Iatrogenic ophthalmic artery occlusion and retinal artery occlusion

Progress in single-cell sequencing of retinal vein occlusion or ischemic hypoxic retinopathy

Retinal vein occlusion (RVO) and ischemic hypoxic retinopathy (IHR) are leading cause of irreversible vision loss worldwide, compelled by complex microvascular dysfunction, neuroinflammation, and tissue hypoxia. Despite advances in imaging and treatment, a comprehensive understanding of cellular and molecular heterogeneity underlying these pathologies remains limited. Recently, single-cell RNA sequencing (scRNA-seq) has emerged as a transformative technology, enabling unprecedented resolution of cellular dynamics, transcriptomic landscapes, and intracellular communication within the retina. Single-cell technologies continue to evolve, they are poised to revolutionize our understanding of retinal vascular diseases, ultimately paving the way for precision diagnostics and targeted interventions. This technique has revolutionized our understanding regarding complex biological systems and enables proper analysis of cellular heterogeneity. This review highlights the recent progress for the application SCS to dissect the pathophysiology of RVO and IHR. Moreover, current study summarizes findings on altered gene expression endothelial cells, Muller glia, micro glia and photoreceptors under ischemic and hypoxic stress, shedding light on potential therapeutic targets and biomarkers. Furthermore, this study explores the integration of snRNA-seq, spatial transcriptomics, and multi-omics approaches to enhance the spatial and temporal mapping of retinal responses. Additionally, discuss the current challenges, including sample preservation, retinal cell-type annotation, and cross-species translation, while offering insights into future directions such as personalized medicine and regenerative strategies. This paper aims to provide clinicians and researchers with a comprehensive update on the rapidly expanding frontier of single-cell analysis in retinal ischemic diseases.

Enhancing Ophthalmic Anesthesia Optimization with Predictive Embedding Models

Ophthalmic anesthesia the crucial factors in success and safety of ophthalmic surgery, which involves the delicate aspects of pain control, sedation, and patient response. Advances in ophthalmic surgery cause a need for exact and individualized anesthetic procedures to maximize patient satisfaction and outcomes. This research investigates the machine learning (ML) and natural language processing (NLP) to personalize the practice of ophthalmic anesthesia. Text data includes preoperative assessments; drug history, procedure information, and discharge summary are preprocessed using the NLP approach, stop word removal, and lemmatization. Word2Vec technique is applied for feature extraction to represent clinical terms with vectors which carry semantic meaning, helping the model comprehend the text better. This research proposes a ML algorithm of Efficient Osprey Optimized Resilient Random Forest (EOO-RRF) model to forecast ideal anesthesia plans and patient results. Experimental results show that the EOO-RRF model is superior to traditional methods and achieves metrics such as MSE = 28.424, RMSE = 4.321, AUC=98.32% and R2 = 0.956. The results indicate that combining NLP and ML in ophthalmic anesthesia leads to safer, more efficient, and personalized anesthetic management.

Ophthalmic artery branches and adjacent nerves observed on sectioned images of cadaver

The ophthalmic artery plays a vital role in supplying the eyeball and neighboring structures, and is associated with various clinical conditions. In this study, high-resolution cadaver-sectioned images were used to provide an intricate morphology of the ophthalmic artery and its branches, along with the oculomotor, trochlear, ophthalmic, and abducens nerves. This study presents a combination of schematics and cadaver-sectioned images, allowing for a clear representation of intricate anatomic structures. This study elucidated the spatial relationships among the ophthalmic artery, cranial nerves, and adjacent anatomic features. The branches of the ophthalmic artery were classified into three categories. The complex anatomy of the ophthalmic artery and adjacent nerves was examined on cadaver-sectioned images and is schematically illustrated. The utilization of cadaver-sectioned images presents advantages over traditional dissection techniques. This approach maintains the original positioning of the ophthalmic artery and nerves, enhancing accuracy. This study enriches the comprehension of ophthalmic anatomy, offers a helpful resource for interpreting clinical images, and facilitates various medical procedures. As a result, we anticipate that our research will contribute to advancing the diagnosis and management of eye disorders, offering fresh perspectives on the relationship between the ophthalmic artery and the surrounding structures.

Ipsilateral, Multi-Phasic Retinal Vascular Events following Intralesional Triamcinolone Acetonide Injection for Earlobe Keloid: A Case Report

Introduction

Intralesional triamcinolone acetonide is a widely used treatment for scarring skin conditions such as keloid and is known to have retinal vascular complications if administered in the periocular region.

Case Presentation

A 32-year-old female experienced a prompt onset transient vision decrease and a delayed onset, slow-resolving vison loss in the right eye (OD) following the last of a series of triamcinolone acetonide corticosteroid (TAC) injections in her right earlobe for a disfiguring keloid. Clinically, she developed a branch retinal arterial occlusion accompanied by features of a central retinal vein occlusion. The TAC particles that entered the retinal circulation are implicated in the thrombo-embolic occlusion of the branch retinal artery and subsequent blockage of the central retinal vein.

Conclusion

This case should alert clinicians that there is always a potential hazard for retinal vascular occlusion when corticosteroid is injected in the region of the head and face because of the rich anastomoses between the external and internal carotid artery circulations.

A unique complication of thyroidectomy for Hashimoto's thyroiditis: central retinal artery thrombosis

BACKGROUND

Central retinal artery occlusion (CRAO) is a rare ophthalmological emergency and also a unique complication after thyroid surgery.

METHODS

We present the first case of CRAO following thyroid surgery in a patient with Hashimoto's thyroiditis, along with a variety of interventions to overcome this complication.

RESULTS

A 42-year-old female patient suffering from sudden vision loss following total thyroidectomy was diagnosed with CRAO. Hyperbaric oxygen therapy was started within the postoperative first 6 hours.

CONCLUSION

Although it is extremely rare, it should be noted that patients may experience retinal artery occlusion following the thyroid surgery. Immediate evaluation of patients with visual impairment in the early postoperative period, and planning of emergent hyperbaric oxygen therapy for the management are critical.

Update on Blindness From Filler: Review of Prognostic Factors, Management Approaches, and a Century of Published Cases

Vision loss secondary to aesthetic filler treatment is a rare but disastrous complication. The aim of this review was to update the published cases of blindness after filler injection that have occurred since our group published reviews of 98 cases in 2015 and an additional 48 cases in 2019. A literature review was performed to identify all cases of visual complications caused by filler injection published between September 2018 and March 2023. The cases were analyzed independently and in combination with previously reviewed cases. Analyses were based on the number of cases with data available. A total of 365 new cases of partial or complete vision loss after filler injection were identified. The sites that were highest risk were the nose (40.6%), forehead (27.7%), and glabella (19.0%). The filler injected was hyaluronic acid in 79.6% of cases. The most common associated signs were ptosis (56.2%), ophthalmoplegia (44.1%), pain (31.2%), and skin changes (73.2%). Strokelike features were seen in 19.2% of cases. Of the cases reporting visual outcomes (318), 6.0% experienced complete vision recovery, 25.8% had partial improvement in visual acuity, and 68.2% had no vision recovery. Partially preserved visual acuity at onset was a significant predictor of visual improvement (P < .001). The 3 most common treatments were subcutaneous hyaluronidase at or near the filler site (70.1%), systemic steroids (57.3%), and intraarterial thrombolytic therapy (56.0%). No treatments were significantly associated with visual improvement (P > .05). Although blindness and stroke from fillers is a rare complication, practitioners who inject filler should have a thorough knowledge of prevention and management strategies.

LEVEL OF EVIDENCE: 3

"Filler-Associated Acute Stroke Syndrome": Classification, Predictive Modelling of Hyaluronidase Efficacy, and Updated Case Review on Neurological and Visual Complications

INTRODUCTION

The rising use of soft tissue fillers for aesthetic procedures has seen an increase in complications, including vascular occlusions and neurological symptoms that resemble stroke. This study synthesizes information on central nervous system (CNS) complications post-filler injections and evaluates the effectiveness of hyaluronidase (HYAL) treatment.

METHODS

A thorough search of multiple databases, including PubMed, EMBASE, Scopus, Web of Science, Google Scholar, and Cochrane, focused on publications from January 2014 to January 2024. Criteria for inclusion covered reviews and case reports that documented CNS complications related to soft tissue fillers. Advanced statistical and computational techniques, including logistic regression, machine learning, and Bayesian analysis, were utilized to dissect the factors influencing therapeutic outcomes.

RESULTS

The analysis integrated findings from 20 reviews and systematic analyses, with 379 cases reported since 2018. Hyaluronic acid (HA) was the most commonly used filler, particularly in nasal region injections. The average age of patients was 38, with a notable increase in case reports in 2020. Initial presentation data revealed that 60.9% of patients experienced no light perception, while ptosis and ophthalmoplegia were present in 54.3 and 42.7% of cases, respectively. The statistical and machine learning analyses did not establish a significant linkage between the HYAL dosage and patient recovery; however, the injection site emerged as a critical determinant.

CONCLUSION

The study concludes that HYAL treatment, while vital for managing complications, varies in effectiveness based on the injection site and the timing of administration. The non-Newtonian characteristics of HA fillers may also affect the incidence of complications. The findings advocate for tailored treatment strategies incorporating individual patient variables, emphasizing prompt and precise intervention to mitigate the adverse effects of soft tissue fillers.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Exploring Superselective Intraarterial Thrombolysis for Autologous Fat Injection-Induced Vision Loss

BACKGROUND

Intravascular injection represents the most severe complication in fat transplantation procedures. Currently, the prognosis for patients who suffer from blindness due to fat transplantation-induced ocular vascular occlusion is far from optimistic.

OBJECTIVES

The aim of this study was to explore and evaluate the efficacy and safety of arterial thrombolysis in the treatment of ocular vascular occlusion caused by fat transplantation.

METHODS

We analyzed the data of 12 patients who underwent intraarterial thrombolysis and conservative treatments for facial autologous fat grafting-associated ocular vascular occlusion. Among the cases, there were 6 instances of ophthalmic artery embolism and 6 cases of central retinal artery occlusion. All patients suffered with sudden blindness, sometimes accompanied by eye pain, ptosis, strabismus, skin necrosis at the injection site, or cerebral microinfarction. They received symptomatic conservative treatments and intraarterial thrombolysis, encompassing mechanical vessel recanalization, vessel dilation, and dissolution of thrombus constituents.

RESULTS

Following intraarterial thrombolysis, a noteworthy improvement in the blood flow of both the main trunk and peripheral branches of the ophthalmic artery was observed in the majority of patients when contrasted with their pretreatment status. One patient experienced a headache intraoperatively, while no significant discomfort was reported by the remaining patients. After conservative treatments and intraarterial thrombolysis, all patients experienced improvement in ocular symptoms, skin necrosis, and cerebral infarction. Three patients demonstrated improvement in visual acuity. These patients had surpassed the recommended time window for treatment, yet the occlusion of the ophthalmic artery was not complete.

CONCLUSIONS

Intraarterial thrombolysis combined with conservative treatments achieves early perfusion and is expected to promote visual recovery. Hospitals that possess the necessary treatment capabilities are encouraged to establish this therapeutic pathway.

Single-Cell Transcriptomic Sequencing Reveals Tissue Architecture and Deciphers Pathological Reprogramming During Retinal Ischemia in Macaca fascicularis

Purpose

Acute retinal arterial ischemia diseases (ARAIDs) are ocular emergencies that require immediate intervention within a restricted therapeutic window to prevent blindness. However, the underlying molecular mechanisms contributing to the pathogenesis of ARAIDs remain enigmatic. Herein, we present the single-cell RNA sequencing (scRNA-seq) alterations during ischemia in the primate retina as a preliminary endeavor in understanding the molecular complexities of ARAIDs.

Methods

An ophthalmic artery occlusion model was established through ophthalmic artery ligation in two Macaca fascicularis. scRNA-seq and bioinformatics analyses were used to detect retinal changes during ischemia, which are further validated by immunofluorescence analysis. Western blot and flow cytometry assays were performed to measure the microglia polarization status.

Results

The findings of this study reveal notable changes in the retina under acute ischemic conditions. Particularly, retinal ischemia compromised mitochondrial functions of rod photoreceptors, partly leading to the rapid loss of healthy rods. Furthermore, we observed a noteworthy transcriptional alteration in the activation of microglia induced by ischemia. The targeted correction of the proinflammatory cytokine CXCL8 effectively suppresses microglia M1 polarization in retinal ischemia, ultimately reducing the proinflammatory transformation in vitro. In addition, retina ischemia induced the apoptotic inclination of endothelial cells and the heightened interaction with microglia, which signifies the influence of microglia in disrupting the retinal-blood barrier.

Conclusions

Our research has successfully identified and described the pathologic alterations occurring in several cell types during a short period of ischemia. These observations provide valuable insights for ameliorating retinal damage and promoting the restoration of vision.

Addressing retinal hypoxia: pathophysiology, therapeutic innovations, and future prospects

Retinal hypoxia stands as a pivotal yet often underappreciated factor in the etiology and progression of many retinal disorders such as glaucoma, hypertensive retinopathy, diabetic retinopathy, retinal vein occlusions, and retinal artery occlusions. Current treatment methodologies fail to directly address the underlying pathophysiology of hypoxia and aim to improve ischemia through alternative methods. In this review, we discuss the critical role of retinal hypoxia in the pathogenesis of various retinal diseases and highlight the need for innovative therapeutic strategies that address the root cause of these conditions. As our understanding of retinal hypoxia continues to evolve, the emergence of new technologies holds the promise of more effective treatments, offering hope to patients at risk of vision loss.

Iatrogenic ophthalmic artery occlusion after platelet-rich plasma dermal filler documented with ultra-widefield imaging

PURPOSE

To report a case of iatrogenic ophthalmic artery occlusion (OAO) secondary to platelet-rich plasma (PRP) dermal filler injection for facial rejuvenation documented with ultra-widefield imaging.

METHODS

Case report.

RESULTS

A 45-year-old woman developed a sudden and painful vision loss in the left eye (LE) after a dermal filler injection of PRP in the left glabellar region. She immediately received intravenous corticosteroids with no improvements. Two weeks later a complete ophthalmological examination including visual acuity (VA), fundus examination, ultra-widefield fundus autofluorescence and fluorescein angiography, and optical coherence tomography was performed. A diagnosis of iatrogenic OAO in the LE with profound ocular ischemia was made and VA remained no light perception. Monthly follow-up visits were scheduled to ascertain the onset of any ocular complication.

CONCLUSIONS

Dermal filler injections of PRP can lead to rare but devastating side effects with permanent visual loss. Considering that there is currently no validated treatment strategy, prevention could be the real key of iatrogenic OAO management.

Clinical Manifestations and Prognosis of Embolism Caused by Filler Injection in Different Facial Regions

Background

Embolism is a serious complication after facial filling, with a usually poor prognosis of the symptoms after embolism. The authors systematically reviewed reported cases of facial vascular embolism, explored the relationship between the location and material used for facial filling and occurrence of vascular embolism, and assessed the prognosis of complications after vascular embolism.

Methods

This study provides a systematic review of published cases of vascular embolism after facial filling. A summary of the filling materials and filling sites for each case, the adverse reactions and embolized blood vessels, a recording of the time when each patient experienced adverse reactions and started treatment, and a presentation of their prognosis are provided.

Results

The frontal, eyebrow, and nose are common filling sites causing facial embolism. The main clinical manifestations after embolism were visual impairment, skin necrosis, and ptosis. The prognosis of visual impairment after embolization was poor, whereas skin necrosis and ptosis generally improved after treatment.

Conclusions

This article aimed to review the clinical manifestations, therapies, and prognosis of embolism after facial filling. A better understanding of these complications can help clinicians to detect the occurrence of complications as early as possible and give patients timely treatment.

Incidence of Retinal Artery Occlusion and Related Mortality in Korea, 2005 to 2018

IMPORTANCE

It remains unclear whether comorbidities in patients with retinal artery occlusion (RAO), a rare retinal vascular disorder, differ by subtype and whether mortality is higher.

OBJECTIVE

To examine the nationwide incidence of clinically diagnosed, nonarteritic RAO, causes of death, and mortality rate in patients with RAO compared with that in the general population in Korea.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, population-based cohort study examined National Health Insurance Service claims data from 2002 to 2018. The population of South Korea was 49 705 663, according to the 2015 census. Data were analyzed from February 9, 2021, to July 30, 2022.

MAIN OUTCOMES AND MEASURES

The nationwide incidence of any RAO, including central RAO (CRAO; International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] code, H34.1) and noncentral RAO (other RAO; ICD-10 code, H34.2) was estimated using National Health Insurance Service claims data from 2002 to 2018, with 2002 to 2004 as the washout period. Furthermore, the causes of death were evaluated and the standardized mortality ratio was estimated. The primary outcomes were the incidence of RAO per 100 000 person-years and the standardized mortality ratio (SMR).

RESULTS

A total of 51 326 patients with RAO were identified (28 857 [56.2%] men; mean [SD] age at index date: 63.6 [14.1] years). The nationwide incidence of any RAO was 7.38 (95% CI, 7.32-7.44) per 100 000 person-years. The incidence rate of noncentral RAO was 5.12 (95% CI, 5.07-5.18), more than twice that of CRAO (2.25 [95% CI, 2.22-2.29]). Mortality was higher in patients with any RAO than in the general population (SMR, 7.33 [95% CI, 7.15-7.50]). The SMR for CRAO (9.95 [95% CI, 9.61-10.29]) and for noncentral RAO (5.97 [95% CI, 5.78-6.16]) showed a tendency toward a gradual decrease with increasing age. The top 3 causes of death in patients with RAO were diseases of the circulatory system (28.8%), neoplasms (25.1%), and diseases of the respiratory system (10.2%).

CONCLUSIONS AND RELEVANCE

This cohort study found that the incidence rate of noncentral RAO was higher than that of CRAO, whereas SMR was higher for CRAO than noncentral RAO. Patients with RAO show higher mortality than the general population, with circulatory system disease as the leading cause of death. These findings suggest that it is necessary to investigate the risk of cardiovascular or cerebrovascular disease in patients newly diagnosed with RAO.

Risk Factors and Treatment Strategy for Retinal Vascular Occlusive Diseases

Retinal occlusive diseases are common diseases that can lead to visual impairment. Retinal artery occlusion and retinal vein occlusion are included in the clinical entity, but they have quite different pathophysiologies. Retinal artery occlusion is an emergent eye disorder. Retinal artery occlusion is mainly caused by thromboembolism, which frequently occurs in conjunction with life-threatening stroke and cardiovascular diseases. Therefore, prompt examinations and interventions for systemic vascular diseases are often necessary for these patients. Retinal vein occlusion is characterized by retinal hemorrhage and ischemia, which may impair visual function via several complications such as macular edema, macular ischemia, vitreous hemorrhage, and neovascular glaucoma. Even though anti-vascular endothelial growth factor therapy is the current established first-line of treatment for retinal vein occlusion, several clinical studies have been performed to identify better treatment protocols and new therapeutic options. In this review, we summarize the current findings and advances in knowledge regarding retinal occlusive diseases, particularly focusing on recent studies, in order to provide an update for a better understanding of its pathogenesis.

Superselective Ophthalmic Artery Thrombolytic Therapy for Hyaluronic Acid Embolization: A Case Report

Blindness caused by embolization of fillers is a rare but catastrophic complication after cosmetic injection. Vision improvement is rarely reported among the various studies on potential clinical treatments. In this case, the patient suffered from ophthalmic artery occlusion with no light perception 48 h after hyaluronic acid injection. After two intra-arterial thrombolytic therapy sessions and traditional sequential therapy, ocular appearance was restored to normal, blood supply to the retina and visual function were improved, and visual acuity was restored to hand motion levels. Our results suggest that intra-arterial thrombolytic therapy with hyaluronidase and papaverine has a positive effect on hyaluronic acid-induced visual loss and is worthy of clinical promotion.

Long-term Outcomes of Ophthalmic and Retinal Artery Occlusion After Cosmetic Facial Filler Injection

BACKGROUND

Ophthalmic artery occlusion (OAO) and retinal artery occlusion (RAO) after facial filler injection have become increasingly significant due to the growth in cosmetic injection procedures for aesthetic purposes.

OBJECTIVES

The aim of this study was to analyze the long-term visual outcomes and complications of cosmetic facial filler-related OAO and RAO.

METHODS

This single-center, retrospective case series included 17 eyes of 16 filler-related OAO or RAO patients with a follow-up period of 1 year or longer. Main outcome measures were best-corrected visual acuity (BCVA) and long-term complications.

RESULTS

The mean [standard deviation] age at diagnosis was 31.7 [9.7] years; all the patients were female. The mean follow-up period was 5.4 [2.4] years. The mean BCVA was 2.34 and 2.41 logMAR at the initial and final visits, respectively, which indicates sustained long-term visual impairment. Ocular complications included retinal atrophy and degeneration (100.0%), optic atrophy and blindess (no light perception) (82.4%), strabismus (80.0%), retinal fibrous membrane (68.8%), posterior synechiae (35.3%), neovascularization (29.4%), iris atrophy and cataract (23.5%), corneal opacity and phthisis bulbi (17.6%), visual field defect and iris defect (11.8%), ophthalmoplegia (7.7%), and pupillary block (5.9%). Extraocular complications of brain infarction and depression were found in 25.0%, whereas skin necrosis was found in 13.3% of patients.

CONCLUSIONS

Facial filler-related OAO or RAO resulted in long-term poor visual outcome, and most of the patients experienced irreversible visual impairment with no light perception despite various treatments. Various long-term ocular and extraocular complications were observed, which should be monitored for a long-term follow-up period. Our findings suggest that prevention should be emphasized more than treatment.

LEVEL OF EVIDENCE: 4

Central Retinal Artery Occlusion after Filler Injection for Upper Lid Retraction

Purpose: We report a case of central retinal artery occlusion after filler injection for upper lid retraction. Diagnosis and treatment were performed to recover visual acuity and good results.Case summary: A 40-year-old woman presented to our clinic with upper lid retraction. She was diagnosed with hyperthyroidism and thyroid orbitopathy. She had been examined regularly at a local clinic since 2016. At the first visit, her visual acuity was 1.0/1.0 and the intraocular pressure was 19 mmHg, with no unusual findings in the anterior segment. Hyaluronic acid filler was injected into the medial part of the left upper lid. As soon as the needle was removed, she complained of blurry vision and visual impairment. This was followed by the development of a relative afferent pupillary defect; her visual acuity was hand motion at 30 cm. After 5 minutes, we performed wide fundus imaging and optical coherence tomography, which revealed retinal artery occlusion and a cherry-red spot, along with inner retina hyperreflectivity. Under a diagnosis of central retinal artery occlusion, we performed anterior chamber paracentesis, intravenous mannitol and acetazole injection, and an ocular massage. Approximately 1.5 hours after filler injection, retinal artery reperfusion and loss of the cherry red spot were observed and, after about 3 hours, her vision had recovered to 1.0 from hand motion at 30 cm.Conclusions: Central retinal artery occlusion after filler injection, when diagnosed promptly, can be treated by anterior chamber paracentesis, intravenous mannitol and acetazole injection, and ocular massage.

Vision Loss Secondary to Facial and Periorbital Steroid Injection: A Systematic Review

PURPOSE

The risk of ophthalmic and retinal artery occlusions following facial and periorbital steroid injection has not been explored. This systematic review examines the prevalence, risk factors, and treatment outcomes of steroid-induced vision losses.

METHODS

A literature search in Evidence Based Medicine Reviews, MEDLINE, Embase, Pubmed, ClinicalTrials, and WHO ICTRP was performed for vision loss following facial and periorbital corticosteroid injections through July 2020.

RESULTS

Of 35 case reports, series, and reviews, 49 patients (56 eyes) with steroid-induced vision loss were analyzed. Injection sites predominantly involved the nose (45%) and periocular regions (10%). The most common type of steroid is triamcinolone (54%). Most cases were unilateral, except 7 cases of bilateral vision losses, 4 of which resulted from unilateral steroid injection. Symptoms were reported during or immediately after injections in 49% of cases. Most occlusions occurred in the ophthalmic (53%) or central retinal artery (33%). Vision most commonly presented as no light perception (37%), and 90% were 20/200 or worse. Final visual outcomes varied from 20/200 or worse (56%), 20/40 or better (30%), to in between (13%).

CONCLUSION

Most vision losses resulted from steroid injections in the nasal and periorbital area. Triamcinolone was the most common offending agent, likely due to large particle size, low solubility, and extensive particle aggregation. Dexamethasone has the opposite pharmacologic properties and has never been reported in association with vascular occlusion related vision loss. Careful steroid selection, injection techniques, and treatment strategies should be considered to prevent and treat artery occlusion.

Retinal artery occlusion following cosmetic injection of poly-L-lactic acid

Ophthalmic vascular occlusion is an infrequent but devastating complication following cosmetic facial filler injection. We report a case of developing retinal artery occlusion after poly-L-lactic acid (PLLA) injection. A 49-year-old woman with multiple chronic diseases experienced sudden central visual loss and severe ocular pain in the right eye immediately after PLLA injection in the temporal region. Her best-corrected visual acuity in the right eye dropped from 20/20 to 20/200. Fundus photography showed marked optic disc edema and localized retinal whitening in the territory of the blocked vessels. Spectral-domain optical coherence tomography revealed localized hyperreflectivity of the inner retina and retinal edema. Fluorescein angiography showed delayed filling of the retinal arteries and absence of retinal perfusion in the affected areas. Despite prompt aggressive management of the condition with ocular massage, topical brimonidine eyedrops, and hyperbaric oxygen therapy, the patient suffered permanent visual loss due to optic atrophy. Among all the subcutaneous filler materials, PLLA has not been a common cause of vascular complications, especially when injected in the temporal region, as this area has not been considered dangerous in the previous literature. Practitioners should be aware of the risk of visual loss, and extra care should be given on those who originally have a higher risk for vascular complications.

Prevention and Management of Filler Induced Iatrogenic Stroke of the Eye

In the past few decades, minimally-invasive esthetic treatments and the use of injectable Hyaluronic Acid Gels and other filling agents to treat facial esthetics have increased dramatically. Although extremely rare, a filler can cause ocular and orbital ischemia by retrograde flow from the ophthalmic artery when injected in any of the anastomosis of the face. Once filler reaches the central retinal artery, blindness is inevitable, and no treatment is effective. While the risk of blindness happening with any filler injection is rare, the life-altering irreversible consequence of a procedure that was anticipated to be simple and beautifying is a reality that each injector must be prepared for with every injection. The parameters associated with an iatrogenic stroke of the eye are the site of injection, the injection technique, patient characteristics, and the material injected. Understanding the interplay of each of these variables might help us reduce the possibility of blindness during the injection of a soft-tissue cosmetic filler. Here, we explore the causes of Hyaluronic Acid Gels Filler embolic phenomena, review the natural course of the process, and discuss appropriate immediate interventions. We also (1) propose an education plan for injectors and describe how to carry out a focused ophthalmologic examination and procedural activities for a referral to an ophthalmologist, (2) outline steps to prevent emboli during filler injection, and (3) how to manage and support a patient with a sudden loss of vision during or immediately after a Hyaluronic Acid Gels filler treatment.

Thrombolysis for Central Retinal Artery Occlusion in 2020: Time Is Vision!

BACKGROUND

Acute nonarteritic central retinal artery occlusion (CRAO) is an eye stroke with poor visual prognosis and no proven effective therapies. Given advances in acute stroke care, thrombolysis in CRAO merits critical re-examination. We review the evidence for intravenous (IV) and intra-arterial (IA) tissue plasminogen activator (tPA) in CRAO management.

EVIDENCE ACQUISITION

MEDLINE, Scopus, and Cochrane online databases were systematically searched from 1960 to present, for reports of acute IV or IA therapy with alteplase or tenecteplase in nonarteritic CRAO patients. English language case reports, case series, interventional studies, or randomized controlled trials were included. The study type, age and number of subjects, the regimen administered, the time since symptoms' onset, visual outcome, and safety reports were noted.

RESULTS

Use of IV thrombolysis with alteplase was reported in 7 articles encompassing 111 patients, with 54% of them receiving IV tPA within 4.5 hours of symptom onset, and none developing symptomatic intracranial or ocular hemorrhage. Six studies described IA alteplase administration, with only 18 of a total of 134 patients (13.4%) treated within the first 6 hours after visual loss. The reported adverse events were minimal. Visual outcomes post-IV and IA thrombolysis were heterogeneously reported; however, most studies demonstrated benefit of the respective reperfusion therapies when administered very early. We found no reports of tenecteplase administration in CRAO.

CONCLUSIONS

In 2020, nonarteritic CRAO patients should theoretically receive the same thrombolytic therapies, in the same time window, as patients with acute cerebral ischemia. Eye stroke and teleeye stroke code encounters must include an expert ophthalmologic evaluation to confirm the correct diagnosis and to evaluate for ocular signs that may help guide IV tPA administration or IA management. Future research should focus on developing feasible retinal penumbra imaging studies that, similar to cerebral tissue viability or perfusion imaging, can be incorporated into the thrombolysis decision-making algorithm.