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Review Article

Journal of Cosmetic Dermatology, 0, 1--7

Ocular adverse effects after facial cosmetic procedures: a review of
case reports
€ derberg,1 &
Lucas H. Ricci,1 Samia V. Navajas,1 Paula R. Carneiro,1 Stephanie A. So
Caroline A. Ferraz, MD, PhD
School of Medicine, Anhembi Morumbi University, Laureate International Universities, São Paulo, SP, Brazil
Department Ophthalmology, School of Medicine, Anhembi Morumbi University, Laureate International Universities, São Paulo, SP, Brazil

Summary To review indexed literature concerning adverse ocular effects of the most common
aesthetic facial procedures (light-emitting therapy, dermal fillers injection, and
botulinum toxin). Literature search using three online databases – PubMed, SciELO,
and Capes – selecting case reports, series of cases and reviews, with no language
restriction, published in a period of the last twenty years (1995–2015). After reviewing
48 case reports and most recent reviews, the authors found the most common ocular
adverse effects of dermal fillers were related to vascular occlusion; light-emitting
therapy was associated with pigmented tissue damage leading to anterior uveitis and
iris atrophy, and ptosis presented the higher relative risk associated with botulinum
toxin. Even though ocular adverse effects are not very frequent, some of them can lead
to permanent ocular dysfunction and visual impairment. Professionals involved in
cosmetic procedures should be aware of the risks.
Keywords: intense pulsed light, radiofrequency, dermal fillers, botulinum toxin, facial
cosmetics, ocular effects

demonstrated in the past.2,3 In most cases, the lack of
ability of the physician is the main trigger to those
The demand for cosmetic procedures, such as the use events.4,5 They could be avoided when professionals
of botulinum toxin and dermal fillers, has become have the knowledge of potential risks, ensure an ade-
increasingly popular. A recent study1 about trends in quate protection, such as safety goggles, trained proce-
cosmetic procedures in the United States revealed that, dures, experienced technique, and professional
according to American Society of Plastic Surgeons judgment,6 preventing an irreversible effect.
report, there has been a 680% increase in the cosmetic
use of botulinum toxin type A and a 205% increase in
soft tissue fillers from 2000 to 2012 among plastic sur- Methods
geons, with 6.1 million and 2.0 million procedures, A critical literature review of articles was performed.
respectively, being performed in 2012. Study analysis was conducted using three online data-
Ocular events are not often described, but it pos- bases – PubMed, SciELO, and Capes – selecting case
sesses great clinical relevance, as it has been already reports, series of cases and reviews, with no language
restriction, published in a period of the last twenty
Correspondence: Lucas H. Ricci, Rua Dr. Almeida Lima, 1.134, S~ao Paulo, years (1995–2015).
SP 03164-000, Brazil. E-mail: For this study, the articles that described ocular
Accepted for publication January 17, 2015 adverse effects after (1) light-emitting procedures, (2)

© 2015 Wiley Periodicals, Inc. 1

27reported endothelial detailed in its specific topic. right eye after the attempt to remove freckles with alexan- ics ahead. people with low light (308 nm). pupillary distortion. Nanni et al. but possess remark- for each topic above as follows: able clinical repercussion. with pigment dispersion and temporary increase in intra- Botulinum toxin injection was the exception. dermal fillers. and diode Light-emitting procedures laser. facial substances. For each topic. such as erbium: YAG lasers. once the first is preventable. photothermal. comprising than the last two.Ocular effects after cosmetic procedures . radiofrequency techniques do not require safety goggles.8. the IPL is another common procedure used nowadays. ocular effects. Other sys. aesthetic procedure. resurfacing and skin tightening membrane better allowing laser penetration and. diode laser. it was designed two tables drite laser.14. fractional lasers. and foveal photocoagulation. tion to adverse effects after laser procedures.17.15–25 Lin et al. hyaluronic acid. and photome. hyperemia. It less deep effects it can cause. and. tems are being used in periocular surgeries. in the last.22 Results and discussion reported a woman with traumatic macular hole in the The three most common procedures are divided in top. as alexandrite laser. Lin et al. pig. The keywords used were divided Ocular effects are not common. through a small crystal slit. inadequate laser technique. like vascular abnormalities10.5 times higher and only 88 attended to the criteria above. and conjunctival lar effects.12 Longer Bell’s phenomenon and the eventual thin skin of the wavelength lasers such as the 810 and 1064 nm Nd: eyelid were demonstrated to be the main risk factors to YAG. Inc.19–22. iris atrophy. Frequent immediate responses after the procedure dures. and radiofrequency amount of melanin in iris stroma possess a lesser dense devices have all been used safely for hair removal. ruby and neodym. 48 different patients. Dermatology36. lopia. ra. as it It was possible to note that the most frequent ocular has been already documented. cataracts. Profes- severe adverse effects when not adequately handled. The shorter the wavelength. and Carrim et al. intense pulsed light and monochromatic excimer ocular damage. facial aesthetic proce.  intense pulsed light. accidental laser. but ocular and vision injury is yet widely reported. Recent and main complications described were uveitis.11) serious complications were due to diode laser.14 affecting only the consists in a flash lamp that emits bright beams of superficial area of the skin.26 reported patients selected procedure and the respective ocular event. pared to alexandrite and ruby lasers. include ocular pain. and the most of periocular defects.33 were among the first to call atten- chanic reactions producing great results and. and laser exposure. diagnoses. vitreous hem- orrhage.18. once ocular pressure associated with eyebrow epilation with there are already recent major revisions about it. L H Ricci et al.35 The first attempt to correct these problems ium: yttrium–aluminum–garnet (Nd:YAG) laser. photophobia. suggesting a defect in photoreceptors recent years7 with a tendency to go on.28 reported patients developing anterior uveitis after treatment with alexandrite laser.9 as well as corrections effects were related to alexandrite laser. keratic precipitates. mainly of peripheral retina. macu- lar hole. several laser systems are currently the patient. dip.32 through photochemical. sadly. possess a wavelength approximately 3.29 and the several reports of professional errors. as the first one Two hundred and sixty-seven articles were found.15 diofrequency. thus.13 was developed with the aid of German Society of Laser associated or not with carbon suspension. and ptosis. Unlike other procedures. Sheik’s patient also presented an altered These techniques had an increase in popularity in electroretinography. inaccurate information to In clinical practice. erbium: YAG light in brief pulses. The difference between the types Intense pulsed light of laser is essential. evolving with immediate central blurred with case reports and series of cases according to the vision. and incorrect in use. toxin A. because of its good results (in skin imperfections. . That way.18.26.31 Besides that. layer than those with dark eyes. dermal fillers.  Botulinum toxin. while Gunes et al. diode.34 The Laser devices errors include lack of report. Yalcßindag and Uzun16 and Sheik et al. visual field defects. in the first. and ocu.30. in ethnic skin. posteriors synechiae. and (3) botulinum toxin injection were lasers can cause more intense reactions when com- considered. resulting in a thin mentary abnormalities. 2 © 2015 Wiley Periodicals. such as alexandrite. These procedures interact posterior structural lesions. sional errors can be (and must be) distinguished from adverse events. respectively.  Facial fillers.

pupillary distortion. it is possible to hit small vessels unwillingly.39 That way. The thin iris cedure.. the energy of IPL can be dispersed.. some lary deformity and localized reduction in pupil dilation. there is no vision adverse effects. loss of in aesthetic medicine. unlike lasers (with monochromatic beams). sectorial iris lesion was noted. associated with pupillary mide and calcium hydroxylapatite fillers.35.. Although it is a technique based All mentioned case reports and series of cases are on light. in Also. all patients enough to reverse the blood flow from supratrochlear.. probably nently affect pigmented ocular structures. Bilateral anterior uveitis. plications are not often described. Ocular effects after cosmetic procedures . polylactic and deformity enough to difficult regular activities.40 reported two patients with continuous ogous fat. The short related to retrograde flow due to applied pressure when time period of 1 h between IPL exposure and the initial injecting the filler.50 Table 1 Case reports: light-emitting procedures Study Light device Type of procedure Ocular events Brilakis et al. 201425 Alexandrite laser Facial hair removal Foveal photocoagulation with macular injury © 2015 Wiley Periodicals. 200728 Diode laser Periocular epilation Uveitis and visual field defect Hammes et al.38 Dermal fillers The iris absorbs the length of this kind of light. and even ophthalmic artery itself. glare in dim light and problems with dark adaptation  et al.44–46 ocular pressure.. 200526 Alexandrite laser Laser eyebrow epilation High intraocular pressure. Although com- case reports. after IPL sector and pupillary abnormalities demon. resulting in inflammation.37. In three hyaluronic acid.. posterior For periorbital procedures. in recent years. it is recommended scleral ciliary arteries. Inc. iatrogenic vision loss. 200420 Diode laser Laser eyebrow epilation Iris atrophy and nuclear cataract Herbold et al.. and pupilar distortion. 201042 Intense pulsed light Pigmented skin lesion treatment. such as central retina artery. Anterior bilateral uveitis Javey et al. this case. presented in Tables 1 and 2. the iris dilator muscle.. so that different high lengths of amplitude and a broad spec. should use opaque glasses with lateral protections supraorbital. the pressure of injection (for a moment. mic branches. and dorsal nasal arteries back to ophthal- during procedures in the neck and facial region. synechiae. such as autol- Lee et al. anterior uveitis. the mechanism of ocular dysfunction. 200715 Alexandrite laser Wine port stain treatment Posterior synechiae... with pupil.40 possibly made with stainless steel.42 trum of light waves. adverse effects presented a great impact in those proce- Synechiae and iris atrophy with possible muscular dures. with no evidence of cataracts or increased intra. 201316 Yalcßındag Alexandrite laser Laser epilation eyebrow Anterior uveitis Chen et al. lies on arterial occlusion events.. unlike laser devices.47. patients usually has a false assumption that.48 result- presentation indicates that the IPL exposure was the ing in vision loss and ophthalmoplegia. pigmented dispersion Sheikh et al. polyalkyli- photophobia and ocular pain. lead- ing to degradation of melanosomes and pigmented Due to its satisfactory results and minimally invasive lesions. it reaches lenses.. just like laser devices. 200521 Laser Laser eyebrow epilation Iris atrophy and subcapsular cataract Lin et al. periorbital treatment with IPL may perma. 3 .41–43 In general. iris is highly vulnerable to IPL approach. 201039 Intense pulsed light Periocular facial treatment Punctate epithelial erosions and corneal pigment deposition from contact lenses Passos et al. higher than patient’s systolic arterial pressure) is As prevention.. heightening the possibility of late or immediate lesion. L H Ricci et al.. targeting the iris. 200843 Intense pulsed light Pigmented skin lesion treatment. 201118 Alexandrite laser Periorbital cosmetic treatment Irregular oval pupil. polymethylmethacrylate (PMMA). iris sphincter dysfunction Pang et al.40–43 considered according to its final aspects. 201130 Alexandrite laser Laser eyebrow epilation Iritis and iris atrophy Lin et al. were described. this procedure has been widely reproduced damage..49. 201141 Intense pulsed light Facial cosmetic treatment Iris atrophy. During the pro- direct cause of damage. 201424 Laser Facial cosmetic treatment Inferior retinal burn and vitreous hemorrhage Alaminos et al. atrophy. 200522 Alexandrite laser Laser eyebrow epilation Macular hole Carrim et al. posterior synechiae Elkin et al. and the collagen itself. Several substances have been pigmentation. poor pupillary motility pupillary distortion Hong et al. due to the extensive anastomotic connection between strated especially with pharmacologic dilation suggest the circulation of external and internal carotid systems. as demonstrated before.35. permanent structural damage due to photo ablation of At that point. poor pupillary motility.

. pupillary distortion. unilateral vision loss is ocular sites. lower lip. vision effects are also comment. posterior synechiae.. sion. a number of damage was also observed in three patients57. . Inc. with visual impairment being transitory or even More recently. 201140 2 Pigmented skin lesion Anterior uveitis and pupillary distortion treatment/intense pulsed light Parver et al.70 Table 3 Case reports: dermal fillers Study Substance Site of injection Area of embolism Schanz et al. Left middle cerebral artery.. and PMMA retinal arterioles 4 © 2015 Wiley Periodicals. 201527 2 Eyebrow epilation/alexandrite laser Anterior uveitis and endothelial keratic precipitates.51. 201060 Autologous fat Glabella Left internal carotid artery Lee et al. left distal facial artery and distal middle cerebral artery Sung et al. five cases57–60 were ana.61–65 and a case of bilat- tors also include technical aspects. such as professional eral vision loss is already presented. When considering different substances. Table 2 Series of cases: light-emitting procedures Study Number of cases Type of procedure Main ocular events Shulman et al.68 For the remain- occurred immediately after the procedure and the ing substances. 3 Forehead Central retinal artery and bovine collagen. visual effect after treatment with corticosteroids.52 glabella. 200754 Autologous fat Glabella Posterior ciliary artery Kwon et al. left ophthalmic artery Hsieh et al.. other substances started to demon- permanent. already well documented.. 200917 3 Eyebrow epilation/diode laser Iritis. For hyaluronic acid..69 and bovine collagen. 201059 Autologous fat Forehead Left ophthalmic artery and left middle cerebral artery Lee et al. effects. cerebral vessels embolism. facial filler procedures. 201155 Autologous fat Periocular Ophthalmic artery and left middle cerebral artery Kim et al. 200469 PMMA Glabella Central retinal artery and anterior and long posterior ciliary arteries Kubota and Hirose. During the review. 199857 Autologous fat 2 Nasolabial folds.54 or peri... L H Ricci et al. Further neurologic polymethylmethacrylate51. 200658 Autologous fat Glabella Branches of ophthalmic artery Kang et al.66 Treatment with experience and material management. chin and periocular region retinal and choroidal arterioles.53. deserving a special part for For calcium hydroxylapatite. all related to arterial occlu. and transillumination defects Gunes et al....69 and only one patient recovered sight lyzed and compared. 201084 Calcium hydroxylapatite Glabella and nose base Multiple conjunctival vessels Yoon et al. Other risk fac. 200262 Hyaluronic acid Glabella Left dorsal nasal artery Peter and Mennel. In all of them.53. increased kinds of laser intraocular pressure. 200568 PMMA Dorsum of the nose Central retinal artery Allali et al. 201467 Calcium hydroxylapatite 2 Glabella and nasal bridge Central retinal artery and chorioretinal vessels 51 Carle et al. 2014 Hyaluronic acid. as well as similar adverse applications in the forehead. 201070 Collagen Left nasal septum Left retinal artery.60 due to cases can be mentioned. vision impairment was related to patients did not regain their vision.56 hyaluronidase has been performed in other aspects67 Fat tissue injection is one of the oldest methods for but no definitive result for vision recovery is known. posterior synechiae Lee et al.. 201161 Hyaluronic acid Nose base Central retina artery He et al.51. The events appear to be more related to strate potential benefits..Ocular effects after cosmetic procedures . described68.55 no matter the substance.. 201229 6 Eyebrow epilation with several Anterior uveitis.. 200263 Hyaluronic acid Glabella and cheeks Superior temporal artery Silva and Curi.. 201365 Hyaluronic acid Glabella Central retina artery Table 4 Series of cases: dermal fillers Study Substances Number of cases Site of injection Area of embolisms Feinendegen et al. autologous fat.

Systematic review of 35 articles comprising 8787 4 Davalbhakta AV. local hemorrhage. Cosmetic surgery—light makes it right. hyaluronic acid. eye sensory disorders (3%) in the upper face and lip 5 Fulton JE Jr. Ann Plast Surg 1998.74 However. No specific treatment is available. In 8 Apfelberg DB. Botulinum toxin treatment. and migra. other than visual loss. 24: 615–6. and 2013. For every case. It is imperative for physicians to be aware of these All mentioned case reports and series of cases are hazards and to use the appropriate protection and presented in Tables 3 and 4. An erfusion.75–81 one systematic review 2 Liu HF. Gao GH. Methods of asymmetries and imbalances in the lower face (6.59%.9%). Erbium:YAG laser skin resurfacing: preliminary botulin toxin were resolved spontaneously. 56: 711–6. tial to the safety of patients. histopathology con. published in last 10 years. ics from recent studies. prevention and management. Early rec- ognition is one of the best goals in vision recovery. clinical evaluation. dry mouth (1.1%). Ocular effects after cosmetic procedures . such as Iris atrophy. the pigmented iris absorbs light in the same firmed infiltrate of substance with or without foreign wavelength range of intense pulsed light. Ann Plast Surg with botulinum toxin. Raulin S. Thermal effect is also sug- Narthoo et al. laser. In a lower frequency. 7 Booth C. requiring a rapid treatment of rep. have already been described as complications. J Clin are at least eight review papers about botulin toxin Aesthet Dermatol 2014. resolved spontaneously. Unfavourable results in facial rejuvena- patients revealed that most common adverse events tion surgery: how to avoid them. in irreversible vision loss and ophthalmoplegia. cataracts.50. brow ptosis (3. the prevention and treatment of facial aging. Health Phys 1989. Greve B.39%) followed by dry 1999. judgment to prevent ocular damage. Middle cerebral recent review83 that investigate safety data on the artery embolism and unilateral visual loss after autolo- three BoNT/A formulations approved for facial aesthet. 46: 359–64. The ultra-pulse carbon dioxide laser with this revision. mass after procedure with hyaluronic acid and poly. anterior uveitis. There of neurotoxins and dermal fillers by US physicians. Complications of laser resurfacing. nausea were also described. Wu DC et al. Diplopia. that leads to arterial occlusion resulting tant sites. most found adverse effect. cases may be hidden for a long period before first clini. Macular hole was a rare but tion. Time most frequent adverse effect (3.99). Ocular injuries from acci- dental laser exposure. Indian J Plast Surg were blepharoptosis (2. Arroyo R. brow ptosis was found just in 0. and headache (1. 40: 328–34. laser pro- once retinal ischemia can become irreversible after cedures. Trends in the use use of botulinum toxin was largely investigated. with meta-analysis82 focusing adverse effects and a 3 Egido JA. 154: 69–71. The most severe complications were described with cal signs. Marcos A et al. the position of the mass was the inclusion criteria for In general. L H Ricci et al.71 understanding of the associated complications is essen- It is also important to quote a different complication. periocular Complications of botox were mainly ptosis and masses have also been described. Inc. it is important to note that some present cause of vision loss. chemical peeling. on pigmented epithelium. remaining body reactions. being the mecha- Conclusion nism of injury the same for every substance. 24: 91. gous fat injection into the glabellar area. however. and all adverse events of 9 Bass LS.29). particularly autologous fat and is already known the possibility of migration from dis.5%). like orbital lymphoma. and the necessity to considerate other etiolo. once it the use of dermal fillers. Huang KE. Stroke 1993. laser procedures tend to cause uveal this review.72 presented three cases of periocular gested and could be the cause of macular hole. 28: 100–2. In this case. © 2015 Wiley Periodicals. once similar formations can occur in any damage. and retinal lesions due to its action region that had the injection procedure. 5 . Botulinum toxin a injection References The occurrence of adverse effects associated with the 1 Sandoval LF. and dermal fillers have become key tools in 90 min49and.59). gies.73. Other published article with meta-analysis reported 6 Raulin C. Lasers Surg Med 2001. Those events were consistent to what vulnerable to this procedure. and cataracts were the inflammation. requiring a good history association. 36: 522–9. eye (2. granulomatous reactions. thus. Davis SA et al. and 1996. Ethical considerations con- comprising 1003 patients showed blepharoptosis as the cerning laser medicine. the computer pattern generator automatic scanner for Ptosis presented the higher relative risk associated facial cosmetic surgery and resurfacing. Even though intense pulsed light is not considered a alkylimidefillers. Dermatol Surg 1998. 7: 14–9.

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