RESUMO
PURPOSE: To report a case of sudden unilateral visual loss and total external ophthalmoplegia combined with multifocal brain infarction following injection of hyaluronic acid (Restylane; Q-Med AB, Uppsala, Sweden) into the glabella area. CASE SUMMARY: A 25-year-old woman was referred for sudden unilateral visual loss and blepharoptosis. Visual acuity was no light perception in the right eye and 0.15 in the left eye. The best corrected visual acuity was no light perception in the right eye and 1.0 in the left eye. The right pupil was dilated and a relative afferent pupillary defect was detected. The patient showed blepharoptosis and total external ophthalmoplegia on the right side. Fundus examination revealed central retinal artery occlusion and pale disc in the right eye. The patient had developed skin necrosis and a surrounding reddish reticular pattern on her face around the glabella. She was injected with hyaluronic acid for 5 times into the glabella area. Fluorescein angiography of the right eye revealed markedly prolonged choroidal filling around the optic disc with no retinal arterial filling. Brain MRI showed multifocal punctuate acute infarction in both frontal lobes. After 2 months, ophthalmoplegia improved partially although her right eye vision did not, and 15 PD right exotropia was observed. CONCLUSIONS: Although most complications of dermal fillers are mild and transient, severe and persistent adverse effects can occur including tissue necrosis, retinal artery occlusion, and brain infarction. Therefore cosmetic procedures should be carefully performed when administering periocular dermal filler injection. A prompt consultation with an ophthalmologist is recommended when there is evidence of visual problems after injection.