Finally, we agree that for patients with herpeticstromal keratitis, it is worthwhile to administer systemicand topic prophylactic antiviral agents to prevent herpesrecurrence.

TING HUANG

XUEYAN ZHANG

YUN WANG

HONG ZHANG

ANDINA HU

NA GAO

Guangzhou, China

CONFLICT OF INTEREST DISCLOSURES: SEE THE ORIGINALarticle1 for any disclosures of the authors.

REFERENCE

1. Huang T, Zhang X, Wang Y, Zhang H, Huand A, Gao N.Outcomes of deep anterior lamellar keratoplasty using thebig-bubble technique in various corneal diseases. Am J

Ophthalmol 2012;154(2):282–289.

Iatrogenic Retinal Artery OcclusionCaused by Cosmetic Facial FillerInjections

EDITOR:

WE READ WITH INTEREST THE RECENT ARTICLE BY PARK

and associates titled ‘‘Iatrogenic Retinal Artery Occlu-sion Caused by Cosmetic Facial Filler Injections.’’1 Theauthors are to be commended for reporting the resultsof a retrospective noncomparative case series to evaluatethe clinical manifestation and visual prognosis of retinalartery occlusion resulting from cosmetic facial fillerinjections. Herein, we discuss some key points aboutthis serious eye injury that recently have heightenedawareness.2

In their article, Park and associates reported the clinicalcharacteristics of 12 patients. Patient 6 (Table 1), affectedby ophthalmic artery occlusion, had a follow-up durationof only 3 days after the treatment. In our opinion, thisfollow-up may be too short to consider as definitive forthe final outcome of no light perception because a relativepupillary afferent defect may be predictive for a partialvisual recovery.

With regard to Patients 1 through 4, Park and associ-ates reported in Table 1 a superselective intra-arterialthrombolysis with urokinase as immediate treatment,whereas for the same patients in the Methods section,the interval between the occurrence of iatrogenic blind-ness and thrombolysis is reported as within 24 hours.1

This difference should be clarified by the authors because

VOL. 155, NO. 2 CORRESPON

the interval between the onset of the symptoms ofretinal artery occlusion and the therapy may affect thevisual prognosis significantly. As a matter of fact, someauthors have demonstrated that after 90 minutes, thedamage caused by retinal ischemia becomes irreversibleand retinal necrosis occurs.3,4 Moreover, in ourexperience, selective intra-arterial thrombolysis isa very ultraspecialized surgery that can be performedonly in specialized ophthalmic units. Usually, patientsundergo cosmetic injections in outpatient clinics, andtransportation to the nearest unit may require time.Finally, this procedure is fraught with many importantside effects, such as cerebral bleeding. Thus, it is reason-able to discuss further the benefits and drawbacks ofintra-arterial thrombolysis to treat retinal embolism aftercosmetic facial injections.In our review of 32 cases of iatrogenic blindness after

facial cosmetic injection, we presumed that incompletetreatment also could have contributed to failure of thetreatment(s) in achieving visual recovery. In the Euro-pean Assessment Group for Lysis in the Eye study, the60% of patients with central retinal artery occlusionshowing a significant improvement in best-correctedvisual acuity underwent a 6-step therapy, whereas all ofthe treated patients in the study by Park and associatesunderwent a single-step therapy.1,5 This explains thelack of recovery of all cases of ophthalmic arteryocclusion and central retinal artery occlusion except forPatient 8.Finally, in Table 2, Park and associates reported

a summary of 11 published cases of patients with filler-associated retinal arterial occlusion.1 We identified15 cases diagnosed with blindness after cosmetic fat injec-tion of the face and 17 cases diagnosed with transitory orpermanent blindness after facial aesthetic injections ofother materials.2 We strongly agree with Park and associ-ates with regard to the retrograde embolic mechanism ofthe injected products from peripheral facial vessels intothe ophthalmic arterial system because of the deliveryof a sufficient amount of product into the vessel injectedwith a high injection pressure.1 As soon as the filler hasreached the ophthalmic artery, it may cause occlusionor can be flushed anteriorly and can block the centralretinal artery or its branches, depending on the variableparticle size.

STEFANO LAZZERI

MICHELE FIGUS

MARCO NARDI

DAVIDE LAZZERI

Pisa, ItalyTOMMASO AGOSTINI

Florence, ItalyYI XIN ZHANG

Shanghai, China

407DENCE

CONFLICT OF INTEREST DISCLOSURES: ALL AUTHORS

have completed and submitted the ICMJE Form for Disclosure ofPotential Conflicts of Interest, and none were reported.

REFERENCES

1. Park SW, Woo SJ, Park KH, Huh JW, Jung C, Kwon OK.Iatrogenic retinal artery occlusion caused by cosmetic facialfiller injections. Am J Ophthalmol 2012;154(4):653–662.

2. Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M,Lazzeri S. Blindness following cosmetic injections of the face.Plast Reconstr Surg 2012;129(4):995–1012.

3. Hayreh SS. Vascular disorders in neuro-ophthalmology. CurrOpin Neurol 2011;24(1):6–11.

4. Hayreh SS, Weingeist TA. Experimental occlusion of thecentral artery of the retina. IV: retinal tolerance time to acuteischaemia. Br J Ophthalmol 1980;64(11):818–825.

5. Schumacher M, Schmidt D, Jurklies B, et al; EAGLEStudy Group. Central retinal artery occlusion: localintra-arterial fibrinolysis versus conservative treatment, a multi-center randomized trial.Ophthalmology 2010;117(7):1367–1375.

REPLY

WEAPPRECIATE THE INTERESTOF LAZZERIANDASSOCIATES

in our recent article entitled ‘‘Iatrogenic Retinal ArteryOcclusion Caused by Cosmetic Facial Filler Injections,’’published in the American Journal of Ophthalmology.1 Weapologize if our article was not clear enough to readers;through this correspondence, we would like to clarifyvarious points.

First, Lazzeri and associates had a concern overwhether the short follow-up (3 days) of Patient 6 wasadequate to allow conclusions about this patient’soutcome. For standard cases of central retinal arteryocclusion (CRAO), we agree with their opinion. Herein,we provide outcomes for Patients 1, 4, and 6, for whomlonger follow-up durations of 302, 605, and 405 daysafter the event, respectively, apply. In all of thesepatients, their final vision was still classified as no lightperception. All 7 patients with ophthalmic artery occlu-sion caused by facial filler injections had a final visualacuity of no light perception after 6 months, which isenough time for defining final vision. Thus, the initialpresentation of blindness caused by filler-associatedophthalmic artery occlusion should be regarded as beingnearly definite, and ophthalmic artery occlusion shouldbe differentiated from CRAO, which usually is associ-ated with a remnant temporal visual field. The term rela-tive afferent pupillary defect that we used for Patient 6(Table 1) is a neuro-ophthalmologic term for the asym-metric pupillary response to light, and is not a term forthe degree of pupillary defect. In fact, Patient 6 showedno pupillary response to light at presentation. Because

408 AMERICAN JOURNAL OF

Patients 1 through 4 were in a state of pharmacologicpupillary mydriasis at the initial visit, we could not eval-uate the relative afferent pupillary defect in thesepatients.Second, regarding the intra-arterial thrombolysis

mentioned in our study, we can clarify the intervalbetween the onset of symptoms and intra-arterial throm-bolysis therapy in 4 patients: 2.5 hours in Patient 1, 2.5hours in Patient 2, 3 hours in Patient 3, and 4 hours inPatient 4. A treatment interval within 24 hours isincluded in the inclusion criteria for intra-arterial throm-bolysis for CRAO in our hospital, as mentioned in theMethods section. As Lazzeri and associates pointed out,intervention within 90 minutes after symptom onset isdifficult to conduct, because most patients are transferredfrom clinics or other hospitals. More important than thetiming of treatment was that compared with the usualsuccessful reperfusion achieved in noniatrogenic CRAOpatients (from our unpublished data), intra-arterialthrombolysis could not restore retinal perfusion inpatients with filler-associated ophthalmic artery occlu-sion. Thus, intra-arterial thrombolysis should not beconsidered as a therapeutic option for these patientscurrently.Third, Lazzeri and associates pointed out that intra-

arterial thrombolysis has significant side effects includingcerebral bleeding. In the EAGLE (European AssessmentGroup for Lysis in the Eye) trial,2 the incidence of majorcomplications, such as cerebral infarct or hemorrhage,was not different between the thrombolysis and conserva-tive treatment groups. To obtain the exact risk of majorcomplications of selective intra-arterial thrombolysis forCRAO, data from a larger sample size are required. Fromour experience, we believe that selective intra-arterialthrombolysis has a risk of cerebrovascular complicationscomparable with that of standard transfemoral cerebralangiography.Fourth, vision improvement in patients with retinal

artery occlusion caused by facial fillers should be differen-tiated according to the obstruction site and the extent ofreperfusion. It is natural that most CRAO patients expe-rience visual improvement as retinal reperfusion occurs inthe early period and functional improvement occurs inthe reversibly damaged retina. In patients withophthalmic artery occlusion resulting from cosmeticfillers, there was no retinal reperfusion in the early period(usually within 1 month), which we thought was themajor reason for the absence of visual improvement.However, in cases of CRAO and branch retinal arteryocclusion caused by facial filler injections, there waspartial visual improvement (as in noniatrogenic retinalartery occlusion). This indicates that obstruction by filleremboli was less severe than in ophthalmic artery occlu-sion. However, we cannot understand the differencebetween the 6-step therapy in the EAGLE trialmentioned by Lazzeri and associates and that used in

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