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SUN Chuanbin. Clinical features and influencing factors of visual prognosis of occlusion of ophthalmic arteries and its branches caused by cephalic and facial cosmetic fillers[J]. Chinese Journal of Stroke, 2024, 19(3): 280-287.
Head and face cosmetic filler injections are a technique that uses fillers such as hyaluronic acid (hyaluronic acid) and autologous fat to improve facial details under the skin for microplastic surgery and cosmetic purposes. It is not uncommon in clinical practice to have serious complications such as occlusion of the ophthalmic artery or its branch arteries, or even cerebral artery embolism leading to cerebral infarction immediately after the injection of head and facial cosmetic fillers.
Objects and Methods
The clinical and imaging data of 26 patients with occlusion of the ophthalmic artery or its branch arteries due to cephalic and facial cosmetic filler injection from December 2016 to June 2023 were retrospectively analyzed.
1.1 Diagnostic basis for occlusion of the ophthalmic artery or its branches
The diagnosis of occlusion of the ophthalmic artery or its branches is based on its typical ophthalmologic clinical and radiographic findings. Typical clinical manifestations of ophthalmic artery occlusion (AAO) include: (1) acute loss of vision, usually no light perception or light perception, (2) fundus examination shows diffuse panretinal edema without macular "cherry erythema;(", 3) slit-lamp examination shows non-infectious inflammatory manifestations of the anterior segment (anterior segment ischemic lesions), such as corneal edema, anterior chamber flash, and mydriasis, (4) extraocular muscle paralysis, which can involve all extraocular muscles and cause ocular fixation. Patients with incomplete ophthalmic artery occlusion should meet at least the first two items.
Typical clinical manifestations of complete central retinal artery occlusion (CRAO) include: (1) acute loss or loss of vision, usually reduced to manual or finger counting, and (2) fundus examination showing diffuse posterior pole retinal edema with macular "cherry erythema". Patients with incomplete CRAO may have varying degrees of preservation of visual acuity, and the fundus appears as patchy edema of the posterior pole retinal patch.
Posterior ciliary short arterial occlusion can manifest as nonarteritic anterior ischemic optic neuropathy (NAION), nonarteritic posterior ischemic optic neuropathy (NPION), and choroidal ischemic lesions, depending on the site of involvement. NAION typically presents with (1) mild to moderate loss of visual acuity with obstruction of the upper or lower visual field, (2) segmental or diffuse edema of the optic disc on fundus examination, and (3) quadrant visual field defect or horizontal semi-blindness or total blindness on visual field examination connected to a physiologic blind spot. Fundus examination of choroidal ischemic lesions shows choroidal fan-shaped edema (triangular syndrome) or patchy edema. NPION is currently a clinical exclusionary diagnosis, and all other causes that may cause vision loss or visual field defects need to be ruled out before NPION can be diagnosed.
1.2 Ophthalmology and MRI examinations
All patients underwent best corrected visual acuity (BCVA), slit lamp microscopy, direct ophthalmoscopy, and visual field examination. Patients with a clinical diagnosis of AAO, CRAO, or posterior ciliary short artery occlusion were given fundus color photography, photocoherence tomography (OCT), and fundus fluorescein angiography (FFA). If there is or may be cerebrovascular involvement such as dizziness or impaired consciousness, brain MRI is also given.
1.3 Treatment
After 2 patients developed eye symptoms, cosmetic filler injectors injected hyaluronidase treatment around the injection site on the spot. Patients with AAO or CMAO are treated according to a CRAO emergency regimen that includes eye massage, intraocular pressure lowering, microcirculation improvement, and neurotrophic therapy, and a short course of oral corticosteroids such as prednisone. One patient received one retrobulbar hyaluronidase injection in the hospital the day after the onset of symptoms. Patients with occlusion of other branches of the ophthalmic artery are given only improved microcirculation, neuronutrition, and a short course of oral corticosteroids. Some patients were treated with either a hyperbaric chamber or acupuncture at the same time.
outcome
2.1 General condition of the patient
The general information and clinical manifestations of the 26 patients are shown in Table 1.
According to whether the retinal artery was completely occluded and the extent of optic nerve ischemic involvement, the above 18 patients with retinal or optic nerve involvement were further divided into two subgroups.
Group 1: Complete occlusion of the central retinal artery or diffuse ischemia of the optic nerve, a total of 11 patients, BCVA at the first and last follow-up visits were no light ~ fingers, the median was manual, and the patients' visual acuity did not change before and after treatment.
Group 2: Incomplete occlusion of the central retinal artery or segmental ischemia of the optic nerve, a total of 7 patients, BCVA was 0.02~1.0 at the first diagnosis, the median was 0.1, and the BCVA was 0.12~1.0 and the median was 1.0 at the last follow-up. Subgroup comparisons found that patients with BCVA ≥ 0.02 at initial diagnosis had a better visual prognosis than patients with BCVA ≤ number of fingers.
2.2 Patient's ophthalmic imaging and MRI examination findings
FFA in AAO is characterized by the absence of fluorescent filling in the retina and choroid, or severe delay in filling, and OCT is characterized by full-thickness retinal edema and loss of normal layers. FFA in CRAO shows that the retinal arteries are consistently unfilled or sluggishly filled, and the choroidal fluorescence is normal. OCT of complete CRAO is characterized by full-thickness retinal edema and loss of normal layers. OCT of incomplete CRAO presents with focal (or multifocal), segmental retinal edema, and loss of normal levels. FFA in NAION is characterized by segmental or diffuse absence or sluggish filling of the optic disc, and visual field examination shows a fan-shaped visual field defect associated with an enlarged physiological blind spot, horizontal hemiblindness, or diffuse decreased light sensitivity. FFA is normal on NPION, and perimetry shows a central scotoma or diffuse decrease in light sensitivity.
Patchy neocerebral infarction lesions were found in 3 patients, including 2 cases of hyaluronic acid injection, 1 case of autologous fat, 1 case of ophthalmic artery occlusion, 1 case of NAION+ localized choroidal edema, and 1 case of mydriasis.
Case 1: Fundus examination and brain MRI results
Diffuse anterior ischemic optic neuropathy and cerebral infarction in the right eye after autologous fat injection of the head and face. Fundus examination showed grayish-white edema on the temporal side of the optic disc in the right eye, congestion and edema in the rest of the eye (arrows shown in figure A), and no abnormalities in the retina. FFA examination showed sluggish vasofluorescein filling in the upper and lower choroids of the optic disc and peridisc in the right eye (shown by the arrow in the B panel) and diffuse fluorescein leakage from the surface of the optic disc in the late optic disc (shown by the arrow in the C panel). The brain MRI T2WI FLAIR sequence shows multiple punctate hyperintensities in the cerebral frontal cortex, suggesting multiple de novo infarcts (arrows in the D panel). After 8 months of follow-up, fundus examination showed pallor of the optic disc (shown by arrow in figure E). FFA—fluorescein fundus angiography.
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Case 2: Fundus examination results
Hyaluronic acid injection causes complete central retinal artery occlusion in the right eye. Fundus examination shows diffuse edema of the retina at the posterior pole of the optic disc and "cherry erythema" in the macula (arrows in panel A). FFA examination shows that most branches of the central retinal artery in the right eye are consistently unfluorescein-filled during the contrast (arrows shown in panel B). OCT showed diffuse hyperreflexia in the inner layer of the retina in the posterior pole of the right eye, and the normal layer disappeared (as shown by the arrow in Figure C). FFA—fluorescein fundus angiography, OCT—optical coherence tomography.
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Case 3: Fundus examination results
Incomplete central artery occlusion and localized choroidal edema in the right eye after head and facial hyaluronic acid injection. Wide-angle fundus photography shows mild edema of the optic disc in the right eye, localized posterior pole retinal edema with cotton wool spots (shown by the short arrows in panel A), and wedge-shaped edema of the choroidal choroids in the middle and periphery of the nasal side (shown by the long arrows in panel A). Visual field examination showed only a small central visual field in the right eye (B). OCT showed multifocal, segmental hyperreflexia in the posterior pole inner retina of the right eye, with the loss of normal levels (arrow shown in figure C). After 8 months of follow-up, wide-angle fundus photography showed a pale optic disc in the right eye, extensive subretinal hyperpigmentation in the middle and periphery of the nasal side (shown by the arrow in the D panel), and a visual field examination showed a tubular visual field in the right eye (E panel). MD—mean deviation;OCT—optical coherence tomography.
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conclusion
Occlusion of the ophthalmic arteries and their branch arteries caused by head and facial injections of hyaluronic acid and autologous fat often has a poor visual prognosis, and there is currently a lack of effective treatment. Patients with incomplete central retinal artery occlusion, segmental ischemia of the optic nerve, and BCVA ≥ 0.02 at initial diagnosis have a relatively better visual prognosis than patients with complete central retinal artery occlusion or diffuse optic nerve ischemia.