Spontaneous subconjunctival orbital fat prolapse: presentation of four cases

The Overweight and Obese Patient in Oculofacial Plastic Surgery: A Narrative Review

PURPOSE

The oculofacial plastic surgeon will more frequently encounter challenges related to overweight and obese patients as the incidence rises. There is a paucity of data in the oculofacial plastic surgical literature regarding this topic. The goal of this review is to detail the role obesity plays in the perioperative course and the considerations for a surgeon treating this patient population.

METHODS

The authors conducted a computerized search using PubMed, Embase, and Google Scholar. The search terms used were "(obesity OR overweight) AND surgery," "(obesity OR overweight) AND oculoplastic," "(obesity OR overweight) AND oculofacial," "(obesity OR overweight) AND 'facial plastic surgery', " "(obesity OR overweight) AND 'bariatric surgery', " "(obesity OR overweight) AND (pre-operative OR post-operative OR intraoperative," " (obesity OR overweight) AND complications," "(obesity OR overweight) AND (facial plastic surgery) AND complications)," "(obesity OR overweight) AND eyelid," "(obesity OR overweight) AND (nasolacrimal OR 'nasolacrimal duct')," "(obesity OR overweight) AND IIH," "(obesity OR overweight) AND exophthalmos."

RESULTS

A total of 127 articles, published from 1952 to 2022 in the English language or with English translations were included. Articles published earlier than 2000 were cited for foundational knowledge. References cited in the identified articles were also used to gather further data for the review.

CONCLUSIONS

Overweight and obese patients pose specific challenges that the oculofacial plastic surgeon should be aware of to better optimize patient outcomes. Multiple comorbidities, poor wound healing, and nutritional deficits all contribute to the complications experienced in this patient population. Further investigation on overweight and obese patients is needed.

Long-Term Outcomes of a Surgical Technique in Management of Subconjunctival Orbital Fat Prolapse

Objective This retrospective, single-center, interventional study presented the long-term results of a novel surgical technique for the management of subconjunctival orbital fat prolapse. Methods Nine eyes of seven consecutive patients were surgically repaired using the technique involving connective tissue repair and were intended to be followed-up for more than five years. Results All surgeries performed were uneventful and esthetic enhancement was achieved for each patient. No postoperative complications were noted. There was no recurrence throughout the follow-up period; six eyes of four patients were followed-up for more than five years. Conclusions This technique with connective tissue repair achieved good long-term results.

Subconjunctival Orbital Fat Prolapse: An Update on Diagnosis and Management

Subconjunctival prolapse of orbital fat is an uncommon clinical entity in which intraconal orbital fat herniates into the subconjunctival space. Its diagnosis is mainly clinical in character and usually based on palpation, patient clinical history, and lesion features along with a slit lamp examination. Its pathophysiology remains unclear. Although frequently asymptomatic, clinical features may simulate conditions such as a prolapsed lacrimal gland, orbital lymphoma or dermolipoma and may worsen over time. In such cases, surgical removal or repositioning of the herniated fat may be necessary. While several surgical techniques have been described, no reports exist of a customized approach to manage this condition. This paper reviews the diagnosis and management of subconjunctival orbital fat prolapse.

In-Office Sutureless Correction of Prolapsed Subconjunctival Orbital Fat

PURPOSE

To describe a minimally invasive, sutureless, small incision surgical technique for the treatment of subconjunctival orbital fat prolapse (SOFP) performed using local anesthesia in an office setting.

METHODS

Retrospective study of the surgical outcome of 45 patients with either bilateral or unilateral SOFP treated by a single surgeon (R.S.) between July 2010 and February 2015.

RESULTS

Forty-five patients (39 male, 6 female) had a mean age of 67 years. Fat prolapse was bilateral in 23 patients (51%). A total of 68 eyes were operated on. All surgeries were without any intra- or postoperative complications such as infection, dry-eye symptoms, ocular motility impairment, or recurrence with a mean follow up of 37 months. All patients had a favorable postoperative cosmetic improvement.

CONCLUSIONS

The authors propose an office-based, cost-effective, minimally invasive, sutureless technique for treating SOFP with local anesthesia in a safe and effective manner. The lack of complications or recurrence with an adequate follow-up period following this technique is encouraging. Surgeons should consider this technique in the surgical correction of SOFP.

Subconjunctival orbital fat prolapse and thyroid associated orbitopathy: a clinical association

Background

Thyroid associated orbitopathy (TAO) comprises a spectrum of well-recognized clinical signs including exophthalmos, eyelid retraction, soft tissue swelling, ocular misalignment, keratopathy as well as a number of less common manifestations. Subconjunctival fat prolapse is a rare clinical condition occurring typically spontaneously in elderly patients with a mean age of 65–72 years. We describe subconjunctival prolapse of orbital fat as an uncommon clinical association of TAO.

Materials and methods

Observational study of six patients presenting with a subconjunctival protrusion under the lateral canthus in a series of 198 consecutive cases with TAO examined at a tertiary care referral center.

Results

A superotemporally located yellowish, very soft, freely mobile subconjunctival protrusion developed unilaterally in two and bilaterally in four patients with TAO (incidence 3.03%). It was one of the presenting manifestations of TAO in four of ten eyes studied and incited the diagnostic work-up for TAO in two of six patients in this series. Magnetic resonance imaging of the orbit indicated fat density in continuity with intraorbital fat in the area of protrusion. A male to female preponderance of 4:2 and an advanced mean age at onset of TAO is noteworthy for these six patients compared to the pool of 192 patients (64.8 versus 51.8 years, respectively, P=0.003) not bearing this sign.

Conclusion

Subconjunctival orbital fat prolapse, a clinically impressive age-related ocular lesion, may occasionally predominate amid other clinical manifestations of TAO. It is a nonspecific sign developing most commonly among patients with a relatively advanced age at presentation. Awareness of this association may alert to the diagnosis of thyroid orbitopathy and reassure the patient and physician as to the benign character of the lesion.

Surgical repair of orbital fat prolapse by conjunctival fixation to the sclera

Purpose

The aim of the study described here was to report the outcomes of surgery for orbital fat prolapse by conjunctival fixation to the sclera.

Patients and methods

Twenty-three consecutive eyes of 19 patients with orbital fat prolapse were retrospectively reviewed. All cases were treated with the same simple procedure without resection through conjunctival incision: fixation of conjunctiva to the sclera with interrupted sutures of 10-0 nylon in two rows located approximately 12–14 mm posterior to the limbus. These sutures formed an embankment to keep the prolapsed fat posteriorly. Postoperative results were determined by slit-lamp examination and recurrence of prolapse was defined as the presence of orbital fat anterior to the embankment.

Results

During the mean follow-up period of 19 months (range: 1−59 months), one case experienced recurrence which required further surgery. None of the other cases experienced recurrence, and there were no intraoperative or postoperative complications.

Conclusion

Conjunctival fixation to the sclera was a simple and effective surgical technique for orbital fat prolapse, with less invasion compared to the conventional method that requires conjunctival incision.

Efficacy of transconjunctival excision of orbital fat prolapse: a long-term follow-up study

PURPOSE

To describe the long-term efficacy of transconjunctival excision of subconjunctival orbital fat prolapse.

METHODS

Retrospective study of consecutive cases of orbital fat prolapse treated with transconjunctival resection between December 2002 and December 2011.

RESULTS

Thirty-two eyes of 23 patients (19 males and four females) were included. The lesion was unilateral in 14 and bilateral in nine cases. It was located superotemporally in a majority of cases. Excision was performed by opening the conjunctiva and excising the prolapsing orbital fat. The conjunctival wound was closed with 1-2 interrupted sutures. With an average follow-up of 29 months (range 4-108), a recurrence was seen in three cases. The average time to recurrence was 46 months (range 40-52 months).

CONCLUSION

Transconjunctival excision is a simple, safe and effective primary surgical procedure to treat subconjunctival fat prolapse. In our series, the recurrence rate was 9%, but no additional surgery was required. As the average time to recurrence was longer than our average follow-up, more patients may develop a recurrence in future.

A yellowish subconjunctival lesion in an infant-congenital orbital fat herniation

A very rare case of a congenital orbital fat herniation is demonstrated. Clinically, the child presented a progressive, small yellowish and mobile mass on the temporal orbital wall of her right eye. Magnetic resonance imaging showed a fat isointensive structure in T1-weighing without contrast enhancement. The possible aetiology of the herniation could be a congenital weakness of the Tenon's capsule or the conjunctival fornix.