Guide for Managing Vascular Occlusion Due to Fillers with Extended Neuro-Ophthalmic Involvement: A Review of Diagnosis, Classification and Treatment.

introductionFiller-induced ophthalmic vascular occlusion (FIVO) is rare but devastating, while stroke remains even less frequent. Hyaluronic acid (HA) accounts for most reported cases of blindness. Given the emergency nature of these events, rapid recognition and immediate preparedness are paramount.

methodsA systematic search of PubMed, Web of Science, and the Cochrane Library was conducted up to August 2025 in accordance with PRISMA 2020 guidelines. Studies addressing vascular occlusion with neuro-ophthalmic involvement from dermal fillers, including technical and pharmacological management, were reviewed. After screening 48 records, 35 articles met inclusion criteria. Expert consensus statements and recommendations from international panels were also incorporated.

resultsThree thematic domains emerged: etiology, classification, and management. Embolic events occur immediately via direct intra-arterial injection or later through embolus fragmentation, migration, or arteriovenous shunting. Temporal classification distinguishes fulminant, immediate, and delayed presentations with distinct prognostic implications. Ophthalmic involvement typically manifests as vision loss, ptosis, or ophthalmoplegia, while neurological complications, including stroke, occur in up to 24% of cases, often affecting the middle cerebral artery. Imaging provides critical diagnostic and therapeutic guidance. Hyaluronidase (HYAL) remains the only intervention consistently associated with improved outcomes, though the optimal delivery route (extraorbital, peribulbar, retrobulbar) remains debated. Adjunctive measures include intraocular pressure reduction, ocular massage, antiplatelet therapy, and hyperbaric oxygen.

conclusionFIVO is a time-critical emergency. Early intervention with HYAL and supportive measures at the point of care, followed by rapid referral for advanced ophthalmic and neurological evaluation, is essential. Standardized guidelines are urgently needed to harmonize practice and improve patient outcomes. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .