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5 Filler Procedures Based ontheFacial Area
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Weichman BM, Murphy DK.Safety and effectiveness
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SA, Firooz A, Kashani MN.Assessment of the efcacy and safety of hyaluronic acid gel injection in
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Side Eects andTreatment
Methods ofFiller Procedures
6
6.1 Type andTreatment
ofComplication
As ller procedures become more popular, the
frequency and types of side effects are increasing
and becoming more diverse. Prior to the popularization of ller procedures, foreign body reactions and cases of granulomas caused by illegal
procedures were reported as side effects. Since
ller procedures have become more popular, skin
necrosis and, more recently, blindness have
become issues due to vascular complications.
In addition to the above fatal side effects, there
are minor side effects such as bruising, erythema,
edema, soft tissue infection, pigmentation, overcorrection, nodule, and migration.
Most of the vascular side effects after a ller
are caused by the physicians. Therefore, in order
to prevent these side effects, it is essential to
understand the properties of llers, precautions
for various injection methods, and facial anatomy
(especially vasculature).
Side effects of llers can be categorized
according to when they occur—as early or late
complications (Table6.1). Preventing side effects
is a priority, but it is important to detect and treat
them early when they occur. In addition, it is
desirable to understand possible side effects
depending on the timing and to know the appropriate treatment method. Among these, vascular
complications will be discussed in Sect. 6.2.
Table 6.1 Timing and presentation of ller
complications
Early onset
(<1~2weeks) Late onset (>2weeks~1year)
Bruise, hematoma Neovascularization
Edema PIH (post-inammatory
hyperpigmentation
Pain Nodule
Erythema Granuloma
Lump Migration
Infection Chronic infection
6.1.1 Bruising andHematoma
Bruising and hematoma are the most common
side effects after a ller procedure. It occurs
immediately after the procedure or within a few
days and can occur regardless of the type of ller.
If the blood vessels are injured during the
injection into the subdermal layer, the bruise is
visible immediately after the procedure. Injecting
into the supraperiosteum level reduces the likelihood of bruising, but is not 100% preventable. If
the blood vessels are injured by injection into the
deep or intermediate layer (subcutaneous supraperiosteum level), the bruise is not visible immediately after the procedure, so intervention by
compression is usually not performed. Therefore,
it should be noted that hematoma can develop
slowly after injection and may be detected later.
Proper compression even when a slight
amount of bleeding is seen immediately after the
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025
G. Hong et al., The Art and Science of Filler Injection,
https://doi.org/10.1007/978-981-96-9215-6_6
199
200
6 Side Eects andTreatment Methods ofFiller Procedures
procedure will reduce the size of a larger bruise
or hematoma. If patients are taking medication
that can aggravate bleeding, avoid taking it for
several days to a week before the procedure.
Factors associated with bruising/hematoma
• Needle gauge
• Depth of injection plane
• Patient-related factors (age, medication, liver
disease)
• Medications (aspirin, warfarin, NSAIDs, vitamin E, sh oil, etc.)
How to reduce bruising/hematoma during the
procedure
• Apply ice packs before and after the procedure to constrict the blood vessels.
• Use lidocaine mixed with epinephrine for
anesthesia.
• Perform the procedure slowly and gently.
• During the procedure, the skin may swell after
undermining of the space using a cannula. If
the area swells before ller injection, a hematoma may be suspected due to vascular damage. In this case, immediately remove the
cannula and apply sufcient pressure. Even if
the area is no longer swollen after pressing for
at least 5min, it is advisable to postpone the
procedure.
When creating an entry point for llers around
the eyes, bleeding can easily lead to bruising
because the skin in this area is thin and applying
pressure to stop the bleeding is difcult. The
technique for controlling bleeding at the entry
point in this area differs from other regions. If
bleeding occurs, immediate pressure should not
be applied. Applying pressure can cause the
blood to spread into the surrounding tissues,
making it very visible. Therefore, it is crucial to
minimize the spread of blood into the surrounding tissues. Use gauze to absorb the blood and
wait until the bleeding slows down. Once the
bleeding has slowed, apply pressure to stop the
bleeding, preventing the blood from spreading
into the surrounding tissues, which helps to minimize bruising.
6.1.2 Edema
Transient edema immediately after the ller
procedure is normal, usually disappearing
within 2–3 days. Some llers may cause
unpleasant edema due to its high water retention
capacity, so it is a advisable to inform the patient
before the procedure about the possibility of
edema.
Hematoma caused by vascular injury during
the procedure and edema due to water retention
after the procedure needs to be differentiated.
Hematoma is usually unilateral and occurs
within minutes or hours after the procedure.
In case of excessive undermining of the treatment area with a cannula, severe edema can be
accompanied. To prevent this, it is helpful to
refrain from excessive undermining and apply
pressure after the procedure. For example, in case
of ller treatment with severe dissection of the
subgaleal space during forehead treatment, using
an elastic bandage after treatment may minimize
edema.
Water Retention of Filler
Depending on the ller product, some may cause
more severe edema than others. Therefore, it is
advisable to know the properties of the ller used
in advance and explain the possibilities of swelling to the patient.
Delayed Hypersensitivity Reaction
Delayed hypersensitivity reactions occur days to
months after ller procedures. Severe edema
with erythema sometimes accompanies itching
and pain. It may occur in the areas where the
ller was injected or in the areas where the ller
was dissolved.
• Treatment
– Oral steroids (it does not respond to
antihistamines).
– In case of a HA ller, dissolve with hyal-
uronidase. Symptoms resolve only when
the ller is completely gone (See Sects.
4.6.2 Hyaluronic acid ller degradation
test and 6.3 Use of hyaluronidase).
6.1 Type andTreatment ofComplication
201
– For non-HA llers, remove the ller
surgically.
– If a hard nodule is palpated, inject triam-
cinolone by diluting it or inject 5-FU.
6.1.3 Neovascularization
andErythema
It is common for mild erythema to develop at the
treatment area immediately after the ller procedure and resolve after a few days.
A few days or weeks after the ller is injected,
diffuse erythema may develop in a circular or
elliptical manner. This type of delayed diffuse
erythema is more likely to occur in the supercial
layer than in the deep layer or in areas where
there is not enough space from the skin to the
periosteum. This is due to the formation of new
capillaries by the pressure increase in the tissue
as a compensating mechanism.
In this case, a vascular laser can be used for
treatment. Long-term use of steroid ointments is
contraindicated as it causes capillary dilation and
makes symptoms worse.
Differential Diagnosis
• Impending necrosis
It is very important to recognize erythema by
impending necrosis, which appears 1–3 days
after the procedure. In case of impending necrosis, it is red or light purple with a reticular pattern. In this case, immediate treatment is needed
(-> See Sect. 6.2.2 Treatment of skin necrosis).
• Soft tissue infection
Skin infections due to ller treatment appear
2–3days after the procedure. The center of the
erythema is dark red and softens in a gradation
pattern toward the periphery. It usually appears
unilateral and is accompanied by burning sensation and edema. Antibiotic treatment is needed
(->See Sect. 6.1.6 Infection).
6.1.4 PIH (Post-inammatory
Hyperpigmentation)
After ller injection, sometimes postinammatory hyperpigmentation can occur at the
entry point.
In particular, it is more likely to occur with
Fitzpatrick skin types IV–VI. To prevent this,
reduce the number of entry points. When puncturing the skin, it is recommended to use a small
needle.
Treatment
• Whitening agent (hydroquinone).
• Laser treatment: Q-switched Nd:Yag 1064nm
laser, picosecond Nd:Yag 1064nm laser.
6.1.5 Nodule andGranuloma
6.1.5.1 Nodule (Non-inammatory)
Occasionally, after ller injection, lumps can
become visible or palpable through thin skin.
Unlike inammatory nodules, they exhibit little
change in size or color. The causes of noninammatory nodules include uneven injection,
injecting too large a volume, injecting too supercially, and insufcient massaging after the procedure. The treatment for HA llers involves
dissolving the ller with hyaluronidase. For non HA llers, early compression may help spread
out the ller, although this depends on the specic properties of the ller used. If the nodule
does not dissolve easily, injecting lidocaine or
saline followed by massage can disrupt the nodule. If it still persists, a small amount of intralesional steroid (diluted triamcinolone) may be
injected, though caution is needed to avoid skin
atrophy.
6.1.5.2 Granuloma
A good ller should not cause adverse effects
originating from the product itself. If a specic
ller shows adverse effects immediately or within
a few days after the procedure, it can quickly be
identied as problematic, allowing for early
202
6 Side Eects andTreatment Methods ofFiller Procedures
determination of its quality. However, if adverse
effects do not appear until years later, it becomes
difcult to assess the ller’s quality. In the past,
some llers known for their longevity caused signicant problems years after the procedure.
Therefore, the selection of llers must always be
done with caution, using products with proven
safety. As previously mentioned, long-term
adverse effects can make accurate assessment
challenging because the lack of immediate side
effects may lead to the false conclusion that the
ller is safe. Among the long-term side effects
caused by llers is the formation of granulomas.
Granulomas are chronic inammatory states
characterized by masses surrounded primarily by
giant cell. Foreign body granulomas are longlasting inammatory nodules and may appear
several months after the procedure.
Factors Inuencing Granuloma Formation
Various factors inuence the formation of granulomas, including the properties of the ller
(although it is known that all ller materials can
cause granulomas, cases involving HA llers, or
CaHA llers are rare), injecting too large a volume, intramuscular injection, history of infection
or trauma at the injection site, repeated injections, presence of impurities, particle size, and
particle surface charge.
The Treatment ofGranulomas
Treatments include the use of hyaluronidase,
intralesional steroids (triamcinolone), 5-FU, and
surgical removal (typically performed after
aspiration).
For the treatment of granulomas, it is preferable to dissolve them as much as possible if they
can be dissolved. Surgical treatment is generally
not recommended.
In the case of granulomas or inammatory
nodule, there can be multiple smaller masses
within outer mass. Sometimes another smaller
masses can also be scattered throughout the area.
Surgical removal of these masses is challenging
and can lead to issues with scar formation, potentially causing further problems for the patient’s
skin. Therefore, it is preferable to opt for dissolution as much as possible and to perform repeated
treatments. As previously mentioned, if there are
smaller masses within the larger mass, they can
grow again if not fully dissolved.
6.1.6 Infection
An infection may be suspected when accompanied by edema, burning sensation, and erythema
in the affected area within 2–3days after the ller
procedure.
Prevention.
• Thorough disinfection of the treatment site.
• Wear sterilized or non-sterilized gloves during
the procedure. The procedures should not be
performed with bare hands.
• Prescribe oral antibiotics after the procedure
for short period.
Treatment
• Oral antibiotics
Recommended empiric antibiotics therapy
– Amoxicillin + clavulanate
– Cephalexin
– Ciprooxacin 750mg twice daily for 1week
(if has penicillin allergy)
– Once diagnosed, it is advisable to refrain from
massaging to prevent spread to surrounding
tissues.
– An abscess may be suspected if after the rst
oral antibiotics the condition does not improve
and persists for a longer time.
After incision and drainage, pus should be
cultured and administer susceptible antibiotics.
If you suspect an inammatory nodule but not
abscess, administer empiric antibiotics.
Recommended empiric antibiotics therapy
– Clarithromycin 500 mg + moxioxacin
400mg twice daily for 10days
– Ciprooxacin 500–750 mg twice daily for
2–4weeks
– Minocycline 100mg once daily for 6months
6.2 Treatment andPrevention ofVascular Complication
203
Differential Diagnosis with Herpes Infection
If a patient with poor immunity receives a ller
procedure on the face, there is a possibility of
herpes virus recurring. Lesions begin with tingling and develop into vesicles and crusts.
Vesicle patterns need to be differentiated from
skin necrosis. In cases of skin necrosis, the skin
color change in a reticular pattern is accompanied rst.
If there is a history of herpes infection or frequent relapses, prophylactic antiviral therapy
may be considered.
Prophylactic treatment
• Valacyclovir 500mg twice a day for 3days
Antiviral treatment
• Valacyclovir 2000mg twice a day for 1day
Differential Diagnosis with Delayed
Hypersensitivity Reaction
Delayed hypersensitivity reactions are accompanied by itching, edema, diffuse and erythema, but
no burning sensation.
6.2 Treatment andPrevention
ofVascular Complication
6.2.1 Mechanism andClassication
ofVascular Complications
There is an increasing trend in vascular complications due to ller procedures. There are two
main causes of vascular complications: intravascular emboli and extravascular compression
(Table6.2).
6.2.1.1 Extravascular Compression
If the injected ller mass is pressed against an
adjacent artery, ischemia may progress slowly,
and skin necrosis may occur. When the ller
mass compresses a vein, venous congestion
occurs, and this can lead to the oxygen supply
from the arteries connected to it to decrease. This
can eventually cause skin necrosis to progress
slowly.
Table 6.2 Types of vascular complications
Intravascular emboli
Artery Skin necrosis Skin necrosis
Blindness
Cerebral infarct
Vein Pulmonary embolism Skin necrosis
Extravascular
compression
6.2.1.2 Intravascular Emboli
If the blood vessel is blocked by an embolus
which is inadvertently formed in a vessel due to a
ller procedure, oxygen may not be supplied to
the tissue, which may cause fatal side effects.
Blocking the branches of the external carotid
artery can lead to skin necrosis due to insufcient
blood supply even if the vessels are anastomosed
with surrounding arteries.
If the terminal artery is blocked, symptoms of
embolism appear within a few minutes after the
procedure, and irreversible injury can occur if
immediate treatment is not taken. If the ller
material blocks the retinal artery or its branches,
blindness or eye movement dysfunction may
occur. If a branch of the cerebral artery is blocked,
it causes a cerebral infarction.
If injected into a vein, it may cause pulmonary
embolism through venous drainage.
6.2.1.3 Commonly Aected Areas
Skin necrosis cases have been reported before
llers became more common as in recent years.
In the early years, skin necrosis was reported
mainly in the nose and the nasolabial fold, as
ller procedures were performed mainly in these
two areas. However, recently, as llers are being
applied to the whole face, skin necrosis is being
reported in additional areas such as the forehead
and glabella.
Blindness has been reported more recently
being caused by inadvertent injection of ller
into the supratrochlear artery, supraorbital artery,
or dorsal nasal artery which are all associated
with the central retinal artery (during forehead or
glabella injection—see Sect. 6.2.3 Blindness).
It can also occur by injection into other vessels
connected to the vessels mentioned above.
Pulmonary embolism is rarely reported, and it
is most likely to occur during injection in the
204
6 Side Eects andTreatment Methods ofFiller Procedures
temple region which has the sentinel vein and
middle temporal vein, which are the largest veins
in the facial region (see Sect. 6.2.3 Blindness).
Since the facial vessels are connected to each
other, skin necrosis, blindness, and pulmonary
embolism can occur in any part of the facial
region, and care should be taken at all times.
6.2.2 Skin Necrosis
6.2.2.1 Predisposing Factors ofSkin
Necrosis
• Skin thickness
Areas with thick skin are more likely to cause
necrosis by extravascular compression than thinner skin areas. If the space between the dermis
and the periosteum is thin, it is more likely that
the blood vessels will be compressed by the ller
mass.
For example, in the tip of the nose the space
between the skin and the cartilage is small. If a
large amount of ller product is injected, the
arteries can be compressed and skin necrosis
more likely to occur. In particular, if the artery is
not anastomosed with peripheral blood vessels,
the likelihood is even higher.
• Injection technique
Over-injecting ller in one space can cause
the ller mass to compress blood vessels.
• Injection plane
Injecting into the subcutaneous fat layer which
has more vascularity rather than the supraperiosteum level, there is a higher risk of compressing
or damaging blood vessel.
• History of ller/fat injection
If there is a history of fat transplantation,
llers, or surgery, the affected area undergoes a
brotic change, resulting in less tissue exibility
and less mobility of blood vessels. This increases
the likelihood of extra-vascular compression and
vessel damage, so care must be taken.
6.2.2.2 Inuencing Factors
withPrognosis ofSkin Necrosis
• Degree of blockage of blood vessels
The area of skin necrosis caused by an intravascular embolus is much broader than the area
caused by extravascular compression.
• Diameter of blood vessel
The extent of skin necrosis due to complete
obstruction by an embolus in the main artery
is wider than that of a peripheral artery
obstruction.
• Anastomosis with adjacent arteries
In the case of an intravascular embolus or
extravascular compression, the possibility of
recovery depends on the anastomosis with adjacent vessels. The skin necrosis may be reversible
by blood ow from adjacent blood vessels.
However, in the absence of adjacent blood vessels, blood supply failure causes more severe side
effects and makes recovery difcult.
6.2.2.3 Symptoms ofSkin Necrosis
Symptoms of skin necrosis vary, and the treatment of skin necrosis varies depending on the
stage it is discovered and intervention implemented. Therefore, it is important to exactly
know the symptoms at each phase so it can be
treated properly. The symptoms of each phase are
as follows.
Impending necrosis
This is the stage before an eschar occurs on the
skin. When the blood vessels are partially
obstructed, it progresses slowly. About 2–3days
after the procedure, the symptoms develop, and
the skin color changes to purple with a reticular
pattern and is accompanied by pain and edema.
6.2 Treatment andPrevention ofVascular Complication
205
In mild cases, impending necrosis does not progress to the next stage and may recover without
sequelae. If it progresses to the next stage, it will
develop an infection with pustules, which will
result in a mild eschar.
However in the case of complete obstruction
(severe necrosis), the impending necrosis stage
passes briey. The range of infection is more
widespread, and large eschars develop. After the
eschar is removed, atrophic scars usually follow.
If the impending necrosis stage is present within
1day and the skin color change is widespread,
intensive treatment should be administered as
soon as possible.
Skin Necrosis
If the ischemic state persists during the period of
impending necrosis, the skin barrier is broken
which leads to weakening of bactericidal action.
Pustules appear on the skin accompanied by pain
and edema.
As the wound healing process progresses further, the pustules burst and eschars are developed.
Scar Formation
Once the infection has recovered and the large
eschar disappears, skin defects may develop and
can be accompanied by erythematous scars.
6.2.2.4 Treatment ofSkin Necrosis
(Table6.3)
Decompression
Skin necrosis varies in terms of symptoms
depending on its extent and severity. Patients
usually complain of symptoms within 1–2days if
the area of necrosis is wide and after 2–3days if
the area is small. Decompression that can eliminate the cause of vascular compression should be
performed rst, since the blood vessels are compressed by ller masses or edema and oxygen is
not supplied to tissues by ischemia.
If initial symptoms of necrosis are suspected
with skin color change immediately after the procedure, blood ow can be improved by attempting to spread the ller via massage to disperse the
pressure applied in the corresponding space. In
the case of hyaluronic acid llers, attempt to dissolve it by injecting hyaluronidase and subsequent massage.
Puncture and Drainage
In the case of injection into supercial to medium
planes rather than deeper planes, the most obvious decompression method is to incise the skin
and drain the ller. Non-HA llers do not have a
dissolving agent, so decompression is done using
this method. This can be done immediately after
Table 6.3 Symptoms and treatments depending on the timing of necrosis
Impending necrosis Skin necrosis Scar formation
Ischemic state Infection Skin defect
Wound healing state
Symptoms Reticular pattern Pustule Redness
Purple color Eschar Depressed scar
Pain, swelling
Treatments
Decompression
Hyaluronidase
Puncture & Drainage
(if possible)
Warm massage
Revascularization
PGE1 IV (vasodilator)
Hyperbaric O
Aspirin
2
Infection control
PO antibiotics
Remove pustule
Dressing
Antibiotics gauze
Growth factor
EGF/PDRN/PRP/stem cell
Scar Treatment
Vascular laser
Fractional laser
Skin graft
206
6 Side Eects andTreatment Methods ofFiller Procedures
the procedure or during the early stage of necrosis. It is not recommended to use this method if
there are eschars on the skin after several days.
Excessive manipulation of the affected area
with a damaged skin barrier can harm the skin.
If the ller was injected into a deep plane, suction may be attempted with negative pressure of a
syringe using a large bore needle.
Warm Massage
If the vessel suspected of being pressed by the
ller mass is in a conned space, it may be helpful to attempt decompression by pressing and
rolling over the ller mass with massage.
Massage with a wet gauze (warm water or
saline solution) can also be helpful in vasodilation of the vessels.
CaHA llers that do not respond to hyaluronidase may be broken up by massage after infusion
of lidocaine or saline.
Massage should be done with caution as it can
cause harm to vulnerable vasculature. This
method is not helpful when there is a severe skin
infection or eschar.
Hyaluronidase
In cases of HA ller, decompression can be done
by dissolving it with hyaluronidase. Massage
must be performed together since hyaluronidase
is a polymer and it does not penetrate into the
ller mass. Massage the ller mass to increase
the surface area for hyaluronidase to function
properly.
According to an article, hyaluronidase can
penetrate the vessel wall to dissolve the hyaluronic acid in the vessel. Therefore, even if there
is suspected vascular occlusion, hyaluronidase
should be actively administered to the ller injection site
Revascularization
After decompression as an initial treatment,
improvement of blood ow is needed.
PGE1 (Vasodilator)
Intravenous infusion of vasodilators has been
widely used to treat pressure ulcers and necrotic
tissue. It can also be used to treat skin necrosis
after a ller procedure. Mix PGE1 (alprostadil
5μg) in 500cc normal saline and infuse it slowly
over approximately 2h. If you administer it over
too short a period, the vasodilation effect often
causes headaches. Use it for 3–5days until clinical improvement is seen.
Aspirin
Aspirin lowers the viscosity of the blood, which
helps increase blood ow in narrowed blood
vessels.
When ller is injected into a blood vessel,
blood clots along with ller emboli play a role
in the progression to ischemia. The use of aspirin may help to inhibit ischemia progression.
Infection Control andDressing
andGrowth Factor
Infection Control
If impending necrosis occurs after the ller procedure and only skin color changes appear, it can
be treated with oral antibiotics. However, if pustules appear with skin color change, they should
be removed aseptically. After removal of the pustules, wet dressing with antibiotic gauze must be
followed. This minimizes the occurrence of an
eschar. If the infected skin is left dry, not only
will an eschar develop, but later scarring will
occur.
Growth Factor
Applying or injecting growth factors during
wound healing after skin necrosis may help in
recovery. Growth factors such as EFG, PDRN,
and stem cells are commonly used. Care should
be taken to avoid bleeding during needle injection. If there is an eschar or difculty injecting it
directly into the lesion, you can attempt injecting
it at the margin.
Scar Treatment
Proper treatment at the skin necrosis stage can
reduce eschar and minimize scarring. However, if
the extent of infection is large or if it is not treated
properly, permanent scarring can be left over a
wide area. If a scar remains, it is very disheartening
6.2 Treatment andPrevention ofVascular Complication
207
for the doctor as well as the patient. Depression
of the skin seen immediately after resolution of
the eschar is still in the process of wound healing,
so use growth factors to help the skin regenerate.
Multiple fractional laser treatments can also be
helpful. In severe cases, skin grafts may be
necessary.
6.2.2.5 Tips forEarly Detection
andImmediate Treatment
If both the doctor and patient have never experienced skin necrosis before, they might not have
adequate knowledge of how to detect, diagnose,
and treat the condition. The day after the ller
procedure, the clinic staff must call the patient to
check on the condition. If the obstruction of
blood vessels is severe, the symptoms appear the
next day. If the obstruction is present but not
severe, the next day may only be accompanied by
slight pain or edema and no change in skin color.
In this case, differential diagnosis with skin
infection is necessary, and it is advisable to check
whether there is a change in skin color with a
reticular pattern after 2–3days.
If the patient complains of a change in skin
color or an uncomfortable symptom the next day,
the clinic should receive a photograph of the
lesion and decide whether to examine the patient
in the clinic.
An emergency kit containing hyaluronidase
and vasodilators should be prepared for necrosis
treatment. If you have no experience with skin
necrosis or do not prepare an emergency kit, it is
advisable to have an emergency contact network
available to ask for advice or to refer a patient.
The most important point in the treatment of
necrosis is early detection and immediate
treatment.
If you experience necrosis case for the rst
time, the symptoms appearing 1–2days after the
procedure tend to be overlooked and considered a
simple infection or a minor symptom. Care must
be taken to differentiate these scenarios (see Sect.
6.1.3).
6.2.3 Vascular Complication: Blindness
The most fatal complication of intra-arterial ller
injection is blindness. Blindness is caused by
occlusion of the central retinal artery and can be
caused by almost all injections used for cosmetic
purposes such as fat transplantation, hyaluronic
acid, PLLA, and CaHA.
Mechanism
The ophthalmic artery has several branches, one
of which is can be blocked due to backow of
ller material that has been incorrectly injected
into a blood vessel, leading to blindness.
Filler material reuxed mainly from the supratrochlear/supraorbital artery → migrates to the
ophthalmic artery (derived from the internal
carotid artery) → causes the occlusion of the
branches, such as central retinal artery and posterior ciliary artery.
This occurs when injected in the opposite direction to the blood ow at a pressure stronger than
the arterial blood pressure. When continuously
injected, the ller material is more likely to occlude
the terminal artery. Immediately after the procedure, diplopia and visual eld defects appear.
If these symptoms occur, you should call an
ophthalmologist immediately. Even if the patient
receives professional treatment in an eye hospital
after the event, recovery may vary depending on
the extent of the blood vessel’s occlusion.
In severe cases, complete bilateral blindness
or cerebral infarction may result.
Emergency Treatment
First aid may be attempted to dissolve the ller in
the retinal artery before transferring the patient to
an eye hospital. Hyaluronidase is injected into
the retrobulbar space using a cannula, which is
absorbed into the retinal artery by diffusion to
dissolve the ller and recirculate blood ow.
<See Sect. 6.4 retrobulbar injection
technique>