Blindness following filler injection is a devastating complication for the patient and the practitioner. In their article, Rachna Murthy and Jonathan Roos discuss the role of retrobulbar hyaluronidase for visual loss following hyaluronic acid filler injection (https://www.thepmfajournal.com/features/features/post/is-there-a-role-for-retrobulbar-hyaluronidase-in-hyaluronic-acid-vascular-embolism-related-vision-loss).
The problem with treating a condition that is rare is that inadequate reporting and lack of controlled clinical studies make it difficult to provide a definitive protocol for the use of routine retrobulbar hyaluronidase. There some animal studies and a few clinical in-vivo studies that challenge our concept of simple diffusion of hyaluronidase through the arterial wall or through the optic nerve and the ophthalmic artery to then dissolve the hyaluronic acid embolus. The consequences of an inappropriately performed retrobulbar injection reveal the dangers posed by this and therefore, they quite rightly state that it “should not be first line treatment in inexperienced hands”. The inevitable anxiety and delays associated with getting a retrobulbar injection arranged in the heat of the moment with a patient presenting in an aesthetic clinic not normally performing this procedure brings this technique into question. Unlike other emergency procedures that are practiced as part of an annual appraisal (life support / anaphylaxis), retrobulbar injections are rarely practiced annually or assessed routinely. This brings into question whether this technique should then be performed by an inexperienced practitioner.
There are a few anecdotal reports on other techniques, e.g. supra-orbital injections; these still require validation with clinical studies and are currently lacking. Maneuvers described in the paper as first line are best practice and will enable practitioners to provide safe care in the initial stages prior to handing over to the emergency ophthalmic services. Despite the overwhelming desire to “do something in the face of despair” the use of retrobulbar hyaluronidase is unlikely to be the best procedure.