Ophthalmic Complications of Periorbital and Facial Aesthetic Procedures: A Literature Review

Abstract

The emergence and popularity of cosmetic facial procedures may lead to significant ophthalmic complications such as ocular motility dysfunction and visual disability. Here, we present a scoping review to identify common ophthalmic complications in some facial plastic surgeries and cosmetic injections, and to develop clinical approaches for prophylaxis and management in terms of direct attention and awareness of non-ophthalmologists toward such scenarios and appropriate intervention. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following keywords were used to search PubMed, Scopus, Web of Science, and Google Scholar: "facial laser", "facial fillers", "facial injections", "hyaluronic acid", "local facial injections of botulinum toxin", "rhinoplasty", "blepharoplasty blindness", "ophthalmoplegia", "diplopia", "ptosis", "ophthalmic artery occlusion", "posterior ciliary artery occlusion", and "ocular ischemic syndrome". A total of 37 articles published between 1989 and 2021 were included, of which 21 were case reports. The most common ophthalmic complication was vision loss (0.0008%). The risk of ophthalmic complications including ocular pain, sudden unilateral or bilateral vision loss, flashes of light, ptosis, and ophthalmoplegia increase with injection in common anatomical regions like the glabella, nose, and supraorbital and nasolabial folds. The incidence of adverse events ranges from 5% to 18% in rhinoplasty. The most common complications after blepharoplasty were dry eye syndrome and diplopia, caused by eyelid ptosis. Eyelid, cornea, lens, and retina injuries are ophthalmic complications that occur after facial laser treatment. Ophthalmic complications after non-ophthalmic and cosmetic procedures are becoming increasingly common. The cumulative reported cases of ophthalmic complications after hyaluronic acid filler injection from 2016 to 2020 showed different types of adverse events, with the most common being decreased visual acuity, unilateral vision loss, and ptosis, with varying outcomes of each complication ranging from partial resolution to complete recovery. These complications must be recognized early, and prompt treatment must be established.

Keywords: facial fillers; facial injections; facial laser; hyaluronic acid filler; ocular; ophthalmic complications; procedures; rhinoplasty; surgeries.

Figure 1. PRISMA flow diagram for included studies

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Figure 2. Illustration of vascular anatomy comparing the possible obstruction mechanism between hyaluronic acid and autologous fat

(A) This figure illustrates all branches of the external carotid artery that supply the face and might get obstructed if hyaluronic acid or autologous fat gets injected directly into these branches. (B) This figure illustrates all branches of the external carotid artery with normal blood flow or impaired blood flow after injecting hyaluronic acid or autologous fat into those vessels with the increase of intra-tissues pressure in case of obstruction with hyaluronic acid. Image credit: Kim et al., 2015 [19] with permission.

Figure 3. An illustration of the vascular anatomy of the face with selected facial vessels highlighted.

Needle positions show potential means of inducing blindness due to filler injection. In this diagram, the filler is injected directly into the supratrochlear artery, in addition to the angular artery, where it anastomoses with the supratrochlear artery, from which it can travel retrogradely (shown by arrows) into the ophthalmic artery and its branches, leading to blockage of the blood supplying the retina and causing visual adverse events. Image credit: Beleznay et al., 2019 [10] with permission.

Figure 4. MRI brain image showing acute embolic infarction after facial hyaluronic acid filler injection into the glabella area

(A, B) Brain diffusion MRI on day 1 after facial filler injection showing numerous high signal-intensity lesions in both cerebral hemispheres, involving the frontal, parietal, and occipital lobes. These were acute embolic infarcts caused by filler-related emboli. (C, D) In follow-up diffusion MRI on day 7, extensive hemorrhagic transformation that could be categorized as parenchymal hematoma was noted in the previous infarcted foci, especially in both frontal and left parieto-occipital lobes. Image credit: Lee et al., 2021 [27] with permission.

Figure 5. CT brain image showing per-orbital emphysema without crepitation after closed-structured rhinoplasty.

(A) CT (sagittal) showing emphysema in the per-orbital area. (B) CT (axial) showing emphysema in the per-orbital area. Image credit: Charles-de-Sa et al., 2014 [29] with permission.