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
2

School of Medicine, Anhembi Morumbi University, Laureate International Universities, Sao Paulo, SP, Brazil
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

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 surgeons, with 6.1 million and 2.0 million procedures,
respectively, being performed in 2012.
Ocular events are not often described, but it possesses 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

2015 Wiley Periodicals, Inc.

demonstrated in the past.2,3 In most cases, the lack of

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 adequate protection, such as safety goggles, trained procedures, 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 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).
For this study, the articles that described ocular
adverse effects after (1) light-emitting procedures, (2)

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, radiofrequency, accidental laser, and laser exposure;
 Facial fillers, dermal fillers, facial aesthetic procedures, facial substances, hyaluronic acid, and ocular effects;
 Botulinum toxin, toxin A, aesthetic procedure, diplopia, and ptosis.

Results and discussion

The three most common procedures are divided in topics 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, pigmentary abnormalities, resurfacing and skin tightening
in ethnic skin, respectively. These procedures interact
through photochemical, photothermal, and photomechanic 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 neodymium: yttriumaluminumgarnet (Nd:YAG) laser,13
associated or not with carbon suspension. Other systems 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

lasers can cause more intense reactions when compared 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 remarkable 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, macular hole, iris atrophy, posteriors synechiae, vitreous hemorrhage, 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 alexandrite 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 intraocular 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 attention to adverse effects after laser procedures. Professional 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,

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Ocular effects after cosmetic procedures

unlike lasers (with monochromatic beams), it reaches

different high lengths of amplitude and a broad spectrum 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, leading 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 pupillary deformity and localized reduction in pupil dilation.
Synechiae and iris atrophy with possible muscular
lesion, with no evidence of cataracts or increased intraocular pressure, were described.4143
Also, periorbital treatment with IPL may permanently 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 demonstrated 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

. L H Ricci et al.

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 autologous fat, polymethylmethacrylate (PMMA), polyalkylimide and calcium hydroxylapatite fillers, polylactic and
hyaluronic acid, and the collagen itself. Although complications are not often described, in recent years, some
adverse effects presented a great impact in those procedures, 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 resulting in vision loss and ophthalmoplegia. During the procedure, 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 ophthalmic branches, such as central retina artery, posterior
ciliary arteries, and even ophthalmic artery itself.49,50

Table 1 Case reports: light-emitting procedures

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

Diode laser
Laser
Alexandrite laser
Alexandrite laser
Diode laser
Alexandrite laser

Laser eyebrow epilation

Laser eyebrow epilation
Laser eyebrow epilation
Laser eyebrow epilation
Periocular epilation
Wine port stain treatment

Pang et al., 200843

Javey et al., 201042

Intense pulsed light

Intense pulsed light

Pigmented skin lesion treatment.

Pigmented skin lesion treatment.

Hong et al., 201039

Intense pulsed light

Periocular facial treatment

Passos et al., 201141

Elkin et al., 201130
Lin et al., 201118

Intense pulsed light

Alexandrite laser
Alexandrite laser

Facial cosmetic treatment

Laser eyebrow epilation
Periorbital cosmetic treatment

 et al., 201316
Yalcndag
Chen et al., 201424
Alaminos et al., 201425

Alexandrite laser
Laser
Alexandrite laser

Laser epilation eyebrow

Facial cosmetic treatment
Facial hair removal

Iris atrophy and nuclear cataract

Iris atrophy and subcapsular cataract
Macular hole
High intraocular pressure, pigmented dispersion
Uveitis and visual field defect
Posterior synechiae, pupillary distortion,
iris sphincter dysfunction
Anterior bilateral uveitis
Bilateral anterior uveitis, poor pupillary motility
pupillary distortion
Punctate epithelial erosions and corneal pigment
deposition from contact lenses
Iris atrophy, anterior uveitis, posterior synechiae
Iritis and iris atrophy
Irregular oval pupil, poor pupillary motility, glare in
dim light and problems with dark adaptation
Anterior uveitis
Inferior retinal burn and vitreous hemorrhage
Foveal photocoagulation with macular injury

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Table 2 Series of cases: light-emitting procedures

Study

Number of cases

Type of procedure

Main ocular events

Shulman et al., 200917

Lee et al., 201140

3
2

Iritis, posterior synechiae

Anterior uveitis and pupillary distortion

Parver et al., 201229

Eyebrow epilation/diode laser

Pigmented skin lesion
treatment/intense pulsed light
Eyebrow epilation with several
kinds of laser

Gunes et al., 201527

Anterior uveitis, pupillary distortion, increased

intraocular pressure, posterior synechiae,
and transillumination defects
Anterior uveitis and endothelial keratic precipitates.

Eyebrow epilation/alexandrite laser

When considering different substances, a number of

cases can be mentioned, all related to arterial occlusion, 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 periocular sites,55 no matter the substance. Other risk factors 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 analyzed 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 demonstrate potential benefits, as well as similar adverse
effects. For hyaluronic acid, unilateral vision loss is
already well documented,51,6165 and a case of bilateral 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 remaining 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

Peter and Mennel. 200263
Silva and Curi. 200469

Hyaluronic acid
Hyaluronic acid
PMMA

Glabella
Glabella and cheeks
Glabella

Kubota and Hirose. 200568

Allali et al., 200658
Kang et al., 200754
Kwon et al. 201070

PMMA
Autologous fat
Autologous fat
Collagen

Dorsum of the nose

Glabella
Glabella
Left nasal septum

Sung et al., 201084

Yoon et al., 201060
Lee et al., 201059
Lee et al., 201155
Kim et al., 201161
He et al., 201365

Calcium hydroxylapatite
Autologous fat
Autologous fat
Autologous fat
Hyaluronic acid
Hyaluronic acid

Glabella and nose base

Glabella
Forehead
Periocular
Nose base
Glabella

Left dorsal nasal artery

Superior temporal artery
Central retinal artery and anterior
and long posterior ciliary arteries
Central retinal artery
Branches of ophthalmic artery
Posterior ciliary artery
Left retinal artery, left distal facial
artery and distal middle cerebral artery
Multiple conjunctival vessels
Left internal carotid artery
Left ophthalmic artery and left middle cerebral artery
Ophthalmic artery and left middle cerebral artery
Central retina artery
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

Nasolabial folds, lower lip,

chin and periocular region

Hsieh et al., 201467

Calcium hydroxylapatite

Glabella and nasal bridge

Hyaluronic acid, autologous fat,

bovine collagen, and PMMA

Forehead

Left middle cerebral artery,

retinal and choroidal arterioles,
left ophthalmic artery
Central retinal artery and
chorioretinal vessels
Central retinal artery and
retinal arterioles

51

Carle et al., 2014

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Ocular effects after cosmetic procedures

No specific treatment is available, being the mechanism of injury the same for every substance. Early recognition is one of the best goals in vision recovery,
once retinal ischemia can become irreversible after
90 min49and, thus, requiring a rapid treatment of reperfusion.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 polyalkylimidefillers. For every case, histopathology confirmed 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 migration.73,74 However, it is important to note that some
cases may be hidden for a long period before first clinical signs, requiring a good history association, once it
is already known the possibility of migration from distant sites, and the necessity to considerate other etiologies, 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 aesthetics 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.

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. L H Ricci et al.

Conclusion
Botulinum toxin treatment, chemical peeling, laser procedures, and dermal fillers have become key tools in
the prevention and treatment of facial aging. An
understanding of the associated complications is essential 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 suggested 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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