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Case Reports and Small Case Series
May 2001

Ocular and Cerebral Ischemia Following Facial Injection of Autologous Fat

Arch Ophthalmol. 2001;119(5):777-778. doi:

Periocular and paranasal injections of various substances are becoming increasingly common since more procedures are being performed under local anesthesia. Their serious visual adverse effects are rare but potentially devastating when they occur. Because of the multiple anastomoses between the vascular supply of the face and orbit, the potential for retrograde embolization of substances exists. We believe we report the first case of paranasal autologous fat injection resulting in middle cerebral, ophthalmic artery, and central retinal artery occlusion.

Report of a Case

A 43-year-old right-handed man received an injection of autologous fat in the tissue on the left side of the bridge of his nose to repair a soft tissue defect, a result of a previous accident. The autologous fat was obtained from the abdominal area. After anesthetizing the sites with 2% lidocaine without epinephrine, a large-bore cannula was used to inject the autologous fat deep into the soft tissue on the left side of his nose (1/2 mL), each nasolabial fold (3 mL each), and the upper and lower lips (3 mL). Within 10 minutes postinjection, he complained of eye and head pain, became disoriented, and lost vision OS . He also became aphasic with right-sided hemiparesis. There was no light perception OS and the left pupil was amaurotic. The left fundus showed a pale optic disc and widespread retinal whitening with visible emboli in several retinal arterioles (Figure 1). Preretinal and intraretinal hemorrhages were present inferiorly. The right eye remained unaffected. Ocular adnexa, ocular motility, and intraocular pressure were normal. The site of the initial injection underwent patchy necrosis over the ensuing 5 days (Figure 2). His neurological condition improved to normal, the left eye remained blind. The clinical features were consistent with fat embolism to branches of the left middle cerebral artery and the ophthalmic artery. The skin lesions indicated that distal arterial branches supplying the nose were also occluded.

Figure 1.
A, Pallid disc edema and retinal
whitening with interruption of several arteriole branches. B, Peripheral vascular
occlusion with visible fat emboli in arterioles.

A, Pallid disc edema and retinal whitening with interruption of several arteriole branches. B, Peripheral vascular occlusion with visible fat emboli in arterioles.

Figure 2.
A, Site of initial injection.
B, Necrosis 5 days later.

A, Site of initial injection. B, Necrosis 5 days later.

Comment

Visual loss secondary to fat embolization is a recognized, although uncommon, complication of autologous fat injection. The cases in the literature have involved injection of autologous fat around the glabellar area.13 This is the first report of ophthalmic artery occlusion after a paranasal injection of autologous fat. We believe the foreign material was injected into one of the peripheral branches of the ophthalmic artery, probably the dorsal nasal artery. Under the injection pressure of the syringe, the fat was likely forced retrograde into the ophthalmic and internal carotid arteries with subsequent distal movement of the emboli into the left middle cerebral, central retinal, and posterior ciliary arteries. Because the peripheral arteries of the face are small and collapsible, blood may not appear in the delivering syringe during aspiration despite the presence of the needle within an arterial lumen.

Corresponding author and reprints: Helen V. Danesh-Meyer, FRACO, Neuro-ophthalmology Service, Wills Eye Hospital, 900 Walnut St, Philadelphia, PA 19107 (e-mail: hdm90@hotmail.com).

References
1.
Egido  JAArroyo  RMarcos  A Middle cerebral artery embolism and unilateral visual loss after autologous fat injection into the glabellar area. Stroke. 1993;84615- 616Article
2.
Teimourian  B Blindness following fat injections. Plast Reconstr Surg. 1988;82361Article
3.
Dreizen  NGFramm  L Sudden visual loss after autologous fat injection into the glabellar area. Am J Ophthalmol. 1989;10785
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