New Case Submission - Location: Glabella
Submitter Credentials: MD
Case Variables:
Location: Glabella
Product: HA Filler
Complication: Vision Loss
Onset: Immediate
Tx: Hyaluronidase (Tissue Flooding), Hyperbaric Oxygen (HBOT)
Outcome: Full Resolution
History & Presentation:
A 38-year-old healthy female with no medical or ophthalmic history presented to the ED with acute vision loss in the left eye following an at-home injection of 0.5 cc mail-order HA filler (Multi-Crosslinking Hyaluronic Acid Glamour Filler, Fillers Korea) into the left glabella and left medial eyebrow. The injection was performed at 10:30 PM by the patient's friend, who has no medical training or qualifications. Needle gauge, depth, and anatomical approach not specified. The patient immediately noted severe pain and complete vision loss in the left eye, beginning as a central blind spot that enlarged to engulf the entire visual field. On examination at 1:00 AM (2.5 hours post-injection): Right eye 20/20. Left eye hand-motion centrally, 20/400 eccentrically in far periphery. Bilateral IOP 12 mmHg, full extraocular motility, no afferent pupillary defect. Externally: left periorbital edema, erythema, skin mottling above the left eyebrow, mottling and discoloration of the lid extending to the lash line in the V1 distribution. Fundoscopy: well-defined area of retinal pallor extending from the disc to the inferior macula, no visible emboli. Diagnosis: early central retinal artery occlusion secondary to filler injection.
SOURCE REFERENCE: Friedman R, Coombs AV, Stevens S, Lisman RD, Chiu ES. Complete Vision Recovery After Filler-Induced Blindness Using Hyperbaric Oxygen Therapy: Case Report and Literature Review. Aesthet Surg J Open Forum. 2024;6:ojae036. DOI: https://doi.org/10.1093/asjof/ojae036
Management Protocol:
10:30 PM: Injection occurred at home. Immediate vision loss and severe pain.
1:00 AM (2.5 hr post-injury): ED presentation. Examined.
1:30 AM (3 hr post-injury): First hyaluronidase 150 units infiltrated into supraorbital notch and overlying glabellar area in V1 distribution, with massage to ensure distribution and penetration.
1:40 AM: Second hyaluronidase 150 units (10 minutes after first dose) — same location, same technique. Brimonidine-timolol drops administered to lower IOP. Ocular massage performed (standard CRAO maneuver). Patient refused retrobulbar hyaluronidase injection.
4:30 AM (6 hr post-injury): Third hyaluronidase 150 units with massage (total 450 units delivered).
Within 10 hr of injury: First HBOT session — 90 minutes at 2 ATM. Post-session VA improved to 20/25 in the left eye; central scotoma cleared, leaving only peripheral vision loss. This was the first subjective and objective improvement noted — no improvement was seen between hyaluronidase doses prior to HBOT.
Sessions 2 and 3: VA recovered to 20/20. Patient elected to discontinue after 3 sessions despite recommended 10-session protocol.
Day 5 imaging: SD-OCT of left macula revealed edematous and irregular inner retinal layers, representing ischemic infarct of the inner retina. Fluorescein angiogram of nasal macula showed no significant filling defect or areas of ischemia.
1 week post-injury: Photographic documentation showed near-complete resolution of external skin findings. Vision stable at 20/20. The authors attribute primary vision recovery to HBOT, noting that subjective and objective improvement only occurred after the first HBOT session despite multiple prior hyaluronidase doses.
HBOT is hypothesized to preserve oxygen delivery to ischemic inner retinal tissue (perfused by central retinal artery) until the embolus resolves or collaterals form, increasing tissue oxygenation up to 20-fold via increased partial pressure. HBOT is only effective on ischemic but not yet infarcted tissue, emphasizing urgency of early intervention.
