Dermal facial filler injections, especially in the perinasal and glabellar regions, confer a particularly high risk of retrograde passage of filler material into territories supplied by the ophthalmic artery, including the retina and choroid, leading to ocular vascular occlusions. We report multimodal imaging of a rare case of isolated multifocal choroidal emboli in a patient who received “liquid rhinoplasty” with calcium hydroxyapatite.
Report of a Case
A woman in her early 40s with a history of cosmetic facial augmentations received a calcium hydroxyapatite filler injection superior to the left nasal ala. She immediately felt excruciating left eye pain with sudden loss of her temporal visual field but preserved central acuity in the left eye. She was diagnosed as having multiple choroidal infarctions from embolized calcium hydroxyapatite and was treated promptly with sildenafil citrate, oral and topical corticosteroids, and intraocular pressure–lowering medications without symptom improvement.
She presented to us 2 weeks later for a second opinion. Her visual acuity was 20/20 OU. Anterior segment examination and intraocular pressures were normal in each eye. A dilated fundus examination revealed multiple sclerotic-appearing choroidal vessels radiating nasally from the left optic nerve (Figure 1A). Fluorescein angiography of the left eye showed wedge-shaped areas of choroidal hypofluorescence in the superonasal and inferonasal fields, with late hyperfluorescence at the margin of the perfused and nonperfused choroid; the overlying retinal vasculature was perfused normally (Figure 1C and D). Indocyanine green angiography of the left eye similarly showed wedge-shaped areas of nasal hypocyanescence corresponding to the choroidal nonperfusion observed on fluorescein angiographic images (Figure 1B). Near-infrared imaging on spectral-domain optical coherence tomography showed abnormal hyperreflectivity corresponding to the sclerotic vessels (Figure 2A). Cross-sectional optical coherence tomography through these areas showed hyperreflective foci with posterior shadowing within the choroidal vessels, suggesting presumed calcium hydroxyapatite emboli (Figure 2A). Fundus autofluorescence of the left eye showed speckled hyperautofluorescence and hypoautofluorescence along choroidal vessels nasally, likely representing areas of retinal pigment epithelium response to local choroidal ischemia (Figure 2B).
Figure 1.
Fluorescein Angiography (FA) and Indocyanine Green Angiography of the Left Eye
A, Fundus photograph of the left eye shows multiple wedge-shaped areas of hyperpigmentation and hypopigmentation with sclerotic choroidal vessels in the nasal retina. B, Indocyanine green angiography of the left eye in the early phase shows 2 large areas of nasal hypocyanescence representing choroidal nonperfusion without leakage. C and D, Fluorescein angiography of the left eye in the venous phase and late phase demonstrates 2 distinct areas of hypofluorescence in the superonasal and inferonasal retina without choroidal flush and areas of late hyperfluorescence representing late staining at the intersections of the perfused and nonperfused choroid. The retinal circulation is preserved.
Figure 2.
Spectral-Domain Optical Coherence Tomography (SD-OCT) and Fundus Autofluorescence (FAF) of the Left Eye
A, Near-infrared imaging on SD-OCT (Spectralis; Heidelberg Engineering) shows hyperreflectivity corresponding to the sclerotic vessels (white arrowheads; left panel). The green lines represent cross sections of the nasal retina. The bold green arrow specifically identifies the cross section shown in the right panel; in this cross section, hyperreflective foci with posterior shadowing are seen within the choroidal vessels, consistent with emboli of calcium hydroxyapatite (red arrowheads; right panel). B, Fundus autofluorescence of the left eye shows hyperautofluorescent changes along the choroidal vessels nasally.
Dermal filler material can gain access to the ophthalmic artery via retrograde flow when one of its direct tributaries—commonly the supratrochlear, supraorbital, dorsal nasal, or facial/angular artery—or an anastomotic branch of the external carotid circulation is inadvertently cannulated. If the hydrodynamic pressure of injection overcomes the diastolic perfusion pressure, filler material can reflux and then travel in an anterograde fashion, resulting in microvascular infarctions. To cause choroidal ischemia sparing the retina, filler particles would have to travel to the ophthalmic artery and enter the posterior ciliary arteries, bypassing the origin of the central retinal artery, or travel to the posterior ciliary arteries via retrograde flow from the central retinal artery.1 In this patient, emboli likely reached the medial posterior ciliary artery branches to infarct the nasal choroid.
Visual compromise due to facial fillers is rare. Between 1906 and 2015, only 98 cases of filler-induced visual changes were reported.2 Isolated choroidal infarctions are more unusual. Park et al1 described 4 cases of nasal choroidal infarctions that spared the retinal vasculature after filler injections. Reported ocular complications from calcium hydroxyapatite injections include ophthalmoplegia, ptosis, exotropia, anterior segment ischemia, conjunctival vessel embolization, central retinal artery occlusion, branch retinal artery occlusion, and ophthalmic artery occlusion.2-4
The clinical imaging features in this patient resemble classic Siegrist streaks seen in hypertensive choroidopathy. A major difference, however, is the hyperreflective sclerotic vessels of the choroid observed with near-infrared imaging on optical coherence tomography. In addition, this case uniquely shows that noninvasive, cross-sectional optical coherence tomography was able to localize calcium hydroxyapatite emboli in the choroid.
Although prior treatments of ocular complications include lowering of intraocular pressure and administration of corticosteroids and hyperbaric oxygen, these interventions have little supporting evidence.5,6 Ensuring that the injecting practitioner has thorough knowledge of facial vascular anatomy and appropriate injection technique is therefore imperative for the prevention of sight-threatening complications.6
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Article Information
Published Online: May 23, 2019. doi:10.1001/jamaophthalmol.2019.1422
Conflict of Interest Disclosures: Dr Modi reported being on the advisory board for Genentech, Allergan, and Alimera. No other disclosures were reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
References
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