Intra-arterial hyaluronidase and thrombolysis for vision loss from hyaluronic acid filler occlusion

Introduction/Purpose In recent years, hyaluronic acid (HA) filler use has increased dramatically, along with an increase in rare but devastating ischemic complications such as vision loss. HA fillers can produce a retrograde embolism to the retinal and ophthalmic arteries causing vision‐threatening retinal ischemia. Studies have demonstrated that retinal infarction can occur within 12‐15 minutes and can lead to irreversible vision loss retinal damage irreversible vision if not addressed in a timely manner after the ischemic event (1,2). This highlights a need for reliable immediate dissolution and treatment of filler occlusion. Intra‐arterial therapy (IAT) for dissolution of filler emboli offers a fast, effective targeted neuro‐intervention to reperfuse the occluded vessels and possibly restore vision, requiring further study. We hypothesize that early IAT with hyaluronidase and additional thrombolysis can lead to better visual outcomes than later treatment of filler‐related vascular occlusions. This study seeks to evaluate efficacy of intra‐arterial hyaluronidase (HYAL) therapy for emergent management of hyaluronic acid (HA) filler‐related vision loss and other ischemic complications. Methods A meta‐analysis was conducted on existing literature on intra‐arterial therapy (IAT) with HYAL for HA filler‐related vision loss. PubMed, Scopus, Embase and Medline were used to identify these articles. Demographics, IAT protocol (HYAL concentration, thrombolytics, heparinization, time to IAT, occluded artery, recanalization outcome), adjuvant therapy, and clinical features pre/post‐IATT were compared. Results A total of 196 eligible cases were identified, including 191 cases in the literature and 5 additional unpublished cases. Successful arterial recanalization (either complete or partial) was accomplished in 94.1% of cases, with 88.27% requiring one IAT and 12.43% required a second IAT. Of those with some degree of recanalization, vision improvement was noted in 37.6% of cases. Cases with intact light perception post‐filler injection had a higher rate of vision improvement after IAT than those with no light perception (62.5% vs 30.5%, respectively). VA improvement was slightly more frequent following IAT with HYAL and thrombolytics (e.g urokinase, streptokinase, and tPA) than HYAL alone (47.7% vs. 32.5%). On average, a greater degree of visual improvement with combined HYAL and thrombolytics than HYAL alone was also observed (6.1 vs. 2.5 Snellen chart lines). Skin necrosis, ocular motility, and ptosis resolved in 100% of cases. Adverse events of intracranial hemorrhage or small acute infarct occurred in three cases. Conclusion Timely intra‐arterial hyaluronidase and thrombolysis can effectively re‐canalize filler‐occluded arteries and potentially reverse vision loss when performed before permanent damage occurs. Preserved light perception at presentation of occlusion, which may signify partial preserved retinal perfusion, is a key indicator of visual recovery after IAT. As a result, our protocol recommends prompt treatment with hyaluronidase and thrombolytic (tPA or urokinase) infused via a microcatheter into the ostium of the affected ophthalmic artery.