting can increase the risk;
3) Cannulae are 'probably' safer in these danger zones;
4) Hyaluronidase has no established role in addressing this problem, as once the small vessels supplying the retina are occluded then the outcome is rapidly poor. Plus, from a logistical point of view, the hyaluronidase would need to be injected into the common carotid or internal carotid given that the aim is to get the enzyme to the retinal arteries a.s.a.p., and this has it's own risks;
5) Safety should trump aesthetics: I do not inject in the aforementioned danger zones. Many do, and to be honest, the risk of this adverse outcome is minute - but should it happen, it is 100% critical.
If a filler is required in the medial nasojugal area, my feeling is that it should be injected as close to the surface as possible, i.e. very superficially. Of course, the risk of the Tyndall effect is higher that way, but this could be mitigated against by the use of a monophasic filler (at least partly, and at least in theory!).
F.w.i.w., I have met a doctor and the business partner of another doctor who've caused this complication - and who have had the integrity/ strength to talk about their experiences/ learnings - and both have categorically now stopped injected anywhere within a large circumference around each eye.
I'd appreciate the thoughts of clinicians who are experienced in this field.
Tear trough correction is one of the indication to improve appearence of a face.
the problem lies in shifting of the fat downwards.
an ultrasound examination is necessary to evaluate the periocular region.
delimiting the fat area and the amount of fat that has moved away. identify the volume of dissplacement and then determine the amount of filler to be administered. the type of filler to be administered also depends on two things.
the filler should not compress any vessel, nor should create any reaaction.periocularly.
and it is important that the injection must be given under ultrasoundguidance.since it a blind area.
te shilft of fat also brings down a bit of the eyeglobe which has to be taken into consideration.
some og these have been my observations while i have observed tear trough corrections.
Im thankful to Dr Sivathasan to have raised this topic. though i had the oppertunity to inject i wanted to put these factors before someone.
I may be wrong in some of my observations.
Thank you for your thoughts, Dr. Venkata. Of course periorbital fat-loss (or re-distribution) is a marker of the ageing process, and we know why that happens. Whilst giving a lovely contour to the area is a good thing, my point was that there are risks involved, et.c..
Plus, as you have stated, fillers in the tear-trough area may compress vessels. However, that would NOT be a concern insofar as adverse-impact to the retina (i.e. external compression of a small artery in the tear trough area shall not critically impair the function of the retina); RATHER, the filler may compress and impair lymphatic vessels and hence cause increased swelling and puffiness.
I do NOT believe that USS-guided filler-injections around the eyes are practical or feasible for the following reasons:
1) tricky to visualize the area and massive impact of user-inefficiencies;
2) the probe may compress small vessels (tributaries and anastomoses), which may thus not get visualized, but a needle may subsequently puncture them;
3) misinterpretation of structures by the clinician;
4) relative cost and impact on speed vs. return on charge for the total service;
5) set-up costs and practical applicability;
What I do to TRY to avoid this known complication of fillers is to ALWAYS pull back on the syringe before injecting to determine if you are in the vessel. Also, detailed knowledge of facial anatomy should be a prerequisite for all injectors and high risk areas should not be attempted by those who do not have formal anatomy training (my bias).
Hello Luciann and thank you for your input. Pulling back on the syringe (as opposed to withdrawing the syringe) is of limited value in this case, due to the size of the needle (i.e. affecting easy flow-of-blood), size of arteries (i.e. small, and hence blood not flowing at high velocity), and product in the syringe (i.e. viscous and likely not accommodating of any blood entering into the syringe).
The key thing, as you have said, is knowledge of facial anatomy - and also, in my opinion, awareness of this possible complication. This is why I disagree with nurse-injectors, esp. with regard to fillers. The fact is that they do not have the same degree of training or anatomical knowledge, and, importantly, I know many, many 'nurse injector trainers' that work for Allergan and Galderma and NONE had a clue about this kind of problem (and some even disagreed with this possibility) when I raised it at various events.
Sadly, money talks, and pharmaceutical companies are more interested in high-volume sales instead of high-quality approaches, so it is better from their points-of-view to have as many injectors as possible, regardless of how low-end they are.
Niroshan,
Thank you for your comments. Agree with limited knowledge by non-physician injectors. Do you have any tips to avoid this complication? I primarily use Radiesse and have not used catheters for injection.
PM your e-mail address to me, Luciann - shall be in touch in due course with some stuff.
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