Role of Retrobulbar Hyaluronidase in Filler-Associated Blindness: Evaluation of Fundus Perfusion and Electroretinogram Readings in an Animal Model

Purpose: Hyaluronic acid gel filler-associated blindness is an uncommon but devastating complication. Hyaluronidase can potentially dissolve intravascular filler and improve perfusion; however, its role in filler-associated blindness has yet to be determined. The purpose of this study is to determine the effect of retrobulbar hyaluronidase on hyaluronic acid gel-induced ophthalmic artery occlusion in a rabbit model. Methods: New Zealand red rabbits were used to simulate hyaluronic acid gel filler-associated vascular occlusive blindness. Ophthalmic artery occlusion and subsequent ischemia were confirmed by both retinal fundus photography and electroretinogram changes. Retrobulbar hyaluronidase 1,000 IU was injected 30 minutes after occlusion. Fundus photography and electroretinogram changes were recorded at 30, 60, 90, and 120 after administration of retrobulbar hyaluronidase. Results: A total of 6 rabbits were used, for a total of 12 eyes. Four eyes were used as controls. Of the 8 experimental eyes, 2 eyes had recorded partial occlusion and 6 eyes had fully occluded ophthalmic arteries by angiographic evaluation. One of the partially occluded eyes demonstrated some improvement in perfusion 60 minutes after injection of retrobulbar hyaluronidase; however, electroretinogram readings remained flat over the 120-minute period of observation. Six eyes with completely occluded ophthalmic arteries showed no improvement in retinal perfusion with corresponding flat electroretinogram readings at 120 minutes following retrobulbar hyaluronidase injection. Conclusions: In this rabbit model, 1,000 IU of retrobulbar hyaluronidase administered 30 minutes after occlusion failed to reverse obstruction or restore function following hyaluronic acid gel occlusion of the ophthalmic artery. Accepted for publication March 25, 2018. Presented at American Society of Ophthalmic Plastic & Reconstructive Surgery (ASOPRS), Chicago IL, October 2016. Supported by Jerome Comet Klein MD Foundation. The authors have no conflicts of interest to disclose. Address correspondence and reprint requests to Catherine J. Hwang, M.D., Cleveland Clinic Foundation, Cole Eye Institute, 9500 Euclid Ave, i-20, Cleveland, OH 44195. E-mail: hwangc2@ccf.org © 2018 by The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc., All rights reserved.