Restylane Injections Cause Blood Vessel Occlusion on my Left Eye, Now I Am 90%blind

Whether your branch artery occlusion was caused by the Restylane injection or not, this is a terrible event.  It sounds like you are getting very good care for this and I advise you to carefully follow the recommendations of the retina specialist.  

Periocular injection of certain materials is a known risk for embolization into the retinal circulation.  Certain injection locations and materials are at increase risk of causing retinal branch artery occlusion.  This occurs when material is embolized into the retinal arterial circulation.  The damage to the retinal circulation, which provides the blood supply to the retina, varies depending on where the embolized material lodges.  When this in closer to the main supply of blood, more of the retina and the vision is affected.  When the material lodges more peripherally, less of the retina is affected.  When the circulation to the macula is affected, the visual loss is most profound, which is consistent with your situation. 

There are other causes of branch retinal vein occlusion.  This included embolization of fat, atheroma from hardening of the arteries, and other materials.  You situation is somewhat unusual because  you did not develop visual loss at the time of treatment.  The fact that this type of visual loss is very rare does not diminish the impact of this loss to you.  Injection of the glabellar area is associated with the highest risk of retinal embolization due to the vascular organization in this area.  For this reason, many experienced injectors wouldn't treat this area or will limit treatment of only high intradermal placement.

Local disturbances in circulation following injection of HA fillers to the nose and parts of the face have been successfully treated with massive local injection of hyaluronidase, the enzyme that breaks down hyaluronic acid, the sugar gel these filler are composed of.  However, the soft tissue of the face is much more tolerant to relative or absolute ischemia than the retina.  The retina is part of the brain.  Deprived of blood supply or sufficient blood supply, very quickly leads to irreversible damage.  This is very much what happens to the brain in an ischemic stroke.  I am not aware of any cases where retinal circulatory disturbance caused by HA fillers was successful reversed by hyaluronidase.  To be of much help, this would need to be done within hours of the insult and this presumes that the occlusion was in fact the result of HA embolization.  Now two weeks later, there would likely be no value to this.

Regarding your visual prognosis, much depends on the precise anatomic details.  The macular structure called the fovea provides the finest vision that we rely on for reading, and resolving fine detail.  This has been affected by the BRAO.  What is not clear in your description is if this has been completely or only partially affected by the ischemia.  It is possible that if it has only been partially affected, some of the central vision will improve as the swelling associated with the event improves.  Your retina specialist will give you a better idea of this as he or she follows you.  

If you have not done so, please consider writing up this experience for the "Real Experience" section.  This will help others learn of this potential risk of glabellar and forehead treatment.  Our thoughts and prayers are with you that your vision improves from this terrible loss.

Thank you for your question. It is difficult to give you advice without examining you in person. However, if necessary you can have the filler dissolved with hyaluronidase. I recommend having a follow up with your injector for an evaluation. Best of Luck!

the blood supply to the glabellar/forehead region is supplied by the same artery that goes to the eye and there are few if any collateral  branches for an inadvertently intravascular injection to follow.  this is not the area for restylane or other injectables save for botox.  the risk is directly related to the amount of filler, the viscosity of the filler, and the pressure under which it is injected. with time some recovery will occur and you are obviously being followed closely by your retina specialist so have faith be optimistic and good luck.

The onset of visual impairment or blindness happens fairly quickly after the filler or any other material that can cause blockage, gets into the artery. It is somewhat unusual for it to happen one day after the injection.  If hyaluronic acid filler is injected into an artery accidentally, an injection with hyaluronidase may help dissolve it if done quickly.  Unfortunately if enough time passes that retinal tissue dies, the loss of vision is permanent.

There are other causes of retinal artery occlusion, both embolic (an embolus goes from a larger artery to a smaller artery and gets stuck, occluding blood flow to distal tissues) or non-embolic.. Emboli can result from a number of systemic causes.  A diagnostic workup should be done to rule out those systemic causes.

You are under the care of a retinal specialist.  They will know how to proceed with the workup and possible treatment.

RE : "i had Restylane injections done on my forehead on 6/2/11 and on 6/3/11 suddenly my left eye lost vision. Now i am diagnose with Branch retinal artery occlusion OS. My retina specialist said in my left eye, there is a BRAO inferlorly with retinal pallor/ischemia and inferior macular pallor/ischemia OCT:OS= macular edema You said its is rare to find this problem, but can it happend and how to reverse it?"

I am VERY sorry to hear of your situation. Such disasters have been reported in our literature beginning with the use of Collagen but with every filler injected on the low, middle forehead and is thought to be caused by direct injection of the filler into the artery system supplying the retina. I have never encountered it in my practice.

The blindness is said to occur almost immediately and is caused by a plugging (embolus) of the retinal artery by a cylinder of the filler. Unless the injector injects a large amount of saline and Hyaluronidase (the enzyme which breaks up Restylane and Juvederm) to try and break up the filler plug the damage may be permanent. This is another compelling reason why Botox and filler injections should only be done by Core Cosmetic Surgery doctors instead of "injectors".

At this point, you need to consult with a Retina Specialist and see what he can advise you.

I'm truly sorry.

Dr. Peter A Aldea

First of all, I am very sorry for the problem you're having.  It is, clearly, an unfortunate situation.

Also unfortunate is that blindness, whether partial or total, has been associated historically with a wide range of treatments, including fillers (hyaluronic acid, collagen), laser treatments, etc.  In the case of fillers it is believed to be a result of either emboli (small bits of tissue or filler that directly occlude - "plug' - the blood vessels to the eye) or to external compression, although this mechanism is believed to occur less commonly for this area.  While not always precisely determined, it is conceivable that small bits of the filler backed up from an area in which it was being injected to a bifurcation (fork) in the blood vessels, and then back down another branch; in this case, to the eye.  In theory, hyaluronidase can "dissolve" hyaluronic acid; the reality is that it would be very difficult to recreate the mechanism a second time, which is what would be necessary to deliver the hyaluronidase to the right spot.  Injection of filler into the glabellar region is believed to have the highest incidence of this complication, but it is not unheard with injections in other areas around the nose and, perhaps, even other areas.

You need to remain under the care of an ophthalmologist/retinal specialist.  Hopefully, it will still correct itself; it is very difficult to effect an external correction at this point.

Again, I am very sorry for this problem that has occurred.

I hope that this helps, and good luck,

Dr. E

You'd have to get recommendations from the ophthalmologist or retinal specialist on how this could be treated and discuss the possible causes. I do not use fillers in the Glabella region because of the potential for vessel (vein) constriction and would add this possibility to the list of reasons that it should not be done IMHO.

Blindness is an extremely rare complication of filler injections into the glabellar area between the eyes. I have been doing filler injections for over 25 years and have never seen this complication and only heard about it rarely. When we first began doing filler injections in the United States over 25 years ago, collagen derived from cows (called Zyderm) was frequently injected into this area of the forehead without any problems. Then "Zyplast" was developed which was a more concentrated form of cow collagen for longer lasting treatments. It was to be injected more deeply into the tissues, just below the level of the skin. It was then that we began to hear reports of rare cases of blindness from these injections. As I had injected Zyplast below the skin into this area of the forehead for many of my patients at that time, I believed it was due to the physician injecting it much too deeply to reach the level of the larger blood vessels such as the arteries. The risks of serious side effects such as these can hopefully be minimized by the skill and experience of your physician injector. I am truly sorry to hear of your unfortunate experience. You are already in the hands of a retina specialist and you need to follow their advice.

While it is possible that there was delayed occlusion of your retinal artery with Restylane® particles, it will be important for your ophthalmologist to rule out other causes of retinal artery occlusion, because if your problem was a coincidence and is in fact due to some medical condition it will be important to treat the medical condition to reduce the chance that you will have another episode like this in the future, perhaps affecting the other eye.

Unlike other HA fillers [which are cohesive, homogenous gels] Restylane® is a slurry composed of tiny particles of crosslinked HA, suspended in a vehicle system composed of normal saline with some non-crosslined HA added to the saline as a gelling agent. Long story short, Restylane® and Perlane® can flow like a fluid immediately after injection, unlike the cohesive homogenous gels [for example, Juvéderm] which tend to stay where they are put and are much less likely to flow upstream or downstream if they get into a vessel. That is one reason I prefer the homogenous HA gels to slurry's like Restylane®.