Blindness from filler – review of causes and treatment

Introduction

Dermal fillers are commonly requested aesthetic procedures. These minimally invasive procedures involve the injection of a filler material, typically a hyaluronic acid gel, to provide volume and support to the skin. Other commonly used products include autologous fat or biostimulators such as poly-L-lactic acid or calcium hydroxyapatite. These procedures are generally safe and are performed routinely in clinics, with an estimated 20 million treatments performed worldwide. Most often, adverse effects (if any) are limited to mild bruising and swelling that resolves after a few days. Rare but serious complications are caused by accidental intravascular injection of filler material, leading to blockage of blood supply- depending on the blood vessel involved, this may result in skin necrosis, blindness or stroke.

What is filler-related blindness?

Blindness following filler injection is a rare but catastrophic outcome from a cosmetic elective procedure, which gained significant media attention when a case was reported in Singapore in July 2024 (3). The exact number of cases worldwide is unknown to date (2024); there have been 511 confirmed cases of filler-related blindness (2) published in the literature.

A Singaporean woman went blind in July 2024 after receiving a filler treatment in a clinic

How do fillers cause blindness?

Blood vessels of the face are closely linked to the blood vessels of the eye, with connections known as anastomoses. Specifically, the blood vessels of the face, known as the angular artery, are linked to the blood vessels of the eye known as the supraorbital and supratrochlear branches of the ophthalmic artery. Accidental intravascular filler injection into these vessels may cause a column of filler that spreads along the ophthalmic artery, eventually blocking off the blood vessel that supplies the retina, known as the central retinal artery.

Blood vessels of the face are closely linked to the eye

Blood vessels of the eye region

Accidental intravascular injection of filler material into a facial blood vessel, with migration of filler into the blood vessels of the eye leads to blindness

How often does it happen?

Filler-related blindness is extremely rare, estimated risk of 0.001% (less than 1  in 100,000 chance), but given the popularity of filler treatments, patients and doctors need to be aware of this.

Diagnosis of filler-related blindness

Blindness after filler injection occurs immediately after filler injection, with patients reporting visual disturbance (ie visual blurring, vision loss, darkening of visual field), eye pain, double vision, droopy eyelids and headache. Emergency eye specialist consultation is required, with the diagnosis confirmed by examination of the retina and visual field testing.

Filler-related blindness 

Prevention of filler-related blindness

Several strategies are recommended to avoid developing filler-related blindness

Knowledge and training of injectors

Filler injectors should be well-trained in facial anatomy, filler injection techniques and emergency treatment of filler-related blindness. High-risk treatment areas, such as nose fillers, should only be attempted by experienced injectors

Cannula vs needle

Blunt-tipped cannulas have a lower risk of puncturing a blood vessel and are preferred by many injectors as the  “safer” option for filler injections, as compared to sharp-tipped needles, which are more likely to enter blood vessels.

Injection technique

Slow, steady filler injections are recommended to minimize the pressure in which filler material is being delivered- in the event of intra-vascular injection, this allows for early detection (patient reports pain) and minimizes the risk of filler material being propagated in a retrograde manner from facial blood vessels into the blood vessels of the eye.

Needle (sharp tip) versus cannula (blunt tip)

Treatment of filler-related blindness

Time is of the essence when dealing with a case of suspected filler-related blindness- ischemic (lack of blood supply) retina tissue becomes irreversibly damaged within 2-4 hours and needs to be reperfused (restored blood supply) urgently. An eye specialist needs to be consulted and be involved in patient care. Immediate treatment of filler-related blindness involves efforts to dislodge the emboli (filler material) into distal blood vessels and to lower the intraocular pressure. This can be achieved with several steps, including

1) Ocular massage (doctor presses down on the eyeball firmly for 5-15 seconds and releases for 45sec, repeat 3-5 minutes)

2) Eye drops and medications to lower intraocular pressure

3) Hyaluronidase injections to dissolve hyaluronic acid gel fillers

Thereafter, Hyperbaric Oxygen Therapy (HBOT) and anticoagulation with heparin may be considered to salvage retinal tissue and prevent further thrombosis (blood clotting).

In a publication reviewing filler-related blindness, of 318 cases that reported visual outcomes, 6.0% experienced complete vision recovery, 25.8% had partial improvement in visual acuity, and 68.2% had no vision recovery.

Diagnosis and treatment of filler-related blindness 

Conclusion

Filler-related blindness is a rare but catastrophic outcome after filler injection that every doctor should train to avoid, but be prepared to address. This complication may occur with any product and with injectors at all experience levels. Timely and appropriate intervention gives the patient the best chance at recovering vision. 

References

1) Loh KT, Chua JJ, Lee HM, Lim JT, Chuah G, Yim B, Puah BK. Prevention and management of vision loss relating to facial filler injections. Singapore Med J. 2016 Aug;57(8):438-43

2) Doyon VC, Liu C, Fitzgerald R, Humphrey S, Jones D, Carruthers JDA, Beleznay K. Update on Blindness From Filler: Review of Prognostic Factors, Management Approaches, and a Century of Published Cases. Aesthet Surg J. 2024 Sep 16;44(10):1091-1104. doi: 10.1093/asj/sjae091. PMID: 38630871.

3) https://www.straitstimes.com/singapore/woman-goes-blind-after-dermal-filler-treatment-in-first-reported-singapore-case