Penetrating globe injury following periocular hyaluronic acid filler injection: A case report

Abstract

Purpose

To describe a case of mechanical eye globe penetration resulting in subretinal and vitreous hemorrhages and retinal tear that occurred immediately following a periorbital hyaluronic acid (HA) filler injection, and to outline acute management and early anatomical outcome.

Observations

A healthy 26-year-old female presented to the emergency department with the sudden onset of floaters in her left eye immediately after receiving a hyaluronic acid filler injection to the eyelid area. The best corrected visual acuity (BCVA) was 20/20 Snellen equivalent in both eyes. Ophthalmic examination showed a dense subconjunctival hemorrhage temporally and inferiorly in the left eye. The fundus examination revealed localized vitreous and subretinal hemorrhage along with an inferior retinal tear, confirming globe penetration. The patient was treated with laser retinopexy and topical antibiotics. Over serial follow-up, she experienced gradual symptom improvement, and imaging showed resolution of hemorrhage with well-formed laser scars. There were no signs of infection or retinal detachment.

Conclusions and importance

This case report highlights the risk of direct mechanical eye globe penetration associated with periocular HA filler injections. Early assessment and prompt ophthalmologic care are essential for saving vision and avoiding additional complications. Cosmetic professionals must follow safe injection practices and be aware of the possible complications to avoid injuries that might impair vision.

1. Introduction

Hyaluronic acid (HA) dermal fillers are widely utilized for cosmetic facial rejuvenation, preferred for their biocompatibility, reversibility, and ease of application. Despite their overall safety, rare but serious ocular complications such as vision loss from vascular embolization have been documented.^1,2

1.1. Case report

A healthy 26-year-old female presented to the emergency department complaining of the sudden onset of multiple floaters in the left eye, occurring a few minutes after receiving a cosmetic hyaluronic acid dermal filler injection for her periorbital region done by her dermatologist. The injection was performed at an external cosmetic clinic for periocular aesthetic enhancement. According to the patient, the procedure involved hyaluronic acid filler injection to the lower eyelid. However, specific procedural details—including depth of injection, point of entry, needle versus cannula use, needle gauge, injection plane, and filler brand—were not available despite direct inquiry. She denied symptoms of pain, reduced visual acuity, photopsia, or a visual field defect. Her past systemic and ophthalmic histories were unremarkable.

On examination, best corrected visual acuity (BCVA) was preserved at 20/20 Snellen equivalent in both eyes. Intraocular pressure was normal. On inspection, there was no sign of lid ecchymosis or swelling. A slit-lamp examination of the left eye showed the presence of a dense temporal and inferior subconjunctival hemorrhage (Fig. 1). The cornea was clear, the anterior chamber was deep and quiet, and the lens was clear. Examination of the fundus in the left eye was positive for a vitreous and subretinal hemorrhage localized to the inferior quadrant of the retina and an area of retinal tear with localized irregular retinal elevation (Fig. 2). No visible hyaluronic acid or foreign filler material was observed within the vitreous cavity or posterior segment on clinical examination or wide-field fundus imaging, suggesting a mechanical penetrating injury rather than intravitreal filler deposition. The rest of the fundus exam, which included the macula, optic disc, and peripheral retina, appeared normal.

Fig. 1.

Anterior segment photographs obtained a few hours after periocular hyaluronic acid filler injection showing dense temporal and inferior subconjunctival hemorrhage. Wide-beam illumination with the eye in (A) superonasal gaze and (B) primary gaze.

Fig. 2.

Wide-field pseudo-color fundus photograph of the left eye showing localized vitreous and subretinal hemorrhage (arrow) with an adjacent inferior retinal tear (arrowhead). (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

The clinical findings confirmed direct globe penetration and retinal injury resulting from the HA filler injection. The patient was counseled about the condition, including the retinal break and the presence of a penetrating globe injury. She underwent laser retinopexy to barricade the inferior retinal tear. Moxifloxacin eye drops at a frequency of every 6 hours were prescribed, and close follow-up was arranged to reassess the retina. She was counseled about the red flag symptoms of retinal detachment, including worsening floaters, photopsia, or a visual field defect. In addition, the need for urgent assessment in the emergency department if any symptoms arise was advised.

The patient was followed up with appointments initially set on a weekly basis for three weeks and then monthly as the vitreous and subretinal hemorrhage resorbed. During follow-up, the patient had a gradual improvement in floaters and gradual resolution of vitreous and subretinal hemorrhage with good laser scars around the retinal break without any signs of infection or inflammation (Fig. 3).

Fig. 3.

Follow-up wide-field pseudo-color fundus photograph three weeks after laser retinopexy (arrow) showing reduced vitreous and subretinal hemorrhage with well-formed laser scars surrounding the retinal break. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

2. Discussion

The widespread use of hyaluronic acid (HA) dermal fillers for non-surgical facial rejuvenation has made them a staple in aesthetic medicine.³ Their biocompatibility, reversibility, and ease of use make HA the most popular filler substance worldwide. While commonly used in the nasolabial folds, lips, and glabella, periocular applications such as tear-trough augmentation are becoming more frequent due to growing demand for minimally invasive rejuvenation.⁴ Despite their favorable safety profile, a growing number of reports highlight rare but severe ophthalmic complications, which can result in irreversible visual impairment.^5,6

Most serious ocular complications from HA fillers are vascular in origin, resulting from inadvertent injection into arterial branches such as the supratrochlear or angular arteries, allowing retrograde embolization into the ophthalmic artery system. This can block the central retinal artery, posterior ciliary arteries, or ophthalmic artery, which can lead to retina or optic nerve ischemia.^2,7,8 Kapoor et al. found that HA accounted for 81% of all filler-induced vision loss cases, with most patients suffering permanent visual impairment despite early intervention.⁴ Beleznay et al. similarly reported that among 98 documented cases of vision loss, only one patient achieved full recovery.⁹

This case demonstrates a direct mechanical trauma mechanism, different from previously documented vascular complications. The presence of subconjunctival, vitreous, and subretinal hemorrhages, along with a localized retinal tear, strongly points to direct penetration by the filler needle. This mechanical injury is different from complications related to vascular pathology, which leads to ischemic and permanent vision loss.^7,8,10

The anatomical complexity and fragility of the periorbital area play a critical role in the potential for complications. The thin orbital septum, the proximity of the eye globe to superficial tissues, and the extensive vascular networks all make cosmetic procedures more susceptible to causing both vascular and mechanical complications.^4,11 This risk becomes significantly greater by using a sharp needle, deeper injection depths, and improper injection angles.¹² Therefore, it is highly recommended that all injectors strictly follow preventive measures like using blunt cannulas, aspirating before injecting, applying low-pressure injection methods, and learning about the anatomy of the area around the eye globe.^8,12,13

Prompt recognition and immediate ophthalmologic evaluation are essential for saving vision. In this case, prompt identification and immediate laser retinopexy effectively sealed the retinal tear and averted retinal detachment, with subsequent monitoring verifying the total resolution of hemorrhages and the preservation of 20/20 vision.

This case underscores the necessity for cosmetic practitioners to maintain vigilance and engage in prompt collaboration with ophthalmologists when ocular symptoms manifest following periocular injections.^4,9 It is crucial for patients to know about urgent symptoms like floaters, photopsia, or visual field defects so that they can seek help urgently. A limitation of this case is the unavailability of detailed procedural information regarding the filler injection technique. This limitation reflects a real-world scenario and highlights the importance of standardized documentation, adequate training, and anatomical awareness among injectors performing periocular aesthetic procedures.

In conclusion, HA filler injections around the eye, while commonly safe, carry risks of sight-threatening ocular complications. Both vascular embolic events and mechanical injuries must be considered. Adherence to safe injection methods and readiness for urgent ophthalmic evaluation ensures the best visual outcomes in rare adverse events. Continued case reporting and research are necessary to optimize prevention and management protocols.

CRediT authorship contribution statement

Yousef A. Alotaibi: Writing – original draft, Supervision, Resources, Investigation. Ashwaq Asiri: Writing – original draft, Data curation. Mohannad F. Tobaigy: Writing – review & editing. Abdulrahman Aljebreen: Writing – review & editing, Methodology. Khaled S. Asharari: Writing – review & editing, Supervision.

Patient consent

Written consent to publish this case report has been obtained from the patient.

Authorship

All authors attest that they meet the current ICMJE criteria for Authorship.

Claims of priority statement

After conducting a literature review on January 1, 2025, utilizing PubMed, Google Scholar, Cochrane Library, Scopus, and Web of Science using the keywords “eye globe penetration after cosmetic procedure,” “filler injection complications,” and “retinal break with hyaluronic acid filler injection.” We did not find any prior reports of eye globe penetration after hyaluronic acid filler injection.

Funding

No funding or grant support.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.