A surgical technique with connective tissue repair for the management of subconjunctival orbital fat prolapse

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.

Subconjunctival Herniated Orbital Fat Mimicking Adipocytic Neoplasm

PURPOSE

To describe and discuss rare and benign conditions of subconjunctival orbital fat herniation that may mimic adipocytic neoplasm.

METHODS

Sixteen eyes of 13 patients with subconjunctival orbital fat herniation were included. They all underwent transconjunctival excision owing to cosmesis, discomfort, or suspicion of malignancy. Histopathologic examination, postoperative complications, and recurrent conditions were analyzed.

RESULTS

Eleven male and two female patients were included. The lesion was unilateral in 10 and bilateral in 3 cases. Excision was performed via conjunctival wound and removing the prolapsed orbital fat. The conjunctiva was then closed with two to three interrupted sutures. All the histopathologic specimens revealed Lochkern cells, floret cells, and mature adipocytes separated by fibrovascular septae without hyperchromatic cells, consistent with subconjunctival herniated orbital fat. All the patients were treated successfully with transconjunctival excision without recurrence at an average follow-up of 10.6 months (range, 6 to 16 months).

CONCLUSIONS

Prolapse of subconjunctival orbital fat is an uncommon entity of intraorbital masses and may mimic adipocytic neoplasm. It is usually associated with a dehiscence in the Tenon capsule. Surgical excision is indicated and pathologic evaluation is necessary if any malignancy is suspected.

Diagnosis and excision of subconjunctival herniation of orbital fat

PURPOSE

To present and discuss a case of herniation of subconjunctival orbital fat, a very rare but benign condition.

CASE REPORT

An 84-year-old man presented to the eye clinic for a cataract surgery consultation but also had a secondary complaint about yellow lesions on the bulbar conjunctiva of both eyes. Examination with biomicroscopy revealed protruding orbital masses superotemporally in both eyes, with the right lesion being larger than the left. After thorough testing, these lesions were diagnosed as being subconjuntival herniated orbital fat (HOF), and the patient underwent surgical excision of the lesions.

CONCLUSIONS

In cases of HOF, appropriate and accurate testing is essential, as this condition can mimic several other neoplasms, all of which require specialized treatment strategies. If cosmesis is unacceptable to the patient or the lesion impedes normal ocular function, a subconjunctival excision of the excess fat may be performed with little concern of recurrence. This article discusses a case of HOF, with an explanation of testing and treatment options.

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.

Small-incision, sutureless repair of subconjunctival fat prolapse

PURPOSE

To present a new, small-incision, sutureless surgical technique for the repair of subconjunctival fat prolapse.

METHODS

This is a retrospective interventional case series. Four eyes of 3 patients who presented with prolapsed subconjunctival fat were surgically repaired using a small-incision, sutureless technique with fibrin glue. No prolapsed subconjunctival fat was excised.

RESULTS

The surgical treatment of prolapsed subconjunctival fat using a small-incision, sutureless technique with fibrin glue was successful in all 4 eyes. There have been no cases of recurrence of the prolapsed subconjunctival fat with a mean follow up of 31 months.

CONCLUSIONS

Small-incision, sutureless repositioning of subconjunctival fat using fibrin glue is an effective new surgical technique for the management of prolapsed subconjunctival fat.

Subconjunctival fat prolapse and dermolipoma of the orbit: differentiation on CT and MR imaging

BACKGROUND AND PURPOSE

Subconjunctival fat prolapse and dermolipoma of the orbit are unfamiliar to radiologists and yet should be differentiated because their treatments are different. The purpose of this study was to investigate the CT and MR imaging findings that distinguish these 2 conditions.

MATERIALS AND METHODS

Between 1995 and 2009, we found 33 patients (27 men, 6 women; mean age, 63 years) with surgically proved subconjunctival fat prolapse and 27 patients (3 males, 24 females; mean age, 17 years) with dermolipoma in our hospital. Among them, 8 patients with subconjunctival fat prolapse and 6 patients with dermolipoma underwent CT and/or MR imaging examinations. We retrospectively reviewed CT scans and MR images in these patients.

RESULTS

In all of the 8 patients with subconjunctival fat prolapse, CT and MR images demonstrated the herniated fat at the superotemporal epibulbar area, continuous with the intraconal fat, extending forward between the lateral wall of the globe medially and the lateral rectus muscle and the lacrimal gland laterally, either bilaterally (n = 7) or unilaterally (n = 1). In contrast, all 6 patients with dermolipoma had a unilateral, crescent- (n = 5), or triangle-shaped (n = 1) fatty mass at the temporal or superotemporal epibulbar area, which lay on the lateral wall of the globe, anterior to the insertion of the lateral rectus muscle and medial to the lacrimal gland, without connection to the intraconal fat.

CONCLUSIONS

The characteristic CT and MR imaging findings may help easily differentiate subconjunctival fat prolapse and dermolipoma, both of which usually present as an epibulbar fatty mass in the lateral canthal area.