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
1,2
Caroline A. Ferraz, MD, PhD
1
School of Medicine, Anhembi Morumbi University, Laureate International Universities, Sao Paulo, SP, Brazil
2
Department Ophthalmology, School of Medicine, Anhembi Morumbi University, Laureate International Universities, Sao 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 (19952015). 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

Introduction
The demand for cosmetic procedures, such as the use
of botulinum toxin and dermal fillers, has become
increasingly popular. A recent study1 about trends in
cosmetic procedures in the United States revealed that,
according to American Society of Plastic Surgeons
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-
geons, with 6.1 million and 2.0 million procedures,
respectively, being performed in 2012.
Ocular events are not often described, but it pos-
sesses great clinical relevance, as it has been already
Correspondence: Lucas H. Ricci, Rua Dr. Almeida Lima, 1.134, S~ao Paulo,
SP 03164-000, Brazil. E-mail: lucholder@hotmail.com
Accepted for publication January 17, 2015
ability of the physician is the main trigger to those
events.4,5 They could be avoided when professionals
have the knowledge of potential risks, ensure an ade-
quate protection, such as safety goggles, trained proce-
dures, experienced technique, and professional
judgment,6 preventing an irreversible effect.
Methods
A critical literature review of articles was performed.
Study analysis was conducted using three online data-
bases 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 (19952015).
For this study, the articles that described ocular
adverse effects after (1) light-emitting procedures, (2)

2015 Wiley Periodicals, Inc. 1

Ocular effects after cosmetic procedures . L H Ricci et al.
dermal fillers, and (3) botulinum toxin injection were
considered.
Two hundred and sixty-seven articles were found,
and only 88 attended to the criteria above, comprising
48 different patients. The keywords used were divided
for each topic above as follows:
 intense pulsed light, ocular effects, diode laser, ra-
diofrequency, accidental laser, and laser exposure;
 Facial fillers, dermal fillers, facial aesthetic proce-
dures, facial substances, hyaluronic acid, and ocu-
lar effects;
 Botulinum toxin, toxin A, aesthetic procedure, dip-
lopia, and ptosis.
Results and discussion
The three most common procedures are divided in top-
ics ahead. For each topic, it was designed two tables
with case reports and series of cases according to the
selected procedure and the respective ocular event.
Botulinum toxin injection was the exception, once
there are already recent major revisions about it, as
detailed in its specific topic.
Light-emitting procedures
These techniques had an increase in popularity in
recent years7 with a tendency to go on, mainly
because of its good results (in skin imperfections, as it
has been already documented,8,9 as well as corrections
of periocular defects, like vascular abnormalities10,11)
and the several reports of professional errors.12 Longer
wavelength lasers such as the 810 and 1064 nm Nd:
YAG; intense pulsed light and monochromatic excimer
light (308 nm), fractional lasers, and radiofrequency
devices have all been used safely for hair removal, pig-
mentary abnormalities, resurfacing and skin tightening
in ethnic skin, respectively. These procedures interact
through photochemical, photothermal, and photome-
chanic reactions producing great results and, sadly,
severe adverse effects when not adequately handled.
Laser devices
In clinical practice, several laser systems are currently
in use, such as alexandrite, diode, ruby and neodym-
ium: yttriumaluminumgarnet (Nd:YAG) laser,13
associated or not with carbon suspension. Other sys-
tems are being used in periocular surgeries, such as
erbium: YAG lasers. The difference between the types
of laser is essential. The shorter the wavelength, the
less deep effects it can cause,14 affecting only the
superficial area of the skin. That way, erbium: YAG
2 2015 Wiley Periodicals, Inc.
lasers can cause more intense reactions when com-
pared to alexandrite and ruby lasers, as the first one
possess a wavelength approximately 3.5 times higher
than the last two.
Ocular effects are not common, but possess remark-
able clinical repercussion. Unlike other procedures,
radiofrequency techniques do not require safety goggles,15
but ocular and vision injury is yet widely reported.
Frequent immediate responses after the procedure
include ocular pain, photophobia, and conjunctival
hyperemia.
Recent and main complications described were uveitis,
pupillary distortion, cataracts, visual field defects, macu-
lar hole, iris atrophy, posteriors synechiae, vitreous hem-
orrhage, and foveal photocoagulation.1525 Lin et al.22
reported a woman with traumatic macular hole in the
right eye after the attempt to remove freckles with alexan-
drite laser, evolving with immediate central blurred
vision. Lin et al. and Carrim et al.18,26 reported patients
with pigment dispersion and temporary increase in intra-
ocular pressure associated with eyebrow epilation with
alexandrite laser, while Gunes et al.27reported endothelial
keratic precipitates. Yalcindag and Uzun16 and Sheik
et al.28 reported patients developing anterior uveitis after
treatment with alexandrite laser, in the first, and diode
laser, in the last. Sheiks patient also presented an altered
electroretinography, suggesting a defect in photoreceptors
of peripheral retina.
It was possible to note that the most frequent ocular
effects were related to alexandrite laser, and the most
serious complications were due to diode laser.17,1922,29
Bells phenomenon and the eventual thin skin of the
eyelid were demonstrated to be the main risk factors to
ocular damage.30,31 Besides that, people with low
amount of melanin in iris stroma possess a lesser dense
layer than those with dark eyes, resulting in a thin
membrane better allowing laser penetration and, thus,
posterior structural lesions.18,26,32
Nanni et al.14,33 were among the first to call atten-
tion to adverse effects after laser procedures. Profes-
sional errors can be (and must be) distinguished from
adverse events, once the first is preventable.34 The
errors include lack of report, inaccurate information to
the patient, inadequate laser technique, and incorrect
diagnoses.35 The first attempt to correct these problems
was developed with the aid of German Society of Laser
Dermatology36.
Intense pulsed light
IPL is another common procedure used nowadays. It
consists in a flash lamp that emits bright beams of
light in brief pulses, through a small crystal slit, and,
 Ocular effects after cosmetic procedures . L H Ricci et al.

unlike lasers (with monochromatic beams), it reaches
different high lengths of amplitude and a broad spec-
trum of light waves. Although it is a technique based
on light, patients usually has a false assumption that,
unlike laser devices, there is no vision adverse
effects.35,37,38
The iris absorbs the length of this kind of light, lead-
ing to degradation of melanosomes and pigmented
lesions.39 That way, iris is highly vulnerable to IPL
damage, resulting in inflammation, atrophy, loss of
pigmentation, synechiae, and pupilar distortion.4043
Lee et al.40 reported two patients with continuous
photophobia and ocular pain, associated with pupillary
deformity enough to difficult regular activities. In three
case reports, sectorial iris lesion was noted, with pupil-
lary deformity and localized reduction in pupil dilation.
Synechiae and iris atrophy with possible muscular
lesion, with no evidence of cataracts or increased intra-
ocular pressure, were described.4143
Also, periorbital treatment with IPL may perma-
nently affect pigmented ocular structures. The short
time period of 1 h between IPL exposure and the initial
presentation indicates that the IPL exposure was the
direct cause of damage, targeting the iris. The thin iris
after IPL sector and pupillary abnormalities demon-
strated especially with pharmacologic dilation suggest
permanent structural damage due to photo ablation of
the iris dilator muscle.
As prevention, just like laser devices, all patients
should use opaque glasses with lateral protections
during procedures in the neck and facial region.
For periorbital procedures, it is recommended scleral
Table 1 Case reports: light-emitting procedures
lenses,35,40 possibly made with stainless steel, so that
the energy of IPL can be dispersed.42
All mentioned case reports and series of cases are
presented in Tables 1 and 2.
Dermal fillers
Due to its satisfactory results and minimally invasive
approach, this procedure has been widely reproduced
in aesthetic medicine. Several substances have been
considered according to its final aspects, such as autol-
ogous fat, polymethylmethacrylate (PMMA), polyalkyli-
mide and calcium hydroxylapatite fillers, polylactic and
hyaluronic acid, and the collagen itself. Although com-
plications are not often described, in recent years, some
adverse effects presented a great impact in those proce-
dures, heightening the possibility of late or immediate
iatrogenic vision loss.4446
In general, the mechanism of ocular dysfunction, in
this case, lies on arterial occlusion events, probably
related to retrograde flow due to applied pressure when
injecting the filler, as demonstrated before,47,48 result-
ing in vision loss and ophthalmoplegia. During the pro-
cedure, it is possible to hit small vessels unwillingly,
due to the extensive anastomotic connection between
the circulation of external and internal carotid systems.
At that point, the pressure of injection (for a moment,
higher than patients systolic arterial pressure) is
enough to reverse the blood flow from supratrochlear,
supraorbital, and dorsal nasal arteries back to ophthal-
mic branches, such as central retina artery, posterior
ciliary arteries, and even ophthalmic artery itself.49,50

Study Light device Type of procedure Ocular events

Brilakis et al., 200420
Herbold et al., 200521
Lin et al., 200522
Carrim et al., 200526
Sheikh et al., 200728
Hammes et al., 200715
Pang et al., 200843
Javey et al., 201042
Hong et al., 201039
Passos et al., 201141
Elkin et al., 201130
Lin et al., 201118
 et al., 201316
Yalcndag
Chen et al., 201424
Alaminos et al., 201425
Diode laser Laser eyebrow epilation Iris atrophy and nuclear cataract
Laser Laser eyebrow epilation Iris atrophy and subcapsular cataract
Alexandrite laser Laser eyebrow epilation Macular hole
Alexandrite laser Laser eyebrow epilation High intraocular pressure, pigmented dispersion
Diode laser Periocular epilation Uveitis and visual field defect
Alexandrite laser Wine port stain treatment Posterior synechiae, pupillary distortion,
iris sphincter dysfunction
Intense pulsed light Pigmented skin lesion treatment. Anterior bilateral uveitis
Intense pulsed light Pigmented skin lesion treatment. Bilateral anterior uveitis, poor pupillary motility
pupillary distortion
Intense pulsed light Periocular facial treatment Punctate epithelial erosions and corneal pigment
deposition from contact lenses
Intense pulsed light Facial cosmetic treatment Iris atrophy, anterior uveitis, posterior synechiae
Alexandrite laser Laser eyebrow epilation Iritis and iris atrophy
Alexandrite laser Periorbital cosmetic treatment Irregular oval pupil, poor pupillary motility, glare in
dim light and problems with dark adaptation
Alexandrite laser Laser epilation eyebrow Anterior uveitis
Laser Facial cosmetic treatment Inferior retinal burn and vitreous hemorrhage
Alexandrite laser Facial hair removal Foveal photocoagulation with macular injury

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Ocular effects after cosmetic procedures . L H Ricci et al.

Table 2 Series of cases: light-emitting procedures

Study Number of cases Type of procedure Main ocular events

Shulman et al., 200917 3 Eyebrow epilation/diode laser Iritis, posterior synechiae

Lee et al., 201140 2 Pigmented skin lesion Anterior uveitis and pupillary distortion
treatment/intense pulsed light
Parver et al., 201229 6 Eyebrow epilation with several Anterior uveitis, pupillary distortion, increased
kinds of laser intraocular pressure, posterior synechiae,
and transillumination defects
Gunes et al., 201527 2 Eyebrow epilation/alexandrite laser Anterior uveitis and endothelial keratic precipitates.

When considering different substances, a number of
cases can be mentioned, all related to arterial occlu-
sion, with visual impairment being transitory or even
permanent. The events appear to be more related to
applications in the forehead,51,52 glabella,53,54 or peri-
ocular sites,55 no matter the substance. Other risk fac-
tors also include technical aspects, such as professional
experience and material management.56
Fat tissue injection is one of the oldest methods for
facial filler procedures, deserving a special part for
comment. During the review, five cases5760 were ana-
lyzed and compared. In all of them, visual effect
occurred immediately after the procedure and the
patients did not regain their vision. Further neurologic
damage was also observed in three patients57,60 due to
cerebral vessels embolism.
More recently, other substances started to demon-
strate potential benefits, as well as similar adverse
effects. For hyaluronic acid, unilateral vision loss is
already well documented,51,6165 and a case of bilat-
eral vision loss is already presented.66 Treatment with
hyaluronidase has been performed in other aspects67
but no definitive result for vision recovery is known.
For calcium hydroxylapatite, vision effects are also
described68,69 and only one patient recovered sight
after treatment with corticosteroids.68 For the remain-
ing substances, vision impairment was related to
polymethylmethacrylate51,53,69 and bovine collagen.70

Table 3 Case reports: dermal fillers

Study Substance Site of injection Area of embolism

Schanz et al., 200262 Hyaluronic acid Glabella Left dorsal nasal artery
Peter and Mennel. 200263 Hyaluronic acid Glabella and cheeks Superior temporal artery
Silva and Curi. 200469 PMMA Glabella Central retinal artery and anterior
and long posterior ciliary arteries
Kubota and Hirose. 200568 PMMA Dorsum of the nose Central retinal artery
Allali et al., 200658 Autologous fat Glabella Branches of ophthalmic artery
Kang et al., 200754 Autologous fat Glabella Posterior ciliary artery
Kwon et al. 201070 Collagen Left nasal septum Left retinal artery, left distal facial
artery and distal middle cerebral artery
Sung et al., 201084 Calcium hydroxylapatite Glabella and nose base Multiple conjunctival vessels
Yoon et al., 201060 Autologous fat Glabella Left internal carotid artery
Lee et al., 201059 Autologous fat Forehead Left ophthalmic artery and left middle cerebral artery
Lee et al., 201155 Autologous fat Periocular Ophthalmic artery and left middle cerebral artery
Kim et al., 201161 Hyaluronic acid Nose base Central retina artery
He et al., 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., 199857 Autologous fat 2 Nasolabial folds, lower lip, Left middle cerebral artery,
chin and periocular region retinal and choroidal arterioles,
left ophthalmic artery
Hsieh et al., 201467 Calcium hydroxylapatite 2 Glabella and nasal bridge Central retinal artery and
chorioretinal vessels
51
Carle et al., 2014 Hyaluronic acid, autologous fat, 3 Forehead Central retinal artery and
bovine collagen, and PMMA retinal arterioles

4 2015 Wiley Periodicals, Inc.


No specific treatment is available, being the mecha-
nism of injury the same for every substance. Early rec-
ognition is one of the best goals in vision recovery,
once retinal ischemia can become irreversible after
90 min49and, thus, requiring a rapid treatment of rep-
erfusion.50,71
It is also important to quote a different complication,
other than visual loss. In a lower frequency, periocular
masses have also been described. In this case, however,
the position of the mass was the inclusion criteria for
this review, once similar formations can occur in any
region that had the injection procedure.
Narthoo et al.72 presented three cases of periocular
mass after procedure with hyaluronic acid and poly-
alkylimidefillers. For every case, histopathology con-
firmed infiltrate of substance with or without foreign
body reactions. Those events were consistent to what
have already been described as complications, such as
inflammation, granulomatous reactions, and migra-
tion.73,74 However, it is important to note that some
cases may be hidden for a long period before first clini-
cal signs, requiring a good history association, once it
is already known the possibility of migration from dis-
tant sites, and the necessity to considerate other etiolo-
gies, like orbital lymphoma.
All mentioned case reports and series of cases are
presented in Tables 3 and 4.
Botulinum toxin a injection
The occurrence of adverse effects associated with the
use of botulinum toxin was largely investigated. There
are at least eight review papers about botulin toxin
published in last 10 years,7581 one systematic review
with meta-analysis82 focusing adverse effects and a
recent review83 that investigate safety data on the
three BoNT/A formulations approved for facial aesthet-
ics from recent studies.
Systematic review of 35 articles comprising 8787
patients revealed that most common adverse events
were blepharoptosis (2.5%), brow ptosis (3.1%), and
eye sensory disorders (3%) in the upper face and lip
asymmetries and imbalances in the lower face (6.9%).
Other published article with meta-analysis reported
comprising 1003 patients showed blepharoptosis as the
most frequent adverse effect (3.39%) followed by dry
eye (2.29), dry mouth (1.99), and headache (1.59). In
this revision, brow ptosis was found just in 0.59%.
Ptosis presented the higher relative risk associated
with botulinum toxin. Diplopia, local hemorrhage, and
nausea were also described, and all adverse events of
botulin toxin were resolved spontaneously.
2015 Wiley Periodicals, Inc.
Ocular effects after cosmetic procedures . L H Ricci et al.
Conclusion
Botulinum toxin treatment, chemical peeling, laser pro-
cedures, and dermal fillers have become key tools in
the prevention and treatment of facial aging. An
understanding of the associated complications is essen-
tial to the safety of patients.
Complications of botox were mainly ptosis and
resolved spontaneously.
In general, laser procedures tend to cause uveal
damage, cataracts, and retinal lesions due to its action
on pigmented epithelium. Thermal effect is also sug-
gested and could be the cause of macular hole.
Even though intense pulsed light is not considered a
laser, the pigmented iris absorbs light in the same
wavelength range of intense pulsed light, remaining
vulnerable to this procedure.
Iris atrophy, anterior uveitis, and cataracts were the
most found adverse effect. Macular hole was a rare but
present cause of vision loss.
The most severe complications were described with
the use of dermal fillers, particularly autologous fat and
hyaluronic acid, that leads to arterial occlusion resulting
in irreversible vision loss and ophthalmoplegia.
It is imperative for physicians to be aware of these
hazards and to use the appropriate protection and
judgment to prevent ocular damage.
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