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Iatrogenic vision loss following aesthetic treatment with hyaluronic acid‐containing filler: Every injector should be prepared

Dear Editor We read with interest the short paper by Jesper Thulesen on the preparedness of the aesthetic physicians in the event of vision loss following Hyaluronic acid (HA) related facial rejuvenation procedures. With over 190 reported cases of the iatrogenic blindness, the numbers continue to rise, with the tremendous growth in HA-based cosmetic interventions. The author deserves felicitation for emphasizing and revisiting such a crucial issue. Vision impairment induced by HA filler embolism, remains an alarming event for which there is no established rescue procedure, given the appropriate strategy concerning preventive measures and commitment to existing care protocols. The author carefully articulated the salient features of retrobulbar hyaluronidase (RBH), taking into consideration the timing, dosage, mindfulness of the volume, to aesthetic procedural-related documentation. However, details regarding the transfer of the patient to a tertiary facility and the caution for the need of an experienced interventionist to perform the procedure has mostly been ignored. Such an intervention would undoubtedly require an emergency protocol rather than the proposed disjointed management. As the initiation of treatment with Hyaluronidase within 90 min is an arbitrary time frame and recent systematic reviews on soft tissue filler related blindness has reported the time of onset of visual symptoms from immediate (in the majority of the cases) to 24 hours; it is of utmost importance to initiate peribulbar or retrobulbar hyaluronidase protocol at the earliest. However, considering the varied specialties and expertise of the aesthetic practitioners, we wonder how safe would it be to perform RBH in a consultation room, or the practicality for patient transfer to tertiary care within 90 min as proposed by the author considering the variability, diversity and availability of such care across the globe. It is quite apparent that ischemic events are best managed at a tertiary care center, well equipped with a skilled interventionist, considering the possibility of cerebral infarction and hemiplegia that could also be associated with post filler blindness. However, when there is no quick access to such care in the vicinity, an alternate and safer option would be to have an interventionist (proficient in RBH) available within proximity, wherever possible as a standard protocol in every aesthetic clinic in case of emergency. Nevertheless, other supportive measures in bedside or during the transfer and emerging thrombolytic therapies should also be considered. We strongly agree with the statement made in a recent consensus on minimizing the risk of HA embolic visual loss that the “Peribulbar or retrobulbar injections should only be performed if the operator has expertise in this injection technique and feels confident in the diagnosis”. The most important message that should echo in every fillerrelated blindness case reporting, consensus or therapy paper, is the sound knowledge of facial anatomy and reinforcement of its the understanding, frequently through a structured training programme.