Cosmetic procedures associated with serious ophthalmologic complications

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Minimally invasive cosmetic procedures that include dermal fillers, botulinum toxin injections, autologous fat grafting, intense pulsed light (IPL) treatments, and platelet-rich plasma (PRP) treatments are popular and generally safe. However, according to a recent report, these procedures can result in rare but serious ophthalmological complications, such as central retinal artery occlusion (RAO) and ischemic optic neuropathy.¹

Other consequences that have varying degrees of severity and reversibility include diplopia, ptosis, dry eye, and orbital cellulitis, according to Lucía De-Pablo-Gómez-de-Liaño, MD, PhD, first author. She is from the Department of Ophthalmology, Hospital Universitario 12 de Octubre; Department of Immunology, Ophthalmology and ENT, Faculty of Optics, Complutense University of Madrid; and Centro Internacional de Oftalmología Avanzada, all in Madrid.

The researchers published their results in the Journal of Clinical Medicine.

RAO caused by inadvertent intravascular filler injection is the most catastrophic event, often resulting in irreversible vision loss.^2-6 The first clusters of filler-induced blindness were reported in the early 2010s (many in East Asia), and by 2015, a literature review had already compiled 98 cases worldwide.⁷ Since then, dozens of additional cases have been published, indicating that while the absolute risk is very low, the growing volume of procedures means ophthalmologists and aesthetic practitioners will inevitably encounter such complications,^8-11 the investigators explained, emphasizing the importance of recognition of potential complications.

They conducted a narrative review and summarized the incidence, mechanisms, clinical features, risk factors, diagnostic approaches, and management strategies of ocular complications associated with aesthetic medical procedures in their report.¹ The literature review emphasized data from clinical studies, case series, and expert consensus published between 2015 and 2025.

Key messages

The investigators compiled a list of clinical and preventive insights from their review.

• “Ophthalmologic complications from aesthetic procedures, though rare, can be severe and irreversible. Prevention is paramount, as effective treatments are often limited.
• RAO due to filler embolism is the most devastating complication. Even with prompt treatment, vision prognosis is usually poor. Early recognition and urgent intervention (within minutes) are essential to attempt to mitigate visual damage.
• Injections in high-risk facial zones (eg, glabella, nasal dorsum) have the greatest risk of vision-threatening complications. Use extreme caution if treating these areas (or consider avoiding them for fillers).
• Employ safe injection techniques: whenever possible, use microcannulas instead of sharp needles in high-risk areas, inject slowly with minimal pressure (e.g., thumb on plunger), and aspirate before injecting (recognizing that aspiration is not 100% reliable). Small aliquots (<0.1 ml) can reduce the chance of large emboli.
• Proper injector training and anatomic knowledge are critical. Many severe complications occurred with injectors lacking specific oculofacial anatomy training. Practitioners should be credentialed and thoroughly trained, especially when operating near the eyes.
• Informed consent is essential. Patients should be made aware of even the rare risks (blindness, stroke, etc.) before undergoing procedures.
• Be prepared: have a “filler complication kit” ready (e.g., hyaluronidase, aspirin) and an emergency referral pathway to an ophthalmologist on call. At the first sign of visual symptoms, stop injection immediately and initiate emergency management.
• Even non-injectable treatments can cause ocular injury. Ensure eye protection (eg, metal corneal shields) during IPL or laser procedures near the eyes. Improper use of these devices can lead to serious complications like corneal burns, uveitis, iris atrophy, or cataract.
• Botulinum toxin complications (ptosis, diplopia) are usually transient and self-limited. Use precise technique (eg, avoid injecting too close to the orbital rim, correct dosing) to minimize these side effects.
• No guaranteed ‘antidote’ exists for many of these complications. Once a filler embolus causes ischemia or a toxin diffuses improperly, reversing the damage is difficult. Thus, prevention remains the main strategy and is far better than any cure.”

In their conclusion, the investigators urged eye care clinicians to remain alert to complication and collaborate closely. “Early detection, prompt intervention, and proper referral can reduce the impact of complications. Continued research and reporting are essential to improve management protocols and develop new strategies, such as better filler formulations or antidotes, to enhance patient safety. The experiences of the past decade have turned previously obscure complications into well-understood clinical issues with evolving standards of care. By applying this knowledge in practice, we can ensure that aesthetic improvements are not only attractive but also safe for our patients’ eyes.”

References

1. De-Pablo-Gómez-de-Liaño L, Ly-Yang F, Burgos-Blasco B, Fernández-Vigo J. Ophthalmological Complications of Aesthetic Medicine Procedures: A Narrative Review. J Clin Med. 2025;14:5399. https://doi.org/10.3390/ jcm14155399

2. Zhao F, Chen Y, He, D, You X, Xu Y. Disastrous cerebral and ocular vascular complications after cosmetic facial filler injections: A retrospective case series study. Sci Rep. 2024;14:3495.

3. Park SW, Woo SJ, Park K.H, Huh JW, Jung C, Kwon O. Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections. Am J Ophthalmol. 2012;154:653–662.e1.

4. Kim YK, Jung C, Woo SJ, Park KH. Cerebral angiographic findings of cosmetic facial filler-related ophthalmic and retinal artery occlusion. J Korean Med Sci. 2015;30:1846–55.

5. Ansari ZA, Choi CJ, Rong AJ, Erickson BP, Tse DT. Ocular and cerebral infarction from periocular filler injection. Orbit. 2019;38:322–4.

6. Lee YJ, Woo SJ. Long-term outcomes of ophthalmic and retinal artery occlusion after cosmetic facial filler injection. Aesthetic Surg J. 2022;42:196–204.

7. Beleznay K, Carruthers JD, Humphrey S, Jones D. Update on avoiding and treating blindness from fillers: a recent review of the world literature. Aesthetic Surg J. 2019;39:662-74.

8. Wang Y, Massry GG, Holds JB. Complications of periocular dermal fillers. Facial Plast Surg Clin North Am. 2021;29:349–57.

9. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Invest Dermatol. 2013;6:295–316.

10. Botha VE, Insull EA. Causes and management of sight-threatening complications of dermal filler injections: A review. Clin Exp Ophthalmol. 2024;52:365–73.

11. Mortada H, Seraj H, Barasain O, Bamakhrama B, Alhindi NI, Arab K. Ocular complications post-cosmetic periocular hyaluronic acid injections: A systematic review. Aesthetic Plast Surg. 2022;46:760–73.