Vision loss after filler: what to know

Vision loss after facial filler is rare, but it is the most serious complication of orofacial harmonization. It happens when the product enters an artery that connects with the circulation of the eye and reaches the retina. Because it is sudden, often irreversible, and linked to areas treated every day in the clinic, it needs to be on the radar of every practitioner who injects.

This is a review guide. It explains the mechanism, the risk areas, the warning signs, and what urgent referral means. It does not replace in-person training in managing complications and it does not include a medication protocol: the response is up to the qualified practitioner, following the rules of their professional board (in Brazil), in coordination with the reference medical service.

Does botulinum toxin cause blindness?

This is one of the most common searches, and the answer matters for reassuring the patient: botulinum toxin is not a filler and does not cause embolism. The mechanism of blindness after filler is physical, a material blocking the artery. The toxin is a solution that acts at the junction between nerve and muscle.

The effects of the toxin around the eyes, such as ptosis and double vision from spread to the muscles that move the eye, are real and need assessment, but they are a different situation. See ptosis after botulinum toxin.

How does filler reach the eye?

The ophthalmic artery arises from the internal carotid and supplies the eye and the orbit. Its terminal branches leave the orbit and connect with arteries of the face:

• supratrochlear artery and supraorbital artery, in the glabella and forehead;
• dorsal nasal artery, in the nose;
• angular artery, at the side of the nose and the inner corner of the eye, which continues the facial artery.

The most accepted mechanism is retrograde embolism: the product is injected into one of these vessels at a pressure higher than arterial pressure, travels against the direction of blood flow to the ophthalmic artery and, when the pressure stops, is carried by normal flow to the central retinal artery or the ciliary arteries. The retina tolerates very little time without circulation, so damage can set in quickly.

The product can also travel to the cerebral circulation, which explains reports of associated neurological signs.

Which areas carry the highest risk?

The risk exists with any filler: hyaluronic acid, calcium hydroxyapatite, poly-L-lactic acid, permanent fillers, and autologous fat. The difference is that hyaluronic acid can be broken down by hyaluronidase, and the others cannot.

What are the warning signs?

Signs usually appear during the injection or shortly afterward:

• sudden loss of vision, total or partial, or very blurred vision;
• pain in or around the eye, sometimes severe;
• sudden, intense headache, nausea, or vomiting;
• eyelid drooping and difficulty moving the eye;
• double vision;
• pallor, purplish patches, or a lace-like pattern on the skin of the treated area, signs of cutaneous vascular occlusion;
• neurological signs, such as weakness on one side of the body, difficulty speaking, or confusion.

They do not always appear together. Any visual complaint during or after filler must be treated as an emergency until proven otherwise.

What does urgent referral mean?

At review level, an organized response usually includes:

1. Stop the injection at the first sign.
2. Activate the written protocol, with defined roles for the team.
3. Contact the reference service arranged in advance, giving the product, area, and time.
4. Refer without delay, with a companion and with the procedure details in writing.
5. Treat the skin too, when there are signs of cutaneous ischemia, following the vascular occlusion protocol, to reduce the risk of necrosis.
6. Record everything: start time, signs, actions taken, contacts, and time of referral.

With hyaluronic acid, the use of hyaluronidase is part of vascular occlusion protocols. Eye-directed approaches, such as injecting hyaluronidase around the orbit, are discussed in the literature, have variable results, and require specific training and qualification. There is no treatment with guaranteed efficacy for restoring vision.

How to organize the kit, the protocol, and team training is covered in hyaluronidase in the clinic. Managing occlusion in another high-risk area is covered in vascular occlusion in the lip.

How can you reduce the risk?

No measure eliminates the risk, but several reduce it:

The choice of technique, instrument, and plan is up to the qualified practitioner. The general overview of prevention is in safety and complications, and the overview of off-label use is in the Anvisa alert on fillers.

How do you talk about this risk with the patient?

The patient needs to know the risk exists, without being frightened. The moment is the consultation, before the procedure, and the record is the informed consent.

For patients who are afraid after seeing the news, also explain the difference between filler and botulinum toxin: the toxin does not cause embolism.

Readiness checklist for a visual complication

1. Vascular anatomy of the risk areas reviewed.
2. Written protocol for vascular occlusion and visual complication, accessible in the room.
3. Hyaluronidase within its expiration date and a complete complication kit.
4. Reference emergency service with ophthalmology defined, with the contact written down.
5. Team trained to recognize the signs and activate the protocol.
6. Consent form that mentions the risk of a visual complication.
7. Product, lot, and area recorded in the patient record for each session.