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Abstract
Purpose
To report a case of sudden unilateral visual loss and total external ophthalmoplegia combined with multifocal brain infarction following injection of hyaluronic acid (Restylane; Q-Med AB, Uppsala, Sweden) into the glabella area.
Case summary
A 25-year-old woman was referred for sudden unilateral visual loss and blepharoptosis. Visual acuity was no light perception in the right eye and 0.15 in the left eye. The best corrected visual acuity was no light perception in the right eye and 1.0 in the left eye. The right pupil was dilated and a relative afferent pupillary defect was detected. The patient showed blepharoptosis and total external ophthalmoplegia on the right side. Fundus examination revealed central retinal artery occlusion and pale disc in the right eye. The patient had developed skin necrosis and a surrounding reddish reticular pattern on her face around the glabella. She was injected with hyaluronic acid for 5 times into the glabella area. Fluorescein angiography of the right eye revealed markedly prolonged choroidal filling around the optic disc with no retinal arterial filling. Brain MRI showed multifocal punctuate acute infarction in both frontal lobes. After 2 months, oph-thalmoplegia improved partially although her right eye vision did not, and 15 PD right exotropia was observed.
Conclusions
Although most complications of dermal fillers are mild and transient, severe and persistent adverse effects can occur including tissue necrosis, retinal artery occlusion, and brain infarction. Therefore cosmetic procedures should be carefully performed when administering periocular dermal filler injection. A prompt consultation with an ophthalmologist is recommended when there is evidence of visual problems after injection.
References
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Figure 1.
Facial photographs and photographs of 9 cardinal gaze, on the first day of symptoms onset and 2 months later. (A) On the day of symptoms onset, photograph shows patch necrosis and surrounding reddish reticular pattern at the glabellar region, the bridge of the nose, and the right eyelid with complete blepharoptosis. (B) 9 cardinal gaze photo shows total external ophthalmoplegia on the right eye. (C, D) 2 months after the onset of symptoms, skin was well recovered with minimal scar formation and blepharoptosis and ophthalmoplegia resolved, but there was exotropia on the right eye.
Figure 2.
Fundus photographs in the right eye, on the first day of symptoms onset and 7 days later. (A) On the day of symptoms on-set, photograph shows central retinal artery occlusion and pale disc. (B) 7 days after the onset of symptoms, photograph shows prob-able reperfusion in the retinal circulation and inner retinal hemorrhages, venous dilatation, macula pallor, and arteriolar narrowing.
Figure 3.
(A, B) Fluorescein angiography revealed no abnormality in the left eye on the day of symptoms onset. (C, D) The right eye it showed markedly prolonged choroidal filling around the optic disc and there was no retinal arte-rial filling. (E, F) The diffusion weighted brain magnetic resonance imaging showed multifocal small nodular high signal foci (white arrows) at both frontal lobes.
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