New Case Submission - Location: Glabella
Submitter Credentials: MD
Case Variables:
Location: Glabella
Product: HA Filler
Complication: Vision Loss
Onset: Immediate
Tx: Hyaluronidase (Tissue Flooding), Aspirin / Anticoagulants
Outcome: Permanent Deficit
History & Presentation:
Patient: 43-year-old healthy Caucasian female, no prior medical or ocular history. Baseline visual acuity 20/20 OU. First filler injection. Injection Details: 0.7 mL hyaluronic acid/lidocaine (Restylane) injected into the glabella by a nonmedical practitioner. Needle vs cannula not reported. Gauge not reported. Injection depth not reported. Anatomical approach not reported. Volume: 0.7 mL — notably high; literature reports permanent vision loss with as little as 0.2 mL via supratrochlear artery. Presentation: Visual field darkening of the left eye occurred during the procedure itself (immediate onset). Patient presented to ophthalmology hospital 1 hour post-injection with left forehead and upper lid swelling, ptosis, complete ophthalmoplegia, and no light perception OS. IOP normal. Left pupil sluggishly reactive with relative afferent pupillary defect. Fundoscopy: thinned arteries, cherry red spot, retinal whitening. MRI: suspected ischemic optic neuropathy. Angiography: ophthalmic artery occlusion could not be confirmed or excluded with certainty. Pathomechanism: unintentional injection into or rupture of supratrochlear artery (terminal branch of ophthalmic artery) with retrograde embolization to ophthalmic artery followed by anterograde multifocal obstruction.
SOURCE REFERENCE: Davidova P, Muller M, Wenner Y, Konig C, Kenikstul N, Kohnen T. Ophthalmic artery occlusion after glabellar hyaluronic acid filler injection. Am J Ophthalmol Case Rep. 2022;26:101407. DOI: https://doi.org/10.1016/j.ajoc.2022.101407
Management Protocol:
Hour 1: Globe massage initiated. ASA 100 mg PO daily, tinzaparin sodium 4,500 IU SC daily, methylprednisolone 100 mg IV daily x3 days then prednisone 90 mg PO, pantoprazole 40 mg PO. Dermatology performed 3 hyaluronidase injections to glabellar injection area (specific IU dose not reported; timing post-presentation not specified). No intra-arterial thrombolysis (non-thrombotic etiology). No retrobulbar/subtenon hyaluronidase given extensive ischemia already present at presentation and lack of literature support for vision recovery in complete OAO. Day 2: Hemorrhagic upper lid, anterior segment ischemia, globe hypotonia, corneal erosion/edema/Descemet folds, fixed pupil. Added dexpanthenol 5% and ofloxacin 3mg/g ointments QID. Day 4: Forehead/lid skin necrosis, lagophthalmos 3mm, lid fissure 9mm, levator 5mm, downgaze 5 degrees, chemosis, flattened anterior chamber. Sonography: globe deformation, choroidal swelling. ENT: necrotic mucosa at left middle nasal concha. Added clindamycin 300mg QID, moisture chamber, dexpanthenol Q2H. Day 6: Added prednisolone 10mg/mL drops TID, atropine 0.5% BID. Prednisone reduced to 60mg. Day 10: Complete lid closure achieved. Slight motility improvement. Corneal erosion decreased. Tapering initiated. 2.5 weeks: Lid swelling and ptosis resolved. Persistent amaurosis and severe globe hypotonia. Tinzaparin discontinued. 6 weeks: Forehead surface irregularity, madarosis inner upper lid, strabismus (esotropia + hypertropia), 2mm enophthalmos, posterior synechiae. IOP rebuilding. OCT: inner/outer retinal atrophy with architectural loss. Fundus: pale optic nerve, near-absent retinal artery filling. 2.5 months: Findings stable. ASA discontinued. Prednisolone drops switched to preservative-free dexamethasone 1mg/mL daily. Persistent blindness, skin lesions, strabismus, madarosis, early enophthalmos. Phthisis bulbi or enucleation could not be excluded.
