NZSCM Filler Blindness Emergency Protocol

• Explain what has happened to the patient
• Keep calm (you and the patient)

• Call staff member (reception/practice manager)

• Test the unaffected eye first, then test the affected eye
• Read some text from the usual reading distance for the patient (get the patient's glasses if required)
• Get patient to count fingers, if they can't read text, light-dark perception if they can't see movement:
  • Check eye movements
  • Cover the affected eye first, then the non-affected eye
  • Check light perception (torch light), pupil reaction
  • Test afferent pupillary defect- Shine torch in unaffected eye. The pupil should get smaller in both eyes. Swing the torch over to the affected eye. Observe pupils contract in both eye-negative test. If both pupils fail to contract when light is shone in the affected eye, it confirms an afferent pupillary defect.
  • Check Visual Fields

• BEFAST
  • Balance
  • Eye (done)
  • Face droop (smile)
  • Arms (raise arms up, squeeze hands, lift legs)
  • Speech
  • Time

If positive, activate your Stroke Protocol. Assistant calls 111

Assistant script: “I am calling from XXX clinic. A patient has stroke symptoms after dermal filler injection. The patient is FAST positive with visual loss. Time of onset is …….. Please send an ambulance and activate the Stroke Protocol. Let me pass you on to the doctor/nurse “….

• Access the skin for signs of ischaemia around the area of injection

• Assistant (reception/practice manager/non-clinical staff) calls to notify the nearest eye hospital or specialist:
  • Assistant script “ I am calling from XXX Clinic. A patient has visual loss after filler treatment. Time of onset was  ….….. The patient will be transferred in 10 minutes. Let me pass you on to doctor/nurse.”
• List of filler blindness contacts available here

• Done by other staff members  while the doctor/nurse draw up Hyaluronidase (Hyalase)
• Decrease intra-ocular pressure
  • Eye massage (firm pressure on the eyeball for 5 seconds on/10 seconds off)
  • Timolol 0.25%, or apraclonidine eye drops ( 1 drop in affected eye at 1-minute intervals for 15 minutes)
  • Oral acetazolamide, sildenafil, and tadalafil
• Increase Vasodilation of CRA
  • Breathe into a paper bag - vasodilation
  • Warm compresses
  • Sublingual nitrates
  • Nitrous Oxide
• Reduce secondary thrombosis
  • Chewable aspirin 300mg

• Hyalase/Hyaluronidase is prepared by the doctor/nurse for subcutaneous and intra-arterial injection (Retrobulbar is less effective)
• High dose 1500 IU (1 ampoule) diluted 2ml 1 % Lignocaine (Xylocaine) in 3ml syringe and 27Gx13mm needle
• 1 ml into supra-trochlear area (14mm from midline)
• 1 ml into supraorbital area (25mm from midline)
• 1 vial into the treatment area
• Repeat 15-20 minutes
  • Patient lying supine or 30-degree reclined position
  • Feel for orbital rim.
  • Find midline
  • Mark point 15 mm (ST area) and 25 mm (ST area) from midline
  • With the thumb on the eyeball and index finger on the orbital margin (stabilizing the non-injecting hand).
  • Insert the needle tip onto the orbital margin
  • Follow the ridge of the medial orbital space, inject ST area 14mm from midline 0.5ml, then SO foramen area 25 mm from midline 0.5ml. Do not try to cannulate the artery; just flood the area
  • Inject treatment area with 1 vial hyalase solution using a 27 G 13mm needle or cannula. Flood the entire area showing signs of tissue ischaemia (blotchy, livedo reticularis)

• Drive the patient to your prearranged nearest eye clinic or hospital
• Assist and accompany the patient by walking/wheelchair to a private car/cab/uber
• Injector equipped with the blindness emergency kit (take 5 vials of Hyalase + saline + lignocaine)
• Patient to continue ocular massage
• Hand over to the Ophthalmologist or eye ward with the blindness emergency kit

None of the above measures should delay transfer.

1. Kapoor KN, Kapoor A, Heyes A, Hayward A. Vision loss associated with hyaluronic acid filler: a systematic review of literature. Aesthetic Plast Surg. 2020 Jun;44(3):929-44. doi:10.1007/s00266-020-01697-5

2. Doyon VC, Roussel J, Moubayed SP. Update on blindness from filler: review of prognostic factors, management approaches, and a century of cases. Aesthet Surg J. 2024 Sep;44(10):1091-1104. doi:10.1093/asj/sjae091 

3. Xiao H, Peng Q, Zhang W, Liu H. Vision loss secondary to hyaluronic acid filler injection: an updated systematic review. Aesthetic Plast Surg. 2024 Feb;48(4):709-18. doi:10.1007/s00266-022-03215-9

4. Royal Australian and New Zealand College of Ophthalmologists (RANZCO). Filler blindness guidelines 2024. Sydney: RANZCO; 2024. Available from: https://ranzco.edu/wp-content/uploads/2024/06/RANZCO-filler-blindness-guidelines-2024

5. Barbarino S, Cotofana S, Bertossi D, et al. EYE-CODE protocol for the non-ophthalmologist for treatment of retinal artery occlusion after intra-arterial injection of soft-tissue filler: 2025 update. J Cosmet Dermatol. 2025;24:e70336. doi:10.1111/jocd.70336