Retinal Tear and Detachment: A Rare Complication of Temporal Filler Injection

Speaker Identity: Cath Porter, a cosmetic physician based at the All Saint Clinic in Double Bay.
Professional Standing: Possesses over 26 years of experience ( $20 + 6$ years) in the field of cosmetic medicine.
Disclosure: The speaker was compensated for a medicolegal report associated with this specific case, which led to her awareness of it. The case has since been published in formal ophthalmological literature.
Topic Focus: Visual loss following temporal filler injection, specifically focusing on a mechanism other than the traditional arterial embolism.

Vascular Communication: Visual disturbance typically occurs via arterial embolism following dermal filler injection.
Relevant Arterial Pathways in the Temporal Area: * Superficial temporal artery. * Deep temporal artery. * Zygomatico temporal artery.
Anastomosis: These complications occur where the external carotid circulation has communications or anastomosis with the internal carotid circulation.
Mechanism of Embolism: * Injection Pressure: The practitioner injects filler into an artery with sufficient force to overcome the internal arterial pressure. This pushes the filler (implant) backward (retrograde) through the vessel into the internal carotid or ophthalmic artery. * Post-Injection Embolization: As the injection pressure ceases, the natural arterial pressure then embolizes the filler forward through these vessels. * Clinical Consequence: If the filler enters the ophthalmic artery and reaches the central retinal artery, it results in visual impairment that can be irreversible.

Significance: This is the first documented case in medical history of a retinal tear and detachment resulting from dermal filler injection.
Patient Profile: A 55-year-old female.
Procedure Details: * Material: Hyaluronic acid (HA) filler. * Location: Left temporal fossa. * Technique: Deep technique, also known as the "gunshot" technique, involving needle on bone (referred to as "one up, one over").
Immediate Clinical Presentation: * Blurred and decreased vision in the left eye shortly after injection. * Vision appeared to improve over the subsequent hour. * Pupils were found to be equal and reactive to light and accommodation. * No definitive reports of flashes or floaters were noted initially. * Because the vision showed signs of improvement, the patient was sent home.
Delayed Presentation: * Two days post-procedure, the patient continued to complain of blurred vision in the left eye. * The prescribing doctor organized an optometry review.

Optometric Referral: The optometrist referred the patient to an eye hospital upon identifying severe pathology.
Pathological Findings: * Large stellate (star-shaped) retinal tear. * Associated retinal detachment in the temporal quadrant. * Severely decreased visual acuity on the affected side. * Evidence of a small, round, needle-sized, full-thickness scleral laceration located in the center of the tear.
Surgical Procedure: Pars Plana Vitrectomy: * Surgeons performed a pars plana vitrectomy to address the detachment. * They identified a significant amount of jelly-like material within the vitreous and at the subretinal space adjacent to the retinal tear. * Intraoperative video footage demonstrates the aspiration (sucking out) of this filler material from the area behind the tear.

The Pterion: The underlying bone in the temporal region where the injection occurred. It is the convergence point of four sutures: * Frontal bone. * Sphenoid bone. * Parietal bone. * Squamous temporal bone.
Bone Morphology and Stability: Variability in the morphology of these sutures can result in significantly reduced bone stability in the area.
Bone Thickness Statistics: Studies looking at intracranial penetration risk have shown that the thickness of the pterion varies from $1\,mm$ through to $5\,mm$ .
The Specific Mechanism in this Case: The practitioner inadvertently pushed the needle through a weak or exceptionally thin ( $1\,mm$ ) portion of the pterion. Due to the specific location and force, the needle penetrated the orbit, causing the scleral laceration and subsequent retinal detachment.

Informed Consent: Retinal detachment must now be included in the informed consent process as a potential complication of dermal filler, particularly for injections in the orbital and temporal regions.
Urgency of Referral: Practitioners must seek urgent ophthalmology review for any visual disturbance post-filler, even if the vision appears to be improving. Delay in specialized care can affect outcomes, though this patient ultimately had a positive result.
Educational Responsibility: Techniques taught by industry educators may be scrutinized in legal proceedings. * In this case, the T1 injection technique as taught by Maurizio De Mayo in the MD codes was explicitly mentioned during legal depositions.
Best Practices for Practitioners: Educators and practitioners must prioritize the safest methods over habitual methods. When performing the deep temporal technique, injectors must be mindful not to apply excessive pressure against the bone to avoid accidental penetration of the pterion.