Blind to the Risk: 4 Ways to Avoid Blindness from Dermal Fillers

Blind to the Risk: 4 Ways to Avoid Blindness from Dermal Fillers
15th February 2016 Beth L. Swingler

5,680% increase has been reported in the popularity of injectable cosmetic treatments over the last 25 years — a trend likely to continue. One reason for this popularity is because they are seen as ‘non-invasive’, alluding to the minimal disruption to tissue when performed competently.

However, whilst the popularity of dermal filler treatments are enjoying an almost exponential increase, so are reports of attendant complications. Although rare, complications from dermal fillers can be devastating.

The most serious complications are vascular. Vascular occlusions can lead to necrosis (tissue death), scarring, and even more seriously, blindness. Indeed, dermal fillers have already led to 98 reported cases of blindness (Beleznay et al., 2015).

In a recent literature review (Beleznay et al., 2015), Hyaluronic Acid (HA, also known under brand names Restylane®, Hydrafill®, Hylaform® and Juvederm®) was the second most common type of filler associated with ocular complications, after autologous fat injections. HA is the most frequently used soft tissue filler in cosmetic practice.

Out of 98 cases of vision complications from dermal fillers, 65 led to unilateral vision loss, and only two cases of vision loss were reversible.

Diagram dermal fillers risk

 Injection sites at highest risk were glabella, nasal region, forehead and nasolabial fold.

How can dermal filler injections induce blindness?

The basic mechanism is fairly simple: central retinal artery occlusion.

If the tip of the needle penetrates the vessel, leading to an intravascular injection, and too much pressure is applied to the plunger when injecting, the arterial pressure can be overwhelmed and retrograde movement of HA into the more proximal arterial network can occur. Eventual embolisation into the central retinal artery will deprive the retina of oxygen, and lead to blindness.

Injection Diagram

How to avoid causing blindness with dermal fillers

Soft tissue fillers are used for multiple cosmetic and therapeutic indications. Adequate clinician training in the use of these agents is essential for the prevention of adverse events.”
– Carruthers et al. (2015),  Injectable soft tissue fillers: Overview of clinical use

1. The only way to avoid arteries is to know where they are. It may seem obvious, but all clinicians delivering dermal filler injections must have an in-depth working knowledge of vascular anatomy.

In their latest guidelines on qualification requirements for delivery of non-invasive cosmetic procedures, Health Education England (HEE) recommend that courses that teach injectables such as Botulinum Toxin and dermal fillers offer 50% theoretical training. This should, of course, include facial anatomy.

One of the changes made in Part Two (.pdf) of the recommendations (2016) was to raise the level of qualification requirements for temporary dermal fillers, so that no treatments are able to be delivered until practitioners have successfully completed a qualification at level 7 (postgraduate level), at which point they would only be able to practise under clinical oversight

2. Inject slowly and incrementally. In many cases of retinal avascular necrosis, filler was injected with too much pressure.

3. Inject to the correct depth and plane, taking into account the relevant anatomy of the skin, muscle, vessels and fascia.

4. Even with all of the above, no procedure is immune to error. You must have a management strategy in place, and be able to refer the patient immediately to an ophthalmologist within the limited window of opportunity to reverse the effect – after complete central retinal artery occlusion, the retinal survival time is 60-90 minutes.

Although a quick intra-occular injection hyaluronidase has been successful in dissolving the filler and preventing permanent blindness, there is no agreed method for reversing central retinal artery occlusion from fillers. Some advanced courses will cover central retinal artery occlusion, and advise using the latest medical knowledge.

Blood vessels around the eye at risk of occlusion by fillers

Blood vessels around the eye at risk of occlusion by fillers


Awareness of risks

Googling “risks of dermal fillers” brings up the following NHS summary:

risks of dermal fillers - google search

So, with only superficial research, one might be led into thinking that beyond a minor risks, fillers are safe — regardless of who is injecting. Clearly, however, patient outcomes can be much worse.

Awareness of the risks should not only be more publically available, but also embedded in the regulatory systems of the cosmetics industry. With no formal qualifications or medical training requirement for delivery of dermal fillers, it is not surprising that some have denounced treatments like dermal fillers as a “crisis waiting to happen” (Keogh report, 2013).

“Anybody, anywhere, anytime can give a filler to anybody else, and that is bizarre”
– Sir Bruce Keogh, NHS Medical Director

Ultimately, only with proper medical training can the far more potentially devastating risks be minimised in the first place. Are you prepared for such a crisis?


Beleznay, K.,Carruthers, J. D. A.,Humphrey, S., Jones, D., (2015) Avoiding and Treating Blindness From Fillers: A Review of World Literature. Dermatologic SurgeryOctober 2015 – Volume 41 – Issue 10 – p 1097–1117 doi: 10.1097/DSS.0000000000000486

Carruthers, A., Carruthers, J., Humphrey, S., (2015) Injecting soft tissue fillers: Overview of clinical use. ©2016 UpToDate

Keogh report, 2013

Further reading:

Beleznay et al., (2014) Vascular Compromise from Soft Tissue Augmentation: Experience with 12 Cases and Recommendations for Optimal Outcomes

Health Education England guidelines: What you need to know

HEE guidelines 2016: A Brief Summary

Comments (19)

  1. Mohamed Sallam 2 years ago

    Impressive and concise

  2. ANITA ROEMPKE 1 year ago

    I wish you could publish a picture of the human face, indicating with lines, points, and also distance in cms from these dangerous points.
    thank you

  3. ANITA ROEMPKE 1 year ago

    How deep in mm:s are arteries and veins I know the Epidermis is about 1 mm, the Dermis about XX mms. I would just like to know why my beauty therapist injected the Cheeks
    until it practically touched the Cheekbones (at about the lateral line of the outer ring of the iris) and two more stitches along the lower line of the cheekbones towards the middle of the ear.

    • Author
      Beth L. Swingler 1 year ago

      Hi Anita,
      There are vessels at all depths – from periosteum (upper surface of the bone) to the dermis. Most large vessels run in the hypodermis fatty layer. Learning which vessels run in which areas in which anatomical planes (i.e. depths) will make injecting safer. Learning in terms of millimetres is not useful as skin and fatty layer thickness can vary considerably between individuals.

      However, you can be reassured that injecting onto the cheekbone for cheek filler is common practice – so your beauty therapist is not necessarily doing anything dangerous. She or he should still be aspirating, though, and we’d recommend you seek treatment (especially dermal filler treatment) from a fully-trained medical professional who has the ability to prescribe and manage complications. You may want to double check that they have hyalurondidase in their clinical supplies, too, given the low probability of devastating complications covered in this article.

  4. Jon 1 year ago

    Hey, this is dangerous stuff, i don’t care who is performing it! I will do botox Again, but never any filler to my glabella, it’s over! Hope all these Doctors have good malpractice insurance!

  5. Sally 1 year ago

    I had HA filler via canular to the temporal region to replace volume. The next day my eye had a ptosis, similar to that of botox, and had a feeling of weight on the top eyelid. It didn’t improve after swelling went. There is a small improvement after 4 months, but the eyelid is still heavy and I am aware of something different behind the eye. Is this migrated filler, is it possible to affect a nerve/muscle. My practitioner is adamant she did not. I’m hoping it will lift as filler degrades. There is still slight blurring, like a foreign object behind the eye, and a feeling of not being able to push the eyelid up. Please tell me its not permanent. Thank you.

    • Shanelle Best 11 months ago

      Hello Sally,

      We are sorry you are experiencing this, we hope you sought medical attention for this if not please do so immediately.

  6. Ron J Marinco 11 months ago

    Very disappointed, but better-informed upon hearing this. I’ve have a dent in the middle of my nasal tip and always wanted to treat it, as well as my bridge. BUT….I never knew this information regarding vision problems, and I’ve already had a torn retina in the past. I’m guessing this might put me even more at risk. Looked forward to this for a long time. Real bummer.

  7. Marie Piekarsi 11 months ago

    I have had Juvaderm many times injected by my dentist, during the last 15 years lips glabella with good results. however I am now quite afraid to continue, especially in the glabella area.

  8. Hayley 10 months ago

    The Accuvein device can help locate the individuals unique facial vascularture. Many dermatologists and nurses now use the Accuvein in the cosmetic setting.

  9. Irene harrison 9 months ago

    Hi I had had Botox an was thinking of getting filler for my lower face but after reading this is don’t think I will so is there anything else that could help add volume to this area thankyou .

  10. Ajay Vaishnav 9 months ago

    Very good knowledge shared about fillers and the point where it should not be injected

  11. Rick 9 months ago

    After reading this, that’s it for me, I am not having fillers again. I hate my wrinkles but i love my eyes more!

  12. Amena Kochnari 5 months ago

    It can locate the veins but not the arteries.

  13. Jessica Mabry 4 months ago

    I am losing the natural fullness in my tear trough area ( I’m 39). I was strongly considering fillers after seeing great results online. After reading this(and seeing those huge arteries running alongside the nose) I’m gonna pass. I am fairly good at applying makeup so I’ll just keep doing that. Thank you for the information!

    • Shanelle Best 4 months ago

      Hello Jessica, thank you for your comment. If you do decide to have a tear trough treatment done, please see a trained medical professional.

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