Ocular Massage for Filler-Induced Blindness

Abstract

Dear Editor, We read with great attention the article from Surek et al. [1] entitled ‘‘Retrobulbar Injection for Hyaluronic Acid Gel Filler-Induced Blindness: A Review of Efficacy and Technique.’’ The authors searched the literature on blindness caused by hyaluronic acid filler injection, reviewing the techniques used for the treatment of this devastating complication. In particular, retrobulbar injection with hyaluronidase is suggested as the only known potential means of reversing this adverse event. Nevertheless, it is important to highlight the function of ocular massage in the treatment of this entity. Previous studies suggested ocular massage as a way to lower intraocular pressure and increase blood flow in the arterioles, potentially by dislodging the embolus and increasing retinal perfusion and oxygen delivery to hypoxic tissues [2–4]. In 2018, a multidisciplinary group of experts in aesthetic treatments convened to propose the management of the complications associated with dermal filler use. Besides the medical treatment with timolol drops and/or acetazolamide tablet, aspirin tablet and mannitol IV, they suggested that digital ocular massage should start immediately while preparing the treatment and to continue once the drugs have been administered. These therapeutic measures should be immediately implemented because maintained central retinal artery (CRA) occlusion for more than 60–90 min might cause irreversible blindness [4]. Ocular massage was suggested by Szantyr, Loh and Prado as well, in three different articles [2, 3, 5]. Furthermore, some risk reduction strategies were proposed [6, 7] to minimize the risk of embolization of filler into the ophthalmic artery following facial cosmetic injections: aspiration before injection, application of a local vasoconstrictor (local anesthesia with epinephrine before filler treatment), use of blunt flexible needles and micro-cannulas, and low-pressure injections with the release of the least amount of substance possible (rather than bolus injections). Injections into prior traumatized tissues should be avoided [6]. Moreover, a detailed anatomical awareness of the likely position and depth of the main facial arteries is of paramount importance [7, 8]. The danger zones should always be considered when approaching filler injections in the face [9, 10].