Abstract
BACKGROUND: Vision loss following cosmetic filler injections is a rare but devastating complication resulting from inadvertent intravascular embolization, most often affecting the ophthalmic artery. Retrobulbar hyaluronidase injection has been proposed as an emergency intervention, yet anatomical guidelines for its administration remain poorly defined. OBJECTIVE: To propose an anatomically informed protocol for safe and effective retrobulbar hyaluronidase injection in cases of filler-induced central retinal artery occlusion. METHODS: Cadaveric dissections and micro-CT imaging were used to map orbital anatomy, focusing on the spatial relationship between the optic nerve, ophthalmic artery, and adjacent structures. The inferolateral quadrant was identified as the safest trajectory for retrobulbar injection, minimizing risk to ocular muscles and nerves. RESULTS: The optimal needle trajectory was from the inferolateral orbital rim toward the superior medial quadrant, avoiding critical neurovascular structures. A 35 mm, 22-23G needle was deemed appropriate for reaching the retrobulbar space while minimizing the risk of globe perforation. CONCLUSION: This study provides a standardized anatomical approach for retrobulbar hyaluronidase injection, aiming to improve safety and potentially restore perfusion in acute filler-induced visual loss. Clinical implementation should proceed with caution and in multidisciplinary settings.