Vision-threatening complications of injection sclerotherapy: case report, literature review, and FAERS database analysis

Abstract Background Injection sclerotherapy using sclerosants such as polidocanol has been widely employed for managing vascular disorders including chronic venous diseases and hemangiomas. Although sclerotherapy is considered a minimally invasive and generally safe procedure, rare but vision-threatening ocular complications have been reported. We present a unique scenario of progressive ophthalmic artery occlusion (OAO) associated with foamed polidocanol injection leading to irreversible blindness in a pediatric patient. Case presentation A 13-year-old male with a history of facial hemangioma underwent intralesional injection of foamed 1% polidocanol under ultrasound guidance at a dental clinic. He experienced transient monocular blindness in his left eye immediately after injection lasting for approximately 30 min, while best-corrected visual acuity at presentation recovered to 20/20. Despite systemic corticosteroids and anticoagulation, his vision deteriorated to no light perception within 1 month, accompanied by blepharoptosis and cutaneous necrosis. Multimodal imaging including fundus photography, optical coherence tomography, and fluorescein angiography demonstrated progressive retinal vascular occlusion, and Doppler ultrasonography at 1 month identified absent flow in the ophthalmic and central retinal arteries confirming OAO. Furthermore, a global pharmacovigilance analysis revealed that ocular complications represented only 3.9% of reported adverse events for sclerosing agents but were disproportionately severe, with 45.7% classified as death, life-threatening, disabling, or requiring hospitalization; permanent blindness occurred in 6.2% of the total cases. Conclusions This case underscores the potential for catastrophic ocular complications after polidocanol sclerotherapy. Given the limited therapeutic efficacy once iatrogenic OAO occurs, we emphasize caution when performing sclerosant injections particularly in the risky regions.