Vision-Threatening Complications of Soft Tissue Fillers: A Report by the American Academy of Ophthalmology.

Summary

Aggregating 198 vision-loss cases from 19 studies, the AAO report shows most events follow injections in the central/upper midface (nose, forehead, glabella/frontal). Hyaluronic acid was implicated in 83% of cases. Therapeutic interventions (e.g., hyaluronidase, intra-arterial thrombolytics) were generally safe but seldom reversed blindness; vision improved in 28%, was unchanged in 70%, and worsened in 2%.

Key Findings

• 198 cases of vision loss identified; filler materials: hyaluronic acid 83% (164/198), autologous fat 15% (29/198).
• High-risk injection sites: nose 40%, forehead 25%, glabella 12%, temple/frontal 9%/7%; central/upper midface accounted for 84% of cases.
• Post-event vision outcomes: unchanged 70% (137/196), improved 28% (56/196), worsened 2% (3/196); treatments generally safe but rarely restored vision.

Clinical Implications

Prioritize risk-reduction: avoid bolus injections and high-pressure delivery in nose/upper midface, use cannulas where appropriate, aspirate judiciously, and consider ultrasound guidance. Establish emergency pathways including rapid ophthalmology referral; consider intra-arterial thrombolysis where available, acknowledging limited evidence.

Limitations

• All included studies rated level III; predominance of case reports/series without controls
• No standardized treatment protocol; potential publication and reporting biases

Future Directions

Prospective registries and standardized emergency protocols with rapid imaging/angiography; randomized or pragmatic trials of reperfusion strategies where ethically feasible.