Failure of Retrobulbar injection of hyaluronidase in 4 cases of blindness

Author: Mike Clague Aesthetic Nurse BSC   Date Posted:16 November 2018 

Blindness after dermal filler treatment is a devastating adverse event.

We all keep discussing the retrobulbar injection of hyaluronidase as the solution that might save a patients sight.  

BUT are we all aware that there is only ONE published case of a reversal of blindness after retrobulbar injection of hyaluronidase?  Dr Cameron Chesnut published his reversal of blindness with retrobulbar injection. The patient was treated with hyaluronidase quickly which seems to be a factor. 

There are now 2 cases of reversal of blindness from many injections of hyaluronidase into the supra-orbital notch. Again the patients in these 2 cases were treated quickly with hyaluronidase. 

There is one published case of a reversal of blindness from hyaluronidase into the dorsum of the nose. (filler was injected into the nose initially).

That is the current state of play as at publication of this blog.

Efficacy of Retrobulbar Hyaluronidase Injection for Vision Loss Resulting from Hyaluronic Acid Filler Embolization

Guo-Zhang Zhu, MD, PhD; Zhong-Sheng Sun, MD; Wen-Xiong Liao, MD; Bing Cai, MD; Chun-Lin Chen, MD; Hui-Hui Zheng, MD; Li Zeng, MD; and Sheng-Kang Luo, MD, PhD

Aesthetic Surgery Journal
2018, Vol 38(1)12–22


  • 4 case studies of blindness after dermal filler injections
  • Retrobulbar injection of Hyaluronidase has not been properly assessed as a solution to blindness after HA dermal filler
  • The objective was to analyze the efficacy of a retrobulbar injection of hyaluronidase in patient who suffered blindness from HA dermal filler



Patients with vision loss caused by HA filler embolization were treated with retrobulbar hyaluronidase injection. Their visual acuity and fundoscopic images before and after treatment were analyzed for efficacy assessment.


One patient with branch retinal artery occlusion (BRAO), one patient with posterior ischemic optic neuropathy (PION), one patient with ophthalmic artery occlusion, and one patient with both BRAO and PION were treated with one or two retrobulbar injections of 1500 or 3000 units hyalu- ronidase.

No patients demonstrated substantial retinal artery recanalization or vision acuity improvement after treatment.

All patients were treated with hyaluronidase MORE THAN 4 HOURS after reporting bloindness.


One or two retrobulbar injections of 1500 to 3000 IU hyaluronidase are unable to recanalize retinal artery occlusion or improve the visual outcome of patients who presented with vision loss caused by HA filler embolization at least four hours after onset.

Read more here


Don't assume that a retrobulbar injection of hyaluronidase is definately going to reverse a case of blindness. It is still recommended to have the patient seen at a hospital and be treated with a retrobulbar injection of hyaluronidase by an expert in the eye area. 

In a case of blindness from HA filler , consider by the bedside injecting hyaluronidase into the supra-orbital notch. Repeat the hyaluronidase until you can get the patient to the hospital.  If you are not comfortable performing a retrobulbar injection then don't do it.  

To try and avoid an ischemic event with filler we teach-

  • Keep your needle tip moving at all times
  • Understand the plane where the blood vessels lay in each area you inject
  • Consider a large bore 22g cannula in areas that are risky
  • Do not treat noses, foreheads or glabellas with dermal fillers, it just isn't safe
  • Inject slowly, gentle pressure on the plunger
  • Inject small amounts less than 0.1ml
  • Avoid semi-permanent and permanent fillers - if you can't take it out, don't put it in

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