Retinal artery occlusion after facial filler injection in a patient with patent foramen ovale: a case report and literature review

Abstract

We describe a young woman with patent foramen ovale who developed multiple retinal artery occlusion in the right eye after injection of hyaluronic acid into the nasal root. She reported a gradual decline in visual acuity, with visual field defects that had developed in two stages. Multiple retinal artery occlusion was confirmed by slit-lamp examination, dilated fundus examination, optical coherence tomography, visual field examination, and fundus fluorescein angiography. A patent foramen ovale was detected by electrocardiography, transesophageal echocardiography, and transthoracic sonography. The patient was treated with intravenous dexamethasone and cobamamide, as well as extracorporeal counterpulsation therapy; this approach has not been described in previous literature regarding retinal artery occlusion. The patient's visual acuity improved from counting fingers at 30 cm to 20/133 within 3 days. Our report emphasizes the need for better understanding of vascular anatomy to minimize the risk of complications. Moreover, patients undergoing hyaluronic acid injection should receive information regarding the potential for mild and severe complications; relevant tests should be performed before surgery to exclude vulnerable patients. Finally, a nursing system is needed to facilitate the emergency recognition, triage, and management of retinal artery occlusion.

Keywords: Hyaluronic acid; case report.; extracorporeal counterpulsation therapy; facial fillers; patent foramen ovale; retinal artery occlusion.

Figure 1.

Fundus examination revealed a clear optic disc margin in the right eye, with a cherry-red spot in the macular region (red arrow). Large fan-shaped white edematous lesions were visible in deep retinal layers below the macula and on the temporal side, with faintly visible transparent emboli (yellow arrow). Scattered lesions were also visible at the distal ends of the nasal and superior microvasculature.

Figure 2.

Optical coherence tomography assessment of the right eye showed increased reflectivity in the retinal nerve fiber layer and thickening in the macular area, along with diffuse thickening and hyperreflectivity in the inner retinal layers.

Figure 3.

Fundus fluorescein angiography revealed that the optic disc margin was clear. Large areas of nonperfusion were visible in the temporal and inferior retinal arteries.

Figure 4.

Transesophageal echocardiography (a, b, c) and transthoracic sonography (d, e, f) revealed mild mitral and tricuspid regurgitation (b), left ventricular filling abnormalities (b), and a patent foramen ovale (a, red arrow). A small trans-septal shunt with a 13-mm-long gap was present in the central part of the interatrial septum. The gap was located between the primary and secondary septa; it had an overall surface width of 3.4 mm (1.4 mm on the right atrium and 2 mm on the left atrium) (c). Postoperative assessment revealed numerous microbubbles (d, e, f) with intense echoes in the left atrium.