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1 Supplementary Online Content Park KH, Kim YK, Woo SJ, et al. Iatrogenic occlusion of the ophthalmic artery after cosmetic facial filler injections: a national survey by the Korean Retina Society. JAMA Ophthalmol. Published online March 27, doi: /jamaophthalmol etable 1. Summary of Total Patients With Iatrogenic Occlusion of the Ophthalmic Artery and Its Branches After Cosmetic Facial Filler Injections etable 2. Comparison of Clinical Characteristics Between Autologous Fat Injected Group and Hyaluronic Acid Injected Group efigure 1. Generalized Posterior Ciliary Artery Occlusion With Relative Central Retinal Artery Sparing efigure 2. Central Retinal Artery Occlusion efigure 3. Localized Posterior Ciliary Artery Occlusion efigure 4. Branch Retinal Artery Occlusion This supplementary material has been provided by the authors to give readers additional information about their work American Medical Association. All rights reserved.

2 etable 1. Summary of Total Patients With Iatrogenic Occlusion of the Ophthalmic Artery and Its Branches After Cosmetic Facial Filler Injections No. Age Sex Eye F R 25 F R 19 F L 30 M B 30 F L 26 F L 37 F R 39 F L 66 F L 24 F L 40 F L Occlusion Cosmetic injection Time to Initial Final Follow-up Brain MRI Associated Ocular Symptom Initial treatment type Substance Site visit BCVA BCVA period OAO Hyaluronic acid G/Rh Normal Pain, ASI IAT 4 hours NLP NLP 3 months OAO Hyaluronic acid G ACA infarct EOM, XT, Ptosis, ASI Steroid 9 hours NLP NLP 20 months OAO Autologous fat G Normal Pain ACP 2 hours NLP NLP 39 days OAO CaHA G/N Normal EOM, XT, Ptosis, ASI Steroid 2 hours NLP NLP 6 months OAO Hyaluronic acid Rh - Pain, EOM, Ptosis, ASI Steroid Immediate NLP NLP 36 months OAO Autologous fat G MCA infarct - ACP 36 hours NLP NLP 16 days OAO Autologous fat G Normal Pain, XT ACP 1 hours NLP NLP 13 months OAO Collagen Rh ACA infarct Pain, EOM, Ptosis, ASI Observation 1 day NLP NLP 38 months OAO Autologous fat G/N/Rh Normal Pain, EOM, Ptosis IAT 2.5 hours NLP NLP 5 days OAO Autologous fat G MCA infarct Pain, EOM, XT, Ptosis, RAPD Steroid 1 day NLP NLP 2 months OAO Autologous fat Rh Normal Pain, EOM, XT, RAPD IAT 2.5 hours NLP NLP 17 months OAO Autologous fat N - Pain, EOM, XT, Ptosis IAT 3 hours NLP NLP 28 months 18 F R F R OAO Autologous fat Unknown MCA infarct Pain, EOM, XT Observation 1 day LP NLP 3 months F R OAO Autologous fat G BZ infarct EOM, XT, Ptosis IOP lowering 1 day NLP NLP 31 months F L OAO Autologous fat G/N MCA infarct EOM ACP 6 hours NLP NLP 1 month F L OAO Autologous fat N MCA infarct - Anticoagulant 4 hours NLP NLP 44 months F L OAO Autologous fat Unknown BZ infarct Pain, EOM, ASI Observation 1 day NLP NLP 1 month F L GPCAO Hyaluronic acid G Normal Pain, EOM, XT, Ptosis, ASI ACP 1 hour NLP NLP 9 months F L GPCAO Autologous fat Unknown Normal - ACP 8 hours FC NLP 22 months F R GPCAO Poly-L-lactic acid Eyelid Normal Pain, EOM, XT Observation 3 hours LP NLP 1 week F L CRAO Autologous fat G Normal Pain, EOM, Ptosis ACP 4 hours NLP NLP 2 months M R CRAO Autologous fat N - Ptosis, RAPD Observation 1 day HM HM 6 months 29 F L CRAO Collagen G - RAPD IOP lowering 1 hour FC 20/63 2 months F R CRAO Autologous fat G Multifocal - Anticoagulant 1 day NLP NLP 24 months F R CRAO Autologous fat G MCA infarct EOM, Ptosis ACP 30 hours LP NLP 1 month F L CRAO Autologous fat G/N Normal Pain Observation 2 hours NLP NLP 1 month F R CRAO Hyaluronic acid G Normal ASI IAT 7 hours NLP NLP 1 month F L CRAO Autologous fat N Multifocal - IOP lowering 1 day NLP NLP 2 months F R LPCAO Hyaluronic acid Rh Normal EOM, XT, Ptosis, ASI Anticoagulant Immediate 20/63 20/20 18 months F L LPCAO Poly-L-lactic acid G Normal - Steroid 1 day HM HM 2 weeks M R LPCAO Hyaluronic acid N Normal Pain, EOM, XT, Ptosis, ASI ACP 20 hours HM 20/25 12 months F L LPCAO Hyaluronic acid G - EOM, XT, Ptosis Anticoagulant 3 hours 20/32 20/25 10 months F L BRAO Collagen N/Rh - - Observation 2 weeks 20/20 20/20 3 months 2

3 F L BRAO Hyaluronic acid G - - ACP 5 hours 20/32 20/32 12 months F R BRAO Hyaluronic acid N/Rh - - Observation 3 weeks 20/20 20/20 2 weeks F L BRAO Unknown Rh - - IOP lowering 1 day 20/32 20/20 19 months F R BRAO Hyaluronic acid G Normal - Observation 2 days 20/200 20/63 3 months F R BRAO Unknown Eyelid - - Anticoagulant 2 days 20/20 20/20 6 months F L BRAO Collagen Rh - ASI Observation 3 days 20/ / months F L BRAO Autologous fat Rh Normal EOM Observation 1 day 20/25 20/50 10 days F R BRAO Autologous fat Eyelid - - Anticoagulant 1 day 20/25 20/40 5 months F R BRAO Hyaluronic acid G - - ACP 5 hours 20/500 20/ months F L PION Autologous fat G - EOM, XT Observation 1 day NLP NLP 6 months F R PION Hyaluronic acid G/Rh Normal Pain, EOM, XT, Ptosis, ASI Observation 4 hours LP LP 3 month Abbreviations: ACA, anterior cerebral artery; ACP, anterior chamber paracentesis; ASI, Anterior segment ischemia (Corneal edema, anterior chamber inflammation); B, bilateral; BCVA, best corrected visual acuity; BRAO, branch retinal artery occlusion; BZ, border-zone; CaHA, calcium hydroxyapatite; CRAO, central retinal artery occlusion; EOM, extraocular muscle movement limitation; F, female; FC, finger count; G, Glabella; GPCAO, generalized posterior ciliary artery occlusion; HM, hand motion; IAT, intra-arterial thrombolysis; IOP, intraocular pressure; L, left; LP, light perception; M, male; LPCAO, localized posterior ciliary artery occlusion; MCA, middle cerebral artery; N, Nasolabial fold; NLP, no light perception; OAO, ophthalmic artery occlusion; PION, posterior ischemic optic neuropathy; R, right; Rh, Rhinoplasty (Nasal dorsum); RAPD, relative afferent pupillary defect; XT, exotropia. 3

4 etable 2. Comparison of Clinical Characteristics Between Autologous Fat Injected Group and Hyalyuronic Acid Injected Group Autologous fat (N=22) Hyaluronic acid (N=13) P-value a Age 38.1 ± ± Cosmetic injection site Single site (n(%)) 16 (72.7) 10 (76.9) Multiple sites (n(%)) 3 (13.6) 3 (23.1) Unknown (n(%)) 3 (13.6) 0 Glabella (n(%)) 13 (59.1) 9 (69.2) Nasolabial fold (n(%)) 7 (31.8) 2 (15.4) Nasal dorsum (rhinoplasty) (n(%)) 2 (9.1) 5 (38.5) Occlusion type (n(%)) OAO 12 (54.6) 3 (23.1) Generalized PCAO with CRA sparing 1 (4.6) 1 (7.7) CRAO 6 (27.3) 1 (7.7) Localized PCAO 0 3 (23.1) BRAO 2 (9.1) 4 (30.8) PION 1 (4.6) 1 (7.7) Diffuse occlusion b 19 (86.4) 5 (38.5) Initial BCVA (logmar) 2.5 ± ± NLP (n(%)) 16 (72.7) 5 (38.5) LP (n(%)) 2 (9.1) 1 (7.7) HM (n(%)) 1 (4.5) 1 (7.7) FC (n(%)) 1 (4.5) 0 20/1000~20/40 (n(%)) 0 3 (23.1) 20/32~20/20 (n(%)) 2 (9.1) 3 (23.1) Final BCVA (logmar) 2.6 ± ± NLP (n(%)) 19 (86.4) 5 (38.5) LP (n(%)) 0 1 (7.7) HM (n(%)) 1 (4.5) 0 20/1000~20/40 (n(%)) 2 (9.1) 2 (15.4) 20/32~20/20 (n(%)) 0 5 (38.5) Visual gain (logmar) -0.1 ± ± Brain lesion (n(%)) 10 (45.5) 1 (7.7) Initial symptoms Visual acuity decrease (n(%)) 20 (90.9) 10 (76.9) Visual field defect (n(%)) 2 (9.1) 2 (15.4) Ocular pain (n(%)) 10 (45.5) 5 (38.5) Ophthalmoplegia (n(%)) 12 (54.5) 7 (53.8) Strabismus (n(%)) 7 (31.8) 6 (46.2) Ptosis (n(%)) 7 (31.8) 7 (53.8) Corneal edema (n(%)) 1 (4.5) 5 (38.5) Anterior chamber inflammation (n(%)) 0 7 (53.8) <0.001 Pupillary abnormality (n(%)) 4 (18.2) Neurologic symptom (n(%)) 6 (27.3) Skin lesion (n(%)) 5 (22.7) 9 (69.2) Final sequelae (N=16, 6 months follow up) Visual acuity decrease (n(%)) 9/9 (100) 3/7 (42.9) Visual field defect (n(%)) 0/9 1/7 (14.3) Iris atrophy (n(%)) 0/9 1/7 (14.3) Strabismus (n(%)) 5/9 (55.6) 1/7 (14.3)

5 Phthisis bulbi (n(%)) Skin lesion (n(%)) 0/9 0/9 1/7 (14.3) 1/7 (14.3) Follow up period (months) 9.6 ± ± a P values by Mann-Whitney U test for continuous variables and chi-square test or Fisher s exact test for categorical values. b Diffuse occlusion: complete ophthalmic artery occlusion, generalized posterior ciliary artery occlusion, and central retinal artery occlusion Abbreviations: BCVA, best corrected visual acuity; BRAO, branch retinal artery occlusion; CRA, central retinal artery; CRAO, central retinal artery occlusion; FC, finger count; HM, hand motion; logmar, logarithm of minimal angle resolution; LP, light perception; NLP, no light perception; OAO, ophthalmic artery occlusion; PCAO, posterior ciliary artery occlusion; PION, posterior ischemic optic neuropathy. 5

efigure 1. Generalized Posterior Ciliary Artery Occlusion With Relative Central Retinal Artery Sparing A 48-year-old woman (Patient 19) after facial autologous fat injection (specific site unknown).

6 efigure 1. Generalized Posterior Ciliary Artery Occlusion With Relative Central Retinal Artery Sparing A 48-year-old woman (Patient 19) after facial autologous fat injection (specific site unknown). (A) Fundus photograph at the initial visit showed only focal retinal edema. (B-D) A fluorescein angiogram shows severe choroidal ischemia, with a relatively preserved retinal circulation (arm to retina = 14 s, arteriovenous transit time = 8 s. (E, F) Optical coherence tomography revealed a normal retinal structure at the initial visit (E), but inner retinal edema was observed 3 days later (F). (G) Optic atrophy and sclerotic retinal arteries were observed 21 months later. Initial and final visual acuity in the left eye was counting fingers and no light perception, respectively. 6

7 efigure 2. Central Retinal Artery Occlusion A 26-year-old woman (Patient 26) after autologous fat injection in the glabella and nasolabial fold. (A) Fundus photograph obtained at the initial visit shows retinal edema with a cherry red spot sign. (B- C) A fluorescein angiogram shows delayed arterial and choroidal filling. Choroidal ischemia is not as prominent as in the retinal circulation. (D) Optical coherence tomography revealed severe inner retinal edema. Initial and final visual acuity in her left eye was no light perception. 7

8 efigure 3. Localized Posterior Ciliary Artery Occlusion A 22-year-old woman (Patient 32) after hyaluronic acid injection in the glabella. (A) Fundus photograph obtained at the initial visit shows a normal retinal appearance. (B-C) A fluorescein angiogram shows normal retinal perfusion (arm to retina = 13 s, arteriovenous transit time = 7 s). (D) Focal choroidal ischemia was observed in nasal area. Initial and final visual acuity in the left eye was 20/32 and 20/25, respectively. 8

efigure 4. Branch Retinal Artery Occlusion A 25-year-old woman (Patient 36) after facial filler injection (specific material unknown) in the nasal dorsum for rhinoplasty.

9 efigure 4. Branch Retinal Artery Occlusion A 25-year-old woman (Patient 36) after facial filler injection (specific material unknown) in the nasal dorsum for rhinoplasty. (A) Fundus photo taken at the initial visit shows inferior retinal edema. (B) A fluorescein angiogram shows a filling defect in the inferior temporal branch. (C) Optical coherence tomography revealed inner retinal edema temporal and inferior to the fovea. (D) Visual field testing showed a corresponding superior visual field defect. Initial and final visual acuity in the left eye was 20/32 and 20/20. 9

AESTHETIC SOFT-TISSUE AUGMENTATION OF THE

AESTHETIC SOFT-TISSUE AUGMENTATION OF THE Iatrogenic Retinal Artery Occlusion Caused by Cosmetic Facial Filler Injections SUNG WOOK PARK, SE JOON WOO, KYU HYUNG PARK, JANG WON HUH, CHEOLKYU JUNG, AND O-KI KWON PURPOSE: To investigate the clinical