Amaurosis as an adverse event after hyaluronic acid injection: A narrative literature review
DOI:
https://doi.org/10.33448/rsd-v14i10.49632Keywords:
Low Blindness, Side effects and adverse reactions, Hyaluronic acid.Abstract
Hyaluronic acid injections have become increasingly popular in minimally invasive aesthetic procedures, especially in orofacial harmonization, due to their ability to rejuvenate facial features and restore volume in areas such as the nasolabial folds, lips, and under-eye region. The aim of this narrative literature review is to evaluate amaurosis as an adverse event of HA application in the facial region. The main cause of hyaluronic acid–induced amaurosis is arterial embolization, which occurs when the filler is injected into facial vessels, blocking the ophthalmic artery and restricting blood flow to the retina, potentially leading to irreversible vision loss. The primary mechanism behind this complication is the embolization of filler material, which travels through the circulatory system and obstructs critical arteries supplying blood to the eye. High-risk areas for this type of complication include the glabella, periocular regions, and nose, where anastomoses between the facial and ophthalmic arteries are more prevalent. Several risk factors contribute to the onset of amaurosis, such as inadequate injection technique, excessive pressure, and injection into unsafe anatomical zones. To prevent such complications, professionals must have a deep knowledge of facial anatomy, employ safe injection techniques, and use appropriate devices, such as cannulas instead of needles, to minimize the risk of vascular injury. In addition, the use of local vasoconstrictors, such as epinephrine, and aspiration prior to injection are further safety measures.
References
Cavallini, M., Gazzola, R., Metalla, M., & Vaienti, L. (2013). The role of hyaluronidase in the treatment of complications from hyaluronic acid dermal fillers. Aesthetic Surgery Journal, 33(8), 1167–1174. https://doi.org/10.1177/1090820X13511970
de la Guardia, C., Virno, A., Musumeci, M., Bernardin, A., & Silberberg, M. B. (2022). Rheologic and physicochemical characteristics of hyaluronic acid fillers: Overview and relationship to product performance. Facial Plastic Surgery, 38(2), 116–123. https://doi.org/10.1055/s-0041-1741560
De Jong, W. H., Jennen, D., Keizers, P. H. J., et al. (2022). Evaluation of adverse effects of resorbable hyaluronic acid fillers: Determination of macrophage responses. International Journal of Molecular Sciences, 23(13), 7275. https://doi.org/10.3390/ijms23137275
Fundarò, S. P., Salti, G., Malgapo, D. M. H., & Innocenti, S. (2022). The rheology and physicochemical characteristics of hyaluronic acid fillers: Their clinical implications. International Journal of Molecular Sciences, 23(18), 10518. https://doi.org/10.3390/ijms231810518
Girish, K. S., Kemparaju, K., Nagaraju, S., & Vishwanath, B. S. (2009). Hyaluronidase inhibitors: A biological and therapeutic perspective. Current Medicinal Chemistry, 16(18), 2261–2288. https://doi.org/10.2174/092986709788453078
Hwang, C. J., Chon, B. H., & Perry, J. D. (2021). Blindness after filler injection: Mechanism and treatment. Facial Plastic Surgery Clinics of North America, 29(2), 359–367. https://doi.org/10.1016/j.fsc.2021.02.002
Juncan, A. M., Moisă, D. G., Santini, A., Morgovan, C., Rus, L. L., Vonica-Țincu, A. L., & Loghin, F. (2021). Advantages of hyaluronic acid and its combination with other bioactive ingredients in cosmeceuticals. Molecules, 26(15), 4429. https://doi.org/10.3390/molecules26154429
Kroumpouzos, G., & Treacy, P. (2024). Hyaluronidase for dermal filler complications: Review of applications and dosage recommendations. JMIR Dermatology, 7, e50403. https://doi.org/10.2196/50403
Landau, M. (2015). Hyaluronidase caveats in treating filler complications. Dermatologic Surgery, 41(Suppl 1), S347–S353. https://doi.org/10.1097/DSS.0000000000000555
Lee, W. (2020). Prevention of hyaluronic acid filler-induced blindness. Dermatologic Therapy, 33(4), e13657. https://doi.org/10.1111/dth.13657
McCann, M. (2019). Intravenous hyaluronidase for visual loss secondary to filler injection: A novel therapeutic approach. Journal of Clinical and Aesthetic Dermatology, 12(12), 25–27.
Murthy, R., Roos, J. C. P., & Goldberg, R. A. (2019). Periocular hyaluronic acid fillers: Applications, implications, complications. Current Opinion in Ophthalmology, 30(5), 395–400. https://doi.org/10.1097/ICU.0000000000000595
Navarro-Hernandez, E., & Pérez-López, M. (2022). Effectiveness of retrobulbar hyaluronidase in the treatment of visual loss caused by periocular hyaluronic acid injection: A systematic review. Archivos de la Sociedad Española de Oftalmología, 97(9), 521–538. https://doi.org/10.1016/j.oftale.2022.06.005
Paap, M. K., Milman, T., Ugradar, S., Goldberg, R., & Silkiss, R. Z. (2020). Examining the role of retrobulbar hyaluronidase in reversing filler-induced blindness: A systematic review. Ophthalmic Plastic and Reconstructive Surgery, 36(3), 231–238. https://doi.org/10.1097/IOP.0000000000001568
Pereira A. S. et al. (2018). Metodologia da pesquisa científica. [e-book gratuito]. Santa Maria/RS. Ed. UAB/NTE/UFSM. 9).
Rother, E. T. (2007). Revisão sistemática x revisão narrativa. Acta Paulista de Enfermagem. 20(2): 5-6.
Surek, C. C., Said, S. A., Perry, J. D., & Zins, J. E. (2019). Retrobulbar injection for hyaluronic acid gel filler-induced blindness: A review of efficacy and technique. Aesthetic Plastic Surgery, 43(4), 1034–1040. https://doi.org/10.1007/s00266-019-01388-4
Walker, L., Convery, C., Davies, E., Murray, G., & Croasdell, B. (2021). Consensus opinion for the management of soft tissue filler induced vision loss. Journal of Clinical and Aesthetic Dermatology, 14(12), E84–E94.
Weber, G. C., Buhren, B. A., Schrumpf, H., Wohlrab, J., & Gerber, P. A. (2019). Clinical applications of hyaluronidase. In Advances in Experimental Medicine and Biology (Vol. 1148, pp. 255–277). Springer. https://doi.org/10.1007/978-981-13-7709-9_12
Woodward, J., Cox, S. E., Kato, K., Urdiales-Galvez, F., Boyd, C., & Ashourian, N. (2023). Infraorbital hollow rejuvenation: Considerations, complications, and the contributions of midface volumization. Aesthetic Surgery Journal Open Forum, 5, ojad016. https://doi.org/10.1093/asjof/ojad016
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Amanda Ribeiro Lemos, Regina Paula de Souza Ranieri, Maria Aparecida Carvalho de Araújo, João Victor Frazão Camara, Daniel Silva Abrahão, Daniella Pilon Muknicka
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
1) Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
2) Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
3) Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.
