1. Mar 26, 2019

AAO: Vascular Occlusion Risk from Use of Fillers in the Periocular Region

The chances are one in a million, but it still keeps this expert up at night. Here’s what she suggests

Research shows that there is a one in one million chance of a vascular occlusion occurring with the use of fillers in the periocular region. With the odds significantly stacked against a problem occurring, not much need to worry about full disclosure and informed consent when using ophthalmic fillers, right?

Wrong! So says Jill Annette Foster, MD, FACS, an oculoplastic surgeon based in Columbus, OH. Even with such a minute risk, “it makes me lose sleep at night because even in he hands of very skilled injectors who know the anatomy,” problems can occur. “So, I cover the risk with patients. I say the odds are one in a million, but that it can happen.”

With an increasing prevalence of use of cosmetic soft tissue fillers comes an increasing recognition from ophthalmologists of the complications that can occur in the periocular region, said Dr. Foster. By far, hyaluronic acid is most-used—in 85% of cases in 2017. Clinicians also use facial fat (6%), calcium hydroxyapatite (5%), and poly-L-lactic acid (4%). There was a 5% increase in the use of fillers in 2017 vs the prior year, and a 41% increase vs 2012.

Complications that can occur at the periocular site include:

  • Localized injection site reactions.  These are common. “You’ll notice some bruising, swelling, and/or discoloration that resolves over time.”
  • Skin discoloration over the top of soft tissue fillers. If you notice bluish discoloration across the patient’s tear troughs in the lower lid, “it’s probably an accumulation or migration of soft tissue fillers.” It is valuable to recognize these so-called blue sausages as such because you can treat by diminishing the filler rather than performing surgery.
  • Technical placement errors. Typically, the fillers are placed too superficially or too deep.
  • Infection. Infections from soft tissue fillers can occur acutely or over time. “Atypical micro-bacteria are difficult to eradicate and treat.”
  • Hypersensitivity or immunologic/allergic reactions. These present as a purplish-red inflammatory response. “This tends to occur not at the time of injection, but perhaps two months later. It also migrates and eventually occurs in all the places where filler material has been injected.”
  • Vascular occlusion. “These are the ones we lose sleep over.” It is manifested by ulceration, as well as changes in the skin. “If you look carefully at the conjunctival vasculature, you usually see a little trail of white particles, which is calcium hydroxyapatite.”

Management Options

Here are the best ways to manage these problems:

  • Injection site reaction: Ice, and/or bruise modification techniques
  • Technical placement errors: Hyaluronidase, 5 FU/Kenalog
  • Skin discoloration: Hyaluronidase, light energy, retinoic acid
  • Infection: Early cephalexin, late clarithromycin
  • Hypersensitivity: Hyaluronidase
  • Vascular occlusion: Hyaluronidase and/or massage, though there is no evidence-based data that these options work.

Regarding the aforementioned blue sausages, Dr. Foster noted that they can be very persistent, particularly with repeated injections. “I’ll see patient three, four, or five years after the injection with this problem.” The good news is that “it goes away very rapidly—within days to a week—after treating with hyaluronidase.” It is also important to point out that the blue color is not a pathologic tissue change. “The blue color is a light refraction issue where you're seeing the light pass through the skin differently where the hyaluronic acid is concentrated underneath the skin.”

Dr. Foster referred to the work published in 2015 regarding loss of vision from fillers [Beleznay K, Carruthers J, Humphrey S, Jones D. Avoiding and treating blindness from fillers: A review of the world literature. Dermatol Surg. 2015 Oct;41(10):1097-117. doi: 10.1097/DSS]. Though the complication was extremely rare, when vision loss did occur it tended to be immediate, most did not regain vision, and treatments were not successful. Nearly a quarter experienced central nervous system complications. So, if by very slim chance you face this issue, she said it was important to know that “when [filler] gets into the ophthalmic artery, check to make sure it’s not also in the brain.”

Dr. Foster noted that data shows that nearly half of complications occur when fat fillers are used. Given the fact that fat is used less frequently than other materials, it might make sense for you to avoid using it. “Fat probably has the highest danger.” The reasons? Particle size—fat is quite large. “Because the material you are injecting has a larger bolus, it is easier to occlude a vessel.” Additionally, the size of the canula used for fat is also larger. “You’re injecting more volume at a time than you would with commercial soft tissue fillers.”

The danger zone for vascular occlusion is the midline. In fact, nearly 40% of injections are made in the glabella; 25% in the nasal region; 13% in the nasolabial fold; and 12% in for forehead. “Recognition of that danger zone—and where the vessels are located in that danger zone--provides us with strategies to minimize side effects.”

What are those strategies, and are they proven? Dr. Foster explained that these methods theoretically work, but lack the backing of evidence-based medicine at this point:

  • Low-volume injection
  • Minimizing extrusion force
  • Aspiration
  • Knowledge of anatomy and depths of vasculature
  • Epinephrine
  • Ocular massage
  • Hyaluronidase for hyaluronic acid

“It makes sense to try all these [strategies] because in theory they may help,” Dr. Foster concluded.

Foster J. Periocular complications of fillers. Talk presented at: AAO 2018 annual meeting; October, 26-30, 2018; Chicago.