| |

Received: 18 December 2019    Revised: 12 February 2020    Accepted: 10 March 2020

DOI: 10.1111/jocd.13393

ORIGINAL CONTRIBUTION

The M.A.STE.R.S algorithm for acute visual loss management

after facial filler injection

Gerardo Graue MD1,2  | Dora Aline Ochoa Araujo MD1 | Cristina Plata Palazuelos MD1 |

Juan Ángel Núñez Medrano MD1 | Fernando José López San Juan MD1 | Daniela Sánchez
Pereda MD3 | Daniel Raúl Capiz Correa MD1,4 | Leopoldo de Velasco MD1,2

1
Orbit and Oculoplastic Department,
Hospital Nuestra Sra. De la Luz I.A.P.,
Mexico City, Mexico
2
Periocular Cosmetic Clinic, Hospital
Nuestra Sra. De la Luz I.A.P., Mexico City,
Mexico
3
Glaucoma Department, Hospital Nuestra
Sra. De la Luz I.A.P., Mexico City, Mexico
4
Ophthalmic Pathology Division, Hospital
Nuestra Sra. De la Luz I.A.P., Mexico City,
Mexico
Correspondence
Gerardo Graue, Orbits and Oculoplastic
Department, Hospital Nuestra Sra. de la Luz,
I.A.P., Ezequiel Montes 135, col. Tabacalera,
ZC 06030, Mexico city, Mexico.
Email: g.graue@gmail.com
Abstract
Objective: To propose an algorithm of treatment for sudden visual loss following
filler injections and perform an English-written literature search for assignment of
evidence level and grade recommendation.
Methods: Algorithm of treatment includes ocular physical Maneuvers, hyAluro-
nidase administration, intravenous STEroids, intraocular pressure Reduction, and
Supplemental Oxygen (M.A.STE .R.S) based on previous acute management reports.
Special consideration for algorithm buildup was made for ophthalmic diseases that
share physiopathological features such as central retinal artery occlusion, systemic
vasculitis affecting vision, and acute glaucoma. Finally, a systematic cross-review of
the reported cases with visual loss was done to identify the level of evidence and
grant a recommendation grade.
Results: A search through PubMed and Medscape databases for English-written
scientific papers using the terms facial filler, retinal artery occlusion, management,
treatment, complications, and adverse events quoted a total of 46 papers (190 cases)
which were then analyzed. A high variability on management for treatment of sudden
visual loss after facial filler injections was observed. This was attributed partially to
the great diversity of medical specialists performing cosmetic facial procedures such
as dermatologists, plastic surgeons, esthetic doctors and ophthalmologists, and the
lack of high evidence level studies.
Conclusions: The proposed algorithm provides an initial guideline based on prior lit-
erature reports and physiopathology involving facial filler injection complications.
Analysis identified 22 successfully treated cases with vision recovery (11.57%).
Ocular physical maneuvers had the best evidence-based level and grade recommen-
dation (A) for the management of acute vision loss secondary to facial filler injections.

KEYWORDS

central retinal artery occlusion, dermal filler complications, dermal filler injections, facial filler
adverse events, ocular complications, sudden visual loss

J Cosmet Dermatol. 2020;00:1–8. wileyonlinelibrary.com/journal/jocd© 2020 Wiley Periodicals, Inc.     1 |

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2       GRAUE et al.
1 |  I NTRO D U C TI O N
Sudden visual loss after facial filler injections represents a devastat-
ing complication that should be previewed and considered among
specialists.
Currently, there is no standardized protocol of treatment for such
cases. In the last years, a significant rise in such procedures, especially
periocular dermal fillers (mainly composed of hyaluronic acid with di-
verse reticulation levels, which makes them more or less dense) are
being used. In spite of the relative security of these products when
applied by experts, several vascular complications, including retinal
artery or vein occlusions, have been reported deriving in sudden vi-
sual loss with a poor final visual outcome. Such complications are ex-
plained by the high vascularity in this area. Superficial vascular supply
originates in the external carotid artery. Its main divisions, the facial
and superficial temporal arteries, give origin to diverse branches that
include the angular, orbito-zygomatic, and transverse arteries that are
responsible for generating a complex fine anastomotic net that irri-
gates the inferior periocular region. Deep irrigation is accomplished
by the interior carotid artery and its main division, the ophthalmic ar-
tery, that runs from the optic foramen in to the orbit and through the
facial region, branching in to the lacrimal, dorsum nasal, frontal, and
supraorbital arteries, which too form a complex fine anastomotic net
that irrigates the frontal and superior periocular regions (Figure 1A,B).
These important superficial and deep intimately related systems
of anastomotic vessels explain why accidental intravascular injec-
tion of filler materials into any of its branches can cause retrograde
migration when applied at certain pressure to the ophthalmic and
central retinal arteries, causing sudden visual loss, especially when
treating the glabellar region.1,2 This adverse event can also be ac-
companied by intense ocular pain, ptosis, ophthalmoplegia, corneal
edema, and cutaneous necrosis.3
Given that diverse medical specialists perform these procedures,
distinct managements have been reported. Taking into account level
of evidence, recommendation grade, physiopathology, and accessibil-
ity, we divided this intervention protocol by means of ocular physical
Maneuvers, hyAluronidase administration, intravenous STEroids, intra-
ocular pressure (IOP) Reduction, and Supplemental oxygen (M.A.STE
.R.S).
2 | M E TH O DS
A search through PubMed and Medscape databases was performed
using the terms facial filler injection, central retina artery occlusion,
management, treatment, complications, and adverse events.
Inclusion criteria included English-written papers published until
July 2019 that mentioned acute management for central retinal
F I G U R E 1   (A) Anatomic scheme
that represents the intimately related
superficial and deep vascular anastomotic
net in the orbit. Close-up image shows a
hyaluronic acid filler thrombus migrating
through the ophthalmic artery into smaller
retinal vessels. (B) Clinical image and
macular optic coherent tomography (OCT)
image of central retinal artery occlusion
showing internal retinal layer edema
GRAUE et al.
artery occlusion and complication management reports during facial
filler injections.
Exclusion criteria included papers mentioning vascular occlu-
sion elsewhere and complications not related with visual loss or
studies performed in animal models. MeSH terms used included
visual loss, blindness, face injections, facial esthetics, cosmetic
products, hyaluronic acid, calcium hydroxyapatite, and facial cos-
metic fillers. Additional search terms were included such as treat-
ment and management. Study type and design were considered
4
for level of evidence and recommendation grade assignment.
Finally, a cross-review of each case with visual loss was per-
formed to avoid information bias (case duplication). Patients with
vision improvement were individually analyzed; then, initial and
final visual acuity and type of treatment received was recorded
separately. (Table 1).
      3|
treatment used by means of ocular physical maneuvers, hyaluroni-
dase administration, intravenous steroids, ocular hypotensors, and
supplementary oxygen. Study design was considered to determine
level of evidence and recommendation grade (Table 2).
3.1 | Maneuvers
Ocular physical maneuvers can be rapidly performed in the office in
case of sudden visual loss following vascular occlusion. These ma-
neuvers are intended to rapidly reduce IOP with the objective to
produce a transitory dilation of the occluded artery and its branches,
forcing embolus migration into a peripheral retinal vessel and rescu-
ing central vision.

3.1.1 | Compressive ocular maneuvers

3 | R E S U LT S
This is the first step in the treatment algorithm, and it consists on
Using the terms previously described, 46 related papers (190 performing manual firm compression to the globe during 15- to
cases) were identified and divided for further analysis according to 20-second intervals followed by sudden releases. Compression can

TA B L E 1   Case reports with final visual

Case Initial management Initial VA Final VA
acuity improvement
41
1 Paracentesis 20/500 20/100
2 Intravenous steroids 42 Hand motion 20/20
43
3 Intravenous steroids 20/70 20/30
4 Intravenous steroids 44 20/200 20/25
45
5 Intravenous steroids NA NA
6 Hyperbaric oxygen46 Hand motion NA
7 IOP reduction47 NA NA
48
8 Hyaluronidase NA NA
9 Hyaluronidase 49 Finger counting NA
50
10 Hyaluronidase Visual loss NA
11 Hyaluronidase + IV steroids 40 Hand motion 20/60
12 Hyaluronidase + IV steroids51 20/63 20/32
41
13 Ocular compression + IOP reduction NA 20/63
14 Ocular compression + paracentesis52 NA 20/130
41
15 IV Steroids + IOP reduction NA 20/200
16 IV Steroids + IOP reduction53 NA 20/200
17 Ocular compression + hyaluronidase + hyperbaric NA NA
oxygen54
18 Hyaluronidase + IV steroids + IOP NLP Hand
reduction + hyperbaric oxygen55 motion
19 Paracentesis + ocular compression + hyperbaric 20/30 20/25
oxygen56
20 Ocular compression + IOP reduction + intravenous NLP NA
steroids57
21 Ocular compression + IOP reduction + IV 20/200 20/16
steroids58
22 IV steroids + hyperbaric oxygen59 20/63 NA

Note: VA in Snellen notation.

Abbreviations: NA, not available; NLP, no light perception; VA, visual acuity.
 |
4       GRAUE et al.

Vision rescue intervention
External compression of the eye
Number of studies Methodologic design
1 Meta-analysis
1 Systematic review
TA B L E 2   Published reports on
PubMed and Medscape until July 2019
with sudden visual loss secondary to facial
soft-tissue filler injections

Retrobulbar hyaluronidase
Intravenous steroids
IOP reduction
Supplementary oxygen (hyperbaric)
2 Case series
11 Case reports
1 Meta-analysis
1 Systematic review
1 Retrospective review
2 Case series
7 Case reports
12 Case series
1 Meta-analysis
1 Systematic review
2 Case series
6 Case reports
1 Meta-analysis
1 Systematic review
2 Case series
6 Case reports

Abbreviation: IOP, Intra ocular pressure.

be done with a Goldman lens as described in previous reports or 3.1.2 | Paracentesis

5
trans palpebral using two fingers. (Figure 2).
Several reports propose this maneuver alone as a first-line
treatment, and others suggest that it may be combined with other
therapeutic interventions. Some reports even compare it with the
use of systemic fibrinolytic agents for central retinal artery oc-
clusion from cardiac origin with no significant difference on final
visual outcome. 6
Main advantages of this treatment are that it may be performed
immediately after visual loss with a high-security profile and without
the need of special equipment. It can be performed on the way to an
ER for urgent ophthalmic evaluation even by the patient or a family
member.
This maneuver is performed inserting a 27-G needle through the
corneoscleral limbus in to the anterior chamber and extracting 0.1-
0.2 mL of aqueous humor.
Published reports with the use of this maneuver are focused on
vascular-origin embolus deriving in central retinal artery occlusion.7
This maneuver is accessible for ophthalmologists, and it has
demonstrated effective IOP reduction with subsequent increase in
retinal perfusion rate in up to 20%, however entails the intrinsic risk
of intraocular complications such as endophthalmitis, choroidal effu-
sion, or even choroidal detachment.8

3.1.3 | Semi-Fowler position

Semi-Fowler position can favor venous drainage of the facial and oc-
ular region through the episcleral veins, avoiding overload to the oc-
ular venous drainage system. Other positions may obstacle venous
drainage and generate relative ocular hypertension from episcleral
vein stasis. This position may be easily adopted while performing
other maneuvers. No reports were found discussing the value of this
intervention.9,10

3.2 | Hyaluronidase administration

F I G U R E 2   The picture despites the correct globe compression Hyaluronidase is the catabolic enzyme of hyaluronic acid; its use
technique with a Goldman Lens in the semi-Fowler position has been recommended in a period no longer than 60-90 minutes
GRAUE et al.
after visual loss when originated by hyaluronic acid fillers. It is usu-
ally delivered through a retrobulbar injection of 150-200 UI/mL in
2-4 mL.
Other delivery methods include intravenous (alone or in combi-
nation with urokinase) or direct injection to the supraorbital artery
11-14
by glabellar dissection. (Video S1)
Technique of retrobulbar injection should be as follows:
1. With a 25-G (1.5 inches) syringe previously filled with 200  UI
hyaluronidase, patient is asked to lean on his back and look
straight forward to a 3-feet fixed point.
2. The needle is then introduced perpendicular to the skin in the su-
peronasal orbit, taking care not to damage the eye, trochlea, or
neurovascular bundle associated in a 90-degree angle. Two thirds
of the needle are then introduced in to the orbit, and hyaluroni-
dase injection is performed slowly.
3. If not familiar with the periocular region, an easier place to in-
ject is the infratemporal quadrant, where more space for needle
introduction is available. The needle is introduced in the union
between the external and middle thirds of the inferior lid just su-
periorly to the orbital rim, perpendicular to skin. Globe displace-
ment can be done with a finger to avoid injury. After two thirds of
the needle are introduced, a 45-degree turn toward de intraconal
space and optic nerve is performed and another half inch is ad-
vanced. Finally, hyaluronidase is slowly injected in the retrobulbar
space. Needle extraction and compression of the globe is then
performed for a couple of minutes. Figure 3.
Complications such as retroocular hemorrhage may occur when
introducing large needles into the orbit. If this occurs, a canthotomy,
cantholysis, and septolysis can be performed to release intraorbital
pressure and reduce proptosis generated by the orbital compart-
ment syndrome induced.15,16
3.3 | Steroids
Intravenous steroids for retinal vascular occlusions limit retinal is-
chemic edema secondary to decreased perfusion.17
Methylprednisolone boluses up to 1000  mg have been part of
the treatment protocol in patients presenting acute vision loss sec-
ondary to vascular occlusions from other origins.
Some reports on the use of methylprednisolone 1000  mg
every 24  hrs for three consecutive days in filler-induced retinal
F I G U R E 3   Video showing the correct technique for retroocular
hyaluronidase injection (https://www.youtu​be.com/watch​? v=0Y5Kt​
edcDP​o&featu​re=youtu.be)
|
      5
artery occlusions have not shown improvement in visual acuity after
6 months follow-up.18,19
Nonetheless, steroids have shown great usefulness for acute
management of other vascular pathologies involving the optic
nerve and retina, such as optic compressive neuropathy (as seen
in Graves’ disease), optic neuritis, and small-vessel vasculitis
with an evidence level Ia and Ib and grade B recommendation,
respectively. 20-22
Blood pressure should be monitored every 15  minutes while
methylprednisolone is being infused after which central glucose
should also be measured to avoid hyperglycemia.
3.4 | Intraocular pressure reduction
Intraocular pressure reduction continues to be the gold standard
for retinal vascular flow improvement and avoidance of visual loss in
chronic optic neuropathies such as glaucoma.
Several hypotensors with diverse mechanism of action are com-
mercially available. First-line drugs include prostaglandin analogs
(being their main disadvantage to promote intraocular inflamma-
tion), carbonic anhydrase inhibitors, and beta-blockers. Second-
and third-line medications include alpha agonists and hyperosmotic
oral and intravenous drugs such as acetazolamide and mannitol. 23,24
Management of an acute glaucoma attack is focused on prompt
IOP reduction and intraocular inflammation control. Initially, top-
ical beta-blockers such as timolol 0.5% can be administered bid,
associated with an alpha agonist such as brimonidine 0.2% tid and
prednisolone acetate qid. 25 Systemic management includes oral ac-
etazolamide 250 mg qid followed by an intravenous bolus of mannitol
20% 100 ml in a 45-minute period with posterior IOP assessment.1,26
Mannitol dose can be calculated in a base of 2  g/kg, higher doses
could generate renal vasoconstriction, leading to acute renal failure.
Maximal accumulated dose to avoid this adverse effect is recom-
mended by 200 gr/day. 27 Mannitol may be administered previous to
methylprednisolone IV bolus using the same vascular access.
No target IOP   value for filler-induced vascular occlusion (with
visual loss) is available to date, and for this reason, we propose a no
higher reduction of 30% from basal IOP. We believe this goal can be
achieved with a single IV 2 gr/kg mannitol 20% dose.
Furthermore, other alternatives include ocular massage combined
with intravenous acetazolamide to reduce IOP in up to 5 mm Hg.28
According to the OHTS study (Ocular Hypertension Treatment
Study), a sustained reduction in basal IOP of 20% is recommended
to avoid glaucomatous damage to the optic nerve. 29,30
Likewise, IOP should be monitored constantly to avoid severe
hypotension (<10 mm Hg).
3.5 | Supplementary oxygen
The use of supplementary oxygen or hyperbaric oxygen chambers
when available allows improvement of plasma oxygen concentration,
6       |
Intervention
M Maneuvers (ocular compression, paracentesis, and
semi-Fowler position)
A hyaluronidase
STE Steroids (IV)
R IOP reduction (IV)
S Supplementary oxygen (hyperbaric/mask/tips)
a
Recommendation grade for optic neuritis not related to facial soft-tissue filler occlusions.
which at the same time allows for a better choroidal perfusion to the
inner retina layers.
Case reports have documented the use of higher oxygen con-
centrations for acute management of vascular filler occlusions.
Published data report the use of hyperbaric oxygen in sessions of
2 hours for up to 14 days at 253 kPa. Other case reports does not
mention hyperbaric oxygen parameters employed.
For vascular occlusions from other origin, treatment regimens of
six sessions bid divided into 3 days with a medium pressure of 2.4-
2.5 atmospheres are used. No complications have been described
with the use of this kind of therapies, and its main disadvantage is
31,32
equipment availability.
Supplementary oxygen delivered by nasal tips or mask with a no
higher flux of 5  L/min may as well increase oxygen concentration
in up to 28-44%. Oxygen mask with reservoir in a flux of 15 L/min
may increase plasma oxygen concentration to an even higher level of
60%-80% being well tolerated.33
4 |  D I S CU S S I O N
Sudden visual loss following dermal filler injection is an uncommon
yet devastating complication with a poor visual outcome in most
cases. It can be accompanied by severe recalcitrant pain that should
be addressesd  concomitantly.
After performing a search through PubMed and Medscape da-
tabases on acute management of this event, lack of controlled trials
and a high variance in therapeutic interventions are evident.
Through the M.A.STE .R.S algorithm, a sequential approach for
management of sudden visual loss is suggested by taking into ac-
count different therapeutic measures reported on scientific English-
written literature and its physiopathology, leading to a systematized
initial approach of this shocking complication.
At the time this review was completed, no high-level evidence
studies exist that allow for a high-level recommendation in such
cases. This can be explained partially because of the low incidence
or an under report of cases. It is also important to remark that the
main majority of cases have been reported in Asian population when
treating the glabellar region.
Ocular physical maneuvers (ocular compression, paracentesis,
semi-Fowler position) have the advantage of being a fast-imple-
mented intervention that can be adopted by any specialist and has a
high level of evidence (Ib, recommendation grade A).
GRAUE et al.
TA B L E 3   M.A.STE.R.S algorithm of
Recommendation grade
treatment and recommendation grade
A
C
A a 
A
B
Hyaluronidase administration allows for the application of a spe-
cific chelator substance when injecting hyaluronic acid fillers that
are the most used till date. In spite of having a low-evidence level (IV,
recommendation grade C), its use is strongly encouraged when the
causal agent is from hyaluronic acid origin.
Intravenous methylprednisolone bolus (1000  mg) diminishes
retinal edema caused by ischemia and secondary damage to reti-
nal ganglionary cells. As for other therapies discussed, the lack of
clinical trials for sudden visual loss after filler-induced occlusions
limits grade recommendation; nevertheless, considering the clinical
experience gained with IV steroids in other similar retinal vasculitic
entities, a high level of evidence (Ia) with a grade A recommendation
should be considered.
Intraocular pressure reduction is a common goal in the manage-
ment of central retinal artery occlusions no matter what the origin
might be, and in this case, ocular maneuvers and systemic hypoten-
sors such as mannitol and acetazolamide contributed importantly to
this matter.
Intraocular pressure reduction in dermal filler occlusions, com-
bined with other therapies, reached a Ib evidence level and grade A
recommendation. Nevertheless severe hypotony should be avoided
(<10 mm Hg).
Finally, hyperbaric oxygen is another therapeutic option that
can be used when available. Despite that existing reports in liter-
ature did not show a significant change in final visual outcome, a
subjective relief was mentioned by most patients (evidence level III,
grade B recommendation). If a hyperbaric chamber is not available,
supplemental oxygen delivered by nasal tips or mask can result in a
significant saturation rise, increasing its choroidal distribution and
amplifying the treatment window; however, this has not yet been
fully documented.
Other elements such as nitroglycerin (topical 2% cream) have
also been proposed when treating periocular ischemia, especially as
flap and graft rescue therapy.34-38 Its benefits are based on vasodi-
lation of small caliber arterioles; however, its penetration into the
deep orbital vessels is uncertain, and so far, no studies in humans
support its use for filler-induced central retinal artery occlusion;
however, it is an alternative for future investigation.
It is important to remark that till July 2019, only 190 cases of
visual loss after facial filler injection had been reported. Autologous
fat graft alone represented almost half of them (47%; 90 cases), fol-
lowed by hyaluronic acid with 53 cases (28%) and calcium hydroxy-
apatite, collagen, and poly lactic acid with 47 cases (25%). Only 22
GRAUE et al.
cases from the whole series improved final visual acuity after treat-
39
ment, representing 11.57% (Table 2).
While prevention is the best tool to avoid complications, some
authors have emphasis the use of blunt cannulas to avoid intravas-
cular filler injections; on the other hand, other authors argue that
sharp needles hypothetically can punch out both vessel walls making
it harder for intravascular injection. 26,29,31-32,40 Regional anatomic
knowledge and treatment by experts also contribute importantly to
complication rate reduction.
Weaknesses of this paper are the lack of evidence due to ab-
sence of clinical controlled trials that support each intervention pro-
posed by the MASTE.R.S algorithm.
Main strengths are a new staggered, evidence, physiopathology,
and experienced-based approach for this rare complication (Table 3).
Further multicenter studies are needed to corroborate its utility
and impact on final visual prognosis. Long-term follow-up should be
performed by ophthalmologist to avoid further complications.
ORCID
Gerardo Graue  https://orcid.org/0000-0001-5355-5454
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S U P P O R T I N G I N FO R M AT I O N
Additional supporting information may be found online in the
Supporting Information section.
How to cite this article: Graue G, Ochoa Araujo DA, Plata
Palazuelos C, et al. The M.A.STE.R.S algorithm for acute
visual loss management after facial filler injection. J Cosmet
Dermatol. 2020;00:1–8. https://doi.org/10.1111/jocd.13393