Background: Blindness or visual loss is the most serious complication resulting from facial hyaluronic acid (HA) injection. In this study, three recent clinical cases were analyzed, and the relevant anatomy of cadavers was evaluated to investigate the mechanism behind visual impairment due to HA injection. Methods: Three patients with different extents of visual loss after HA injection were studied. Ophthalmic testing and corresponding treatments were performed, and the clinical progress was observed. In addition, thirty-six fresh Asian cadaver hemifaces were anatomized to investigate the morphology of the ophthalmic artery and its branches. The minimum dose of HA for central retinal artery embolism was calculated based on the ophthalmic arterial volumes of cadavers. Results: Visual impairment was more severe in central retinal artery occlusion and combined intraocular branch occlusion than in posterior ciliary artery occlusion. During follow-up, no improvement was observed in terms of visual impairment. Cadaver study reconfirmed that the ophthalmic artery included facial and intraocular branches. The ophthalmic arterial volumes running from the supraorbital artery and supratrochlear artery to the central retinal artery were 0.083 cm³ and 0.089 cm³, respectively. Conclusions: The severity of blindness caused by HA injection may be associated with the occlusion site. Our clinical observations indicate that conventional treatments, such as retrobulbar hyaluronidase injection, are insufficient to relieve visual impairment. Injecting as little as 0.08 ml of HA into the facial branch is enough to cause central retinal artery embolism. Limiting the volume per injection could represent a simple prophylactic strategy. Level of Evidence V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Europium (Eu)-doped fluorapatite (FA) nanorods have a biocompatibility similar to that of hydroxyapatite (HA) for use as cell imaging biomaterials due to their luminescent property. Here, we discuss the new application of europium-doped fluorapatite (Eu-FA) nanorods as an anticancer drug carrier. The Eu-FA nanorods were prepared by using a hydrothermal method. The morphology, crystal structure, fluorescence, and composition were investigated. The specific crystal structure enables the effective loading of drug molecules. Doxorubicin (DOX), which was used as a model anticancer drug, effectively loaded onto the surface of the nanorods. The DOX release was pH-dependent and occurred more rapidly at pH 5.5 than at pH 7.4. The intracellular penetration of the DOX-loaded Eu-FA nanorods (Eu-FA/DOX) can be imaged in situ due to the self-fluorescence property. Treatment of melanoma A375 cells with Eu-FA/DOX elicited a more effective apoptosis rate than direct DOX treatment. Overall, Eu-FA exhibits potential for tracking and treating tumors and may be potentially useful as a multifunctional carrier system to effectively load and sustainably deliver drugs.

Background: Blindness is a rare but catastrophic complication of facial hyaluronic acid (HA) injection. Although various means to rescue visual impairment have been employed, no consensus regarding effective treatment has yet been reached. We organized a multidisciplinary team to address this emergency situation by means of endovascular hyaluronidase application. Objectives: The aim of this study was to investigate the direct delivery of hyaluronidase to ophthalmic artery occlusion through endovascular cannulation to resolve HA-induced blindness. Methods: Four patients with visual impairments caused by HA filler embolization were subjected to sequential treatments. Through superselective angiography, a microcatheter was introduced along a guidewire from the femoral artery to the ophthalmic artery to directly deliver hyaluronidase to the HA embolism. The safety and efficiency of this treatment were systematically analyzed. Results: Selective cerebral angiography demonstrated that the endovascular application of hyaluronidase significantly alleviated occlusion in 3 patients. One patient showed slight visual improvement, whereas the other patients showed no improvement in their visual function during a follow-up period of more than 3 months. One patient suffered from cerebral infarction in the left middle cerebral artery during the intervention surgery. Moreover, 2 patients showed multiple lacunar cerebral infarctions after the operation, whereas none exhibited symptoms of hemiplegia during follow-up. Conclusions: Although the endovascular application of hyaluronidase could partially recanalize the occluded branches of the ophthalmic artery, it had limited effects on restoring vision. Considering the risks of vascular intervention surgery, this approach should be considered with caution. Level of Evidence: 5:

Summary: Background: Nonsurgical injectable treatments, including hyaluronic acid (HA) fillers, are increasingly used in Asian patients.Aims: To demonstrate the efficacy and safety of Restylane Lyft compared to Restylane for the correction of nasolabial folds (NLFs).Patients/Methods: This was a randomized, evaluator‐blinded, split‐face, 12‐month study conducted in China using Restylane Lyft in the aesthetic correction of moderate to severe NLFs among adult subjects. One NLF was treated with Restylane Lyft, and the opposite NLF with the comparator Restylane. Efficacy outcomes included improvement in the Wrinkle Severity Rating Scale (WSRS) and aesthetic improvement (using the Global Aesthetic Improvement Scale [GAIS] assessed by the subject and blinded evaluator) for each treatment at Months 3, 6 (primary objective based on WSRS), 9, and 12. Safety was evaluated by the incidence of injection site reactions and adverse events (AEs).Results: A total of 100 subjects were randomized to the treatments. Noninferiority for Restylane Lyft was established according to blinded evaluation of WSRS at 6 months after last treatment. Similarly, the WSRS improved throughout the study, and the responder rate (improvement in WSRS of ≥1 grade from Baseline) was sustained after 6 months (64% and 65% for NLFs treated with Restylane and Restylane Lyft, respectively). For GAIS after 6 months, improvement was approximately 80% in both groups. No treatment‐related serious AEs were reported. The safety profiles were similar between the two treatments.Conclusions: Similar to Restylane, Restylane Lyft was effective and well tolerated for treatment of moderate to severe NLFs in this Chinese population.

Background: Vision loss is a serious complication of hyaluronic acid (HA) filler injections, and long-term observations regarding the prognosis, particularly with angiography, are rare. Objectives: This study aimed to investigate the long-term prognosis and living status of patients with visual defects due to HA filler injections. Methods: Nine patients with vision loss caused by HA filler injections and receiving different treatments were included and followed up for 2 to 6 years after their accident. Follow-ups, including outpatient ophthalmologic examinations, were performed. Results: In the follow-up observation, all patients had reintegrated into society and work. The prognosis was similar for all hyaluronidase treatments, including retrobulbar injections and superselective ophthalmic artery thrombolysis. The facial appearance was not remarkably affected, and only 3 patients reported slight scarring. Ptosis disappeared in all the patients, and slight strabismus was found in 5 patients. However, vision improvement was very limited, even in the patients whose occluded retinal central artery received reperfusion. Conclusions: This long-term follow-up showed that the patients with vision loss caused by HA filler injections could reintegrate into society after treatment. Although the embolization of the retinal central artery led to reperfusion, vision was not restored, which further demonstrated the difficulty of recovering vision with the current treatment and the importance of prophylaxis. Autohydrolysis of HA by incorporating hyaluronidase-containing stimuli-responsive nanoparticles and a dual-pipe syringe are potential future approaches to address this catastrophic event.