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A case report of ophthalmic artery emboli secondary to Calcium Hydroxylapatite filler injection for nose augmentation- long-term outcome
© The Author(s). 2016
Received: 23 November 2015
Accepted: 13 June 2016
Published: 8 July 2016
Filler injection for face augmentation is a common cosmetic procedure in the last decades, in our case report we describe long-term outcomes of a devastating complication of ophthalmic artery emboli following Calcium Hydroxylapatite filler injection to the nose bridge.
A healthy 24-year-old women received a Calcium Hydroxylapatite filler injection to her nose bridge for the correction of nose asymmetry 8 years post rhinoplasty. She developed sudden right eye ocular pain and visual disturbances. Visual acuity was 20/20 in both eyes and visual field in the right eye showed inferior arch with fixation sparing and supero-temporal central scotoma. Examination revealed marked periorbital edema and hematoma, ptosis, ocular movements limitation, an infero-temporal branch retinal artery occlusion and multiple choroidal emboli. Eighteen months post initial presentation ptosis and eye movements returned normal and choroidal emboli absorbed almost completely. However, visual acuity declined to 20/60, visual field showed severe progressive deterioration with a central and supero-nasal field remnant and the optic disc became pallor.
Cosmetic injection of calcium hydroxylapatite to the nose bridge can result in arterial emboli to the ophthalmic system with optic nerve, retinal and choroidal involvement causing long term severe visual acuity and visual field impairment.
Aesthetic soft-tissue filler injection for face augmentation has gained popularity in last decade, owing their relatively easy nonsurgical delivery, rapid results and low cost office based procedure. During the last years a growing amount of complications have been related to the procedure including allergic reaction, granuloma formation, skin necrosis or cellulitis  as well as ophthalmic and retinal artery occlusion or embolization [2–4]. Calcium hydroxylapetite (CaHA) is a semipermanent soft tissue filler, which may last 1 to 2 years in tissue. It is used mainly for face augmentation and is well adopted for the correction of post rhinoplasty deficiencies and asymmetries . To date, only three case reports published on ocular embolism post CaHA injection to the glabella and nose bridge [6–8]. These cases had very poor initial visual acuities and only two cases had a short-term follow-up. We report a case of CaHA emboli to the choroid and retinal artery, demonstrated by spectral domain optical coherence tomography (SD-OCT), with a long-term follow-up. In our case, initial visual acuity was preserved but during 18 months follow-up visual acuity and visual field gradually deteriorated.
A healthy 24-year-old female, underwent injection of CaHA to her nose bridge for the correction of nose asymmetry, 8 years post rhinoplasty. The injection was carried out by an ophthalmologist who is not an oculoplastic specialist. Immediately after the injection the patient complained of right eye (RE) periocular pain and blurred vision. Attempts were made to withdraw material from the injection site by aspiration, in addition to hot water compresses and topical massage.
Our case demonstrates long-term results of a devastating ocular complication post CaHA filler injection to the nose bridge. CaHA emboli to the arterial ophthalmic system caused partial ophthalmoplegia, branch retinal artery occlusion, and multiple choroidal emboli. Vascular related events are major complications of soft tissue filler injection and can occur from direct needle injury to the vessels, external compression of vessels by surrounding filler or intravascular embolism of injected material. Intra-arterial embolism formation after soft tissue filler injection to the nose bridge may be caused by anterograde arterial flow of material injected trough artery-vein anastomosis found in the nose mucosa, or by retrograde arterial displacement of the injected product. The latter can occur when injection pressure is higher than systolic arterial pressure and the injected product moves from peripheral arterial vessels into proximal arterial vessels. After stopping the injection the product flow with the blood stream to peripheral arterial branches and cause an embolic event [2–4]. We assume that in our case the CaHA was directly injected to the dorsal nasal artery which is a peripheral artery in the ophthalmic system and then moved retrograde with the blood stream to the various branches of the ophthalmic artery. Involvement of the central retinal artery and posterior ciliary artery may explain the branch retinal artery and multiple choroidal emboli. Supraorbital, infraorbital and muscular arteries emboli may explain the ophthalmoplegia and ptosis.
To date, only 3 cases on ocular complications following CaHA filler injection were published [6–8]. Of them, only two cases reported on posterior segment involvement. The first case was published by Kim et al.  and demonstrated bilateral blindness after CaHA filler injection for nose augmentation. The patient presented with local skin necrosis, bilateral total ophthalmoplegia, anterior chamber ischemia and ophthalmic artery obstruction with multiple retinal arteries and choroidal emboli. Initial VA was no light perception in both eyes. Unfortunately no information regarding treatment or follow up was provided. Hsiao et al.  recently published a case of unilateral distal retinal arteries and choroidal emboli post CaHA injection to the glabella. Initial VA was hand motion. Management included various topical and systemic treatments, at 3 month follow up VA achieved 20/200.
Our case is the first to demonstrate CaHA emboli documented over 18 months follow up. In our case, the patient initially presented with preserved VA. Treatment included anticoagulants and systemic corticosteroids as recommended in cases suspected of intravascular filler injection . At 18 months follow-up, VA and VF markedly deteriorated although choroidal emboli were reduced significantly. We assume that massive amount of CaHA emboli to the ophthalmic artery branches caused a significant decrease in retinal, choroidal and optic nerve perfusion resulting in irreversible VF damage with progressive deterioration of VF and VA over time. Ptosis and ophthalmoplegia completely resolved which may be explained by renewal of arterial flow and muscle cells rehabilitation.
Ophthalmic artery embolization secondary to CaHA filler injection to the nose bridge may cause a devastating long-term outcome. Physicians should be aware of this complication and inform their patients before offering these cosmetic treatments.
BCVA, best corrected visual acuity; CaHA, calcium hydroxylapetite; EDI, enhanced depth imaging; LE, left eye; RAPD, relative afferent pupillary defect; RE, right eye; SD-OCT, spectral domain optical coherence tomography; VA, visual acuity; VF, visual fields
No funding was obtained for this case report.
Availability of data and materials
All the data supporting our findings is contained within the manuscript, and any identifying or confidential patient data should not be shared.
EC contributed to manuscript conception and design, acquisition and analysis of data. YY, AK, DG and RBC contributed to acquisition, analysis and interpretation of data. IL and AK contributed to conception and design, analysis and interpretation of data, ZHW contributed to manuscript conception and design, acquisition and analysis of data. All authors have been involved in drafting the manuscript or revising it criticall, have given final approval of the version to be published and agreed to be accountable for all aspects of the work.
All the authors of this case report has no commercial associations that might pose a competing interest in connection of the submitted article.
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Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the editor of this journal.
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