Orbital Fat Prolapse Research Articles

A Rare Case of Subconjunctival Nerve Sheath Myxoma Presenting as Orbital Fat Prolapse.

Nerve sheath myxomas are extremely rare myxoid peripheral nerve sheath tumors with a predilection for the distal extremities, particularly common in the fingers and knees. Here, we report a 60-year-old male patient with a subconjunctival epibulbar nerve sheath myxoma, which was clinically diagnosed as an orbital fat prolapse. The lesion was successfully debulked without clinical recurrence over more than 3 years. To our knowledge, this is the first case with subconjunctival presentation and fourth orbital reported case.

Upper Blepharoplasty through Infrabrow Skin Excision to Treat Dermatochalasis with Lateral Hooding and Medial Orbital Fat Loss in Selected Patients.

Dermatochalasis with lateral hooding and medial orbital fat loss are common signs of aging in the upper eyelid. Removing the excess skin in this area through infrabrow skin excision can effectively lift the loose skin of the upper eyelid and minimizes visible scarring. Additionally, we have identified three compartments of orbital fat prolapse based on orbital anatomy. Transferring volume from the lateral compartment to the intermediate region can flatten the lateral upper eyelid and create medial fullness, which ultimately rejuvenates the upper eyelid. This study presents an operative method for correcting age-related changes in the upper eyelid using this technique. A total of 34 eyelids from 17 patients underwent a surgical procedure involving infrabrow skin excision, along with repositioning and lifting of lateral orbital fat. The inclusion criteria consisted of patients with moderate to severe upper eyelid dermatochalasis, coupled with middle fat loss and lateral hooding. To correct lateral hooding and restore midfacial fullness, lateral orbital fat was repositioned to an intermediate position, and the orbicularis oculi muscle was fold-sutured to the corrugator supercilii muscle. The mean age of the patients was 55.59 ± 3.20 years, with a range of 48 to 61 years. The mean follow-up period was 9.94 ± 1.35 months, ranging from 8 to 12 months. Patients were evaluated at 1-month, 3-month, and 6-month intervals. The Strasser system was used to evaluate the surgical outcomes at 3 months. All patients achieved good surgical outcomes, expressed through satisfactory cosmetic improvements, and improved visual field. The procedure effectively corrected lateral hooding and loss of middle orbital fat through infrabrow skin excision. No complications, such as wound dehiscence, lagophthalmos, noticeable scarring, ocular dyskinesia, or sensory changes, were observed. The combination of infrabrow skin excision, repositioning of lateral orbital fat, and lifting of the orbicularis oculi muscle effectively addresses moderate to severe dermatochalasis, lateral hooding, medial fat loss, and improves elasticity of the anterior wall of the upper lid in our patients. This procedure can produce satisfactory and long-lasting aesthetic results with an inconspicuous scar beneath the brow.

Lateral Rectus Muscle Entrapment in Complex Orbital Fracture in a Child.

A 6-year-old boy presented with a lateral rectus muscle entrapment in a complex orbital fracture sustained during bicycle riding. He was diagnosed with a skull-base fracture with pneumocephalus and zygomatic and inferior orbital wall fractures at another hospital. The zygomatic fracture and pneumocephalus were treated conservatively. Although a detailed ocular motility examination could not be performed due to pain and inability to open the eyelid, the inferior wall fracture was surgically repaired. Postoperatively, persistent extraocular movement limitation prompted a referral to our clinic. Orbital CT imaging demonstrated a fracture at the greater wing of the sphenoid with a hypoattenuated area in the adjacent middle cranial fossa. Orbital MRI taken thereafter revealed lateral rectus and orbital fat prolapse into the middle cranial fossa, indicating entrapment of these structures through the lateral wall fracture. The incarcerated lateral rectus was released using an endoscopic transorbital approach via an upper lid crease, resulting in the recovery of extraocular movement.

Clinical efficacy and safety of composite non-cross-linked hyaluronic acid for treating tear trough-lower eyelid bag deformity.

Tear trough-eye bag deformities may appear in young Asian patients due to the weak support of their facial skeletons. For these patients with better periorbital skin elasticity, the injection may be more suitable than surgery for treating tear trough-lower eyelid bag deformity. Identify the clinical efficacy and safety of non-cross-linked HA in the treatment of tear trough-lower eyelid bag deformity. In this study, we analyzed pre- and postinjection photographs of 55 patients treated with non-cross-linked hyaluronic acid (HA) for tear trough-lower eyelid bag deformity. The mean [SD] scores of modified Goldberg score suggested that the most significant improvement of preoperative and postoperative scores was in tear trough depression, followed by infraorbital triangular depression, orbital fat prolapse, loss of skin elasticity, and skin transparency. Only transient localized complications were observed, including bruising, swelling, and erythema. There were no serious complications, such as skin necrosis or visual impairment. Our study confirmed the beneficial efficacy and minor complications of composite non-cross-linked HA for the treatment of tear trough-lower eyelid bag deformity.

Endoscopic dacryocystorhinostomy with bicanalicular silicone tube intubation for treating chronic dacryocystitis secondary to nasolacrimal duct stent incarceration.

To investigate the feasibility of endoscopic dacryocystorhinostomy (En-DCR) with bicanalicular silicone tube intubation for treating chronic dacryocystitis secondary to nasolacrimal duct stent (NDS) incarceration. En-DCRs were performed on 44 chronic dacryocystitis patients (46 eyes) secondary to NDS incarceration from April 2016 to October 2022. The granuloma and scar tissues were separated, and the removal of NDS incarceration was achieved during the surgery; the flap of the lacrimal sac was trimmed and anastomosed with nasal mucosal, a bicanalicular silicone tube was implanted, and lacrimal size and condition were assessed. The tube was removed 3mo after surgery. During the final follow-up of 12mo when the surgery was completed, the complications and the rates of surgical success were assessed. This study covered 40 patients (42 eyes). Intraoperatively, it was found that the lacrimal sac became small, and the sac wall had granulation and scar tissue attached to the incarcerated NDS in all eyes. At 12mo after surgery completed, the rates of the functional and anatomical success reached 80.95% (34/42) and 83.33% (35/42), respectively. Under the effect of intranasal ostial closure, seven eyes failed to achieve anatomical success. No serious complications (e.g., visual impairment, sinusitis, and orbital fat prolapse) was observed. With the success rate over 80% and no serious complications, En-DCR with bicanalicular silicone tube implantation is effective in treating chronic dacryocystitis secondary to NDS incarceration.

Internal Fixation of Redistributed Orbital Fat in Transconjunctival Lower Eyelid Blepharoplasty.

Fat redistribution combined with release of the tear trough ligament in transconjunctival lower blepharoplasty is widely performed to correct lower eyelid bags and tear trough deformities, but suturing the released fat in such a narrow, dissected space remains a challenge. The purpose of this study was to introduce a new surgical technique of internal fixation that advances and sutures the pedicled orbital fat firmly to the midcheek through premaxillary and prezygomatic spaces. Twenty-two patients (age range, 22 to 39 years) with predominant orbital fat prolapse and tear trough deformity without noticeable lower eyelid skin laxity were treated with this method, all of whom had impressive correction of the eyelid bags and tear trough deformities and were pleased with the aesthetic results during an average follow-up of 11.8 months (range, 10 to 14 months). No patient had postoperative hematoma, ectropion, or midface numbness. The maneuver of internal fixation of redistributed orbital fat provides a novel and safe approach to correct eyelid bags and tear trough deformities without additional percutaneous sutures in transconjunctival lower eyelid blepharoplasty. Therapeutic, IV.

Rare case of inferotemporal orbital fat prolapse – Clinical, histopathologic, and anterior segment optical coherence tomography correlation

Orbital fat prolapse (OFP) is the herniation of intraconal fat into the subconjunctival space, which occurs mostly in the superotemporal quadrant and is more common bilaterally. We report a rare case of unilateral inferotemporal OFP and its anterior segment optical coherence tomography (ASOCT) features. On ASOCT, the lesion appeared uniformly smooth with no definite capsule. Fat lobules appeared hyporeflective, while the interlobular septae appeared hyperreflective. A hyporeflective space was noted, separating the fat and the overlying conjunctival stroma. This space was, however, obliterated in the areas corresponding to the maximum convexity of the lobules. These ASOCT findings correlate with the described histopathologic features of the OFP described in literature. Inferotemporal OFP and corresponding ASOCT features, to the best of our knowledge, have not been reported previously. We also propose its role in documenting progression that can aid in surgical decision-making.

Assessment of the levels of interleukin-17 and interleukin-38 in thyroid-associated ophthalmopathy patients.

The objective of the study was to analyse the levels of IL-17 and IL-38 in the samples of unstimulated tears, orbital adipose tissues, and sera of patients diagnosed with active forms of TAO. The correlation of the levels of IL-17 and IL-38 with clinical activity score (CAS) was scrutinized. A study was conducted at the Kazakhstan Scientific Research Institute of Eye Diseases (Almaty city, Kazakhstan). Study participants (n = 70) were sub-divided into 3 groups: (1) a group of patients diagnosed with active TAO (n = 25), (2) a group of patients with an inactive form of TAO (n = 28), and (3) a "control group" (patients diagnosed with orbital fat prolapse, n = 17). All patients underwent a clinical assessment and diagnostics. The activity of the disease and its severity were assessed using the CAS and NOSPECS scales. Thyroid function tests were performed, including the study of the levels of thyroid-stimulating hormone, triiodothyronine, free thyroxine, and antibodies to the thyroid-stimulating hormone receptor. IL-17 and IL-38 levels in non-stimulated tear samples, orbital tissue, and patients' sera were measured using commercial ELISA kits. The results showed that the number of former smokers prevailed among patients with active TAO (48%) in comparison with patients with inactive TAO (15.4%), p = 0.001. The concentration of IL-17 significantly increased in the samples of non-stimulated tears, adipose tissues of the orbit and sera of patients with active forms of TAO. The level of IL-38 was reduced in all types of samples (p ≤ 0.05). The results of a histological study of orbital adipose tissues in the group of patients with an active form of TAO showed the presence of focal infiltration with lymphocytes, histiocytes, plasma cells, severe sclerosis and vascular plethora. We observed an association between the CAS of patients with active TAO and the level of IL-17 in sera (r = 0.885; p = 0.001). On the contrary, a negative correlation was detected for the level of IL-38 in sera. The results highlighted the systemic effect of IL-17 and the local effect of IL-38 in TAO. We observed a significant increase in the production of IL-17, and a decrease in IL-38 in samples of sera and unstimulated tears (the active form of TAO). Our data indicate a correlation of IL-17 and IL-38 levels with the clinical activity of TAO.

The Prevalence of Undiagnosed Ptosis Among Candidates for Upper Eyelid Blepharoplasty.

Because upper eyelid blepharoplasty has become a popular aesthetic facial surgery, surgeons should be aware that age-related changes in the eyelid are not confined to skin laxity and orbital fat prolapse. This study was designed to assess the prevalence of undiagnosed ptosis among blepharoplasty candidates as one of the causes of unsatisfactory surgical results. From December 2018 to December 2022, blepharoplasty candidates were meticulously assessed for their upper eyelid and eyebrow position. Patients who were aware of their ptosis were excluded, and the other patients were classified as mild, moderate, or severe ptotic based on margin reflex distance 1. The eyebrow height was also assessed in the mid-pupillary line to assess the relationship between the severity of ptosis and eyebrow asymmetry. The authors found that 13.7% of the 2530 blepharoplasty candidates in this study had undiagnosed ptosis. Most of these patients had mild ptosis (85.5%), and they were significantly older than nonptotic patients. The rate of prevalence of ptosis was significantly higher in patients with eyebrow asymmetry (75.3% vs 3.7%); however, the severity of ptosis was not associated with the severity of eyebrow asymmetry. Ptosis should be cautiously looked for and addressed for treatment in candidates for upper blepharoplasty. In most patients with masked ptosis, the severity of eyelid drooping is mild and could remain undiagnosed until after the surgery and cause unsatisfactory aesthetic results. The presence of eyebrow asymmetry could be a key feature to unmask an undiagnosed ptosis.

Surgical Correction of Tear Trough Deformity (TTD) with Orbicularis Retaining Ligament Release and Volume Augmentation for Periorbital Rejuvenation: Review of the Literature.

Tear trough deformity is a hallmark of periorbital aging. It is not, however, an exclusive feature of old age. While protruding orbital fat results in lower lid bags that are traditionally corrected by excision, correction of TTD can constitute a real challenge requiring volume enhancement in addition to addressing prolapse of orbital fat and descent of cheek tissues. Described therapeutic options include minimally invasive soft tissue augmentation with fillers or structural autologous fat transfer as well as invasive surgical procedures concomitantly with lower lid blepharoplasty or other facial rejuvenation procedures. Six eponyms have been used in the literature to describe the condition: (1) naso-jugal fold, (2) naso-jugal groove, (3) naso-jugal ditch, (4) tear trough, (5) tear trough deformity, and (6) tear trough depression. A separate PubMed database search of each of the 6 terms was conducted in addition to an advanced literature and systematic PICO searches to identify all described clinical retrospective or prospective, comparative or simple cohort studies related to surgical correction of TTD. An additional screening of references of retrieved clinical studies was performed to identify any missed reports. A total of 435 publications were identified with the initial search. After excluding all none relevant studies, 44 papers were selected for review. 6 additional studies were identified by screening relevant references. Almost all authors agree on the necessity to release the tear trough retaining ligament together with volume enhancement. Transconjunctival and transcutaneous incisions are reported. Most recommend repositioning of the protruding orbital fat for volume enhancement to mostly subperiosteal, or pre-periosteal pockets. Other reported options include pedicled buccal fat pad transposition, segmental fat grafting, and minced micrografts. Internal as well as external fixation of repositioned fat flaps have been described. Despite lack of solid objective evidence, several of these techniques when properly executed for the proper indication in selected patients are reported to result in a rewarding and long-lasting outcome. Unfortunately, it is difficult to determine the most appropriate technique that would universally yield the most pleasant and harmonious facial contour without creating an unnatural puffy appearance. It remains for the surgeon to identify the safe surgical approach that does not compromise lower eyelid function and achieves the most pleasing aesthetic outcome with the least complications and downtime. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Henpecked

Domestic henpecking can cause serious ocular injuries. Here, we report a case of penetrating orbito-cranial injury along with lid laceration and orbital fat prolapse in a two-year-old girl following henpeck injury. The eye ball was spared. Prolapsed fat was relocated and the wound was repaired successfully. Neurosurgery consultation was done and conservative management advised.

Orbital Hemorrhagic Necrosis, Globe Rupture, and Death From Intraorbital Injection of 1% Sodium Deoxycholate in a Murine Model.

Deoxycholic acid (DCA) 1% is an injectable detergent indicated for submental fat reduction, although clinically it is being injected off-label for orbital fat prolapse. It is known to cause severe inflammation, local nerve dysfunction, and tissue necrosis, all of which could be catastrophic in the orbit and periocular region. This study evaluated the effects of periocular DCA on orbital and ocular adnexal tissues in a murine model. Mice were treated via split-face intraorbital injections, subcutaneous injections, and topical cornea application with DCA versus phosphate-buffered saline. Whole heads were fixed, decalcified, and sectioned for orbital histology after 1-7 days. Matched pairs of human globes and mouse globes were immersed in either phosphate-buffered saline or 1% DCA for 72 hours. Six of 11 mice receiving intraorbital DCA injections died within minutes. Surviving mice developed severe orbital inflammatory necrosis. All orbits injected with phosphate-buffered saline were clinically and histologically normal. Six mice were treated with lower concentrations of DCA and all developed variable amounts of orbital inflammation, hemorrhage, and globe necrosis. Mice receiving subcutaneous DCA injection to the lower eyelid showed inflammatory necrosis, edema, and lid malposition. Topical application of DCA to mouse corneas caused no external or histologic changes. Human and mouse globes immersed ex vivo in DCA developed corneal edema and cataract formation without observable scleral changes. Intraorbital and periocular injection of DCA can cause devastating complications in a murine model, and significant caution is advised for off-label use in the periocular region.

Herniation of orbital fat — analysis of the surgical repair

We present a case of an 84-year-old patient with acquired bilateral superotemporal orbital fat prolapse. The disease occurs when there is dehiscence in Tenon’s capsule, allowing fat to herniate forward spontaneously. This can happen when there is a discontinuity of Tenon’s capsule. We discussed visual symptoms at presentation, surgical technique, and visual and aesthetic outcomes.

Eyelid Surgery in Graves' Orbitopathy.

Patients with Graves' orbitopathy often develop eyelid changes. These may be the result of a volume effect or a malposition. Both dermatochalasis with fat tissue increase and eyelid retraction may lead to functional or aesthetic impairment. The present article reviews indications, timing and principles for corrective eyelid surgery. If at all possible, surgical eyelid correction in Graves' orbitopathy should be performed once the disease became inactive and stabile. Surgical details of eyelid lengthening procedures for upper and lower eyelid retraction are presented. Meanwhile anterior blepharotomy became the primary procedure for upper eyelid lengthening. However, there is no such standard procedure for lower eyelid lengthening, although it is recommended to use a spacer. For blepharoplasty it is mandatory to distinguish between orbital fat prolapse and subbrow fat pad. A prolapse of the lacrimal gland should not be missed and generally, skin excision performed sparingly.

Endoscopic Orbital Decompression: Technical Pearls and Pitfalls of an Evolving Technique.

First described in the early 1990s, endoscopic orbital decompression has become increasingly popular and has been shown to be a safe and effective approach for surgical decompression of the medial and inferior orbit. We present our preferred technique for performing an endoscopic orbital decompression, highlighting key pearls and pitfalls. An endoscopic wide maxillary antrostomy and sphenoethmoidectomy is performed in standard fashion. We prefer to resect the middle turbinate for optimal exposure and access. The medial orbital wall is skeletonized and the lamina papyracea is carefully elevated, preserving the underlying periorbita. The orbital floor medial to the infraorbital nerve is resected. Once the periorbita is fully exposed, parallel axial incisions along the medial orbit and orbital floor are made from posterior to anterior using a sickle knife, taking care not to bury the tip to avoid injuring underlying orbital contents. The remaining fibrous bands are incised and prolapse of orbital fat is observed. Post extubation bag mask ventilation is limited to avoid subcutaneous emphysema. Compared to open techniques, endoscopic orbital decompression provides superior visualization of critical anatomical landmarks, assures healthy sinus functioning post procedure, offers a lower complication rate, and avoids external incisions.

Ethmoid Sinus Mucosal and Lacrimal Sac Flap Anastomosing in Patients With Failed Dacryocystorhinostomy.

The aim of this work is to demonstrate the outcomes of endonasal dacryocystorhinostomy (En-DCR) with anterior ethmoid sinus mucosal and posterior lacrimal sac flap anastomosing in patients with previous failed DCR. The clinical data of patients who suffered from recurrent epiphora after failed DCR between September 2014 and March 2018 were reviewed retrospectively. Among them, those who received the second En-DCR procedure were enrolled in this study. During the surgery, anterior ethmoidectomy was performed. Posterior lacrimal sac flap was apposed closely to the mucosal of anterior ethmoid sinus instead of nasal flap at end of the surgery. Patients were followed up more than 12 months were included, the success rate and complications were recorded. Sixty-one eyes of 61 patients were enrolled in the study. The success rate of our modified En-DCR was 83.6% (51/61). Among 10 eyes with postoperative obstruction, 4 eyes caused by granuloma, 2 eyes caused by scar synechia, 2 eyes caused by membranous obstruction, and 2 eyes caused by common canalicular stenosis. No serious complications such as orbital fat prolapse, cerebrospinal fluid leak, sinusitis, or visual impairment were occurred in this study. Endoscopic approach with anterior ethmoid sinus mucosal and posterior lacrimal sac flap anastomosing is a good choice for patients with recurrent epiphora after previous failed DCR.

Small-Incision Sutureless Surgical Technique for Subconjunctival Orbital Fat Prolapse.

Surgical outcomes of 20 patients treated by one surgeon between March 2014 and August 2019 were reviewed retrospectively. The authors included 20 patients with subconjunctival orbital fat prolapse (SOFP) treated by a small-incision, sutureless surgical technique using local anesthesia. All patients were followed for at least 3 months postoperatively. Medical information such as patient's age, number of eyes involved, location of fat, surgical time and whether or not the prolapse recurred was reviewed. Twenty patients (16 men and 4 women) were included and had a mean age of 67.1 years. There were 7 bilateral and 13 unilateral SOFP cases. There were no intra-operative or postoperative complications and no cases of recurrence within a mean follow-up of 3 months. All surgeries were successful from both cosmetic and symptomatic perspectives. Our small-incision, sutureless surgical technique is an effective method to manage SOFP. This technique, performed with local anesthesia, is both cost- and time-effective.

Assessment of the Safety and Efficacy of Prolapsed Orbital Fat Resection During Involutional Entropion Repair.

To assess the recurrence rate of involutional entropion in patients treated with a combined approach including a modified Bick procedure, excision of preseptal orbicularis muscle, and conservative resection of prolapsed orbital fat. A retrospective chart review of patients undergoing repair of involutional entropion with the combined procedure including orbital fat resection and a second group with standard entropion repair without orbital fat resection was performed. Only patients with follow-up greater than 6 months were included in the study. Seventy eyelids of 54 patients met all inclusion criteria for the combined procedure group over a 9-year period from 2008 to 2016. Average follow-up was 46.9 months. There was a documented recurrence of entropion in 1 eyelid during the follow-up period (1.4%). The remaining 69 cases had successful subjective and objective results without need for any additional procedures. In the group undergoing entropion repair without fat resection, 22 eyelids of 19 patients had the required follow-up period with a recurrence rate of 4.5% (p > 0.05). The authors demonstrate good surgical success with a combined approach of a modified Bick procedure, preseptal orbicularis excision, and conservative orbital fat resection. Conservative fat resection during entropion repair was found to be safe, and the combined procedure was found to be effective with a rate of recurrent entropion of 1.4% on extended follow-up.The authors propose that orbital fat prolapse contributes to the mechanics of involutional entropion and that conservative orbital fat resection during surgical repair of entropion can be done safely, resulting in low recurrence rates.

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

ObjectiveThis retrospective, single-center, interventional study presented the long-term results of a novel surgical technique for the management of subconjunctival orbital fat prolapse.MethodsNine 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.ResultsAll 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.ConclusionsThis technique with connective tissue repair achieved good long-term results.

Prolapse of Orbital Fat through the Inferior Orbital Fissure: Description, Prevalence, and Assessment of Possible Pathologic Associations.

A few patterns of orbital fat prolapse have been described. Some are associated with disease, and others may mimic a neoplasm. We have observed prolapse of orbital fat into the infratemporal fossa via the inferior orbital fissure on MR imaging. The clinical relevance of this finding, if any, is unknown. The purposes of this study were to describe the MR imaging appearance of orbital fat prolapse through the inferior orbital fissure, to estimate the prevalence of this finding, and to assess possible pathologic associations. For this retrospective study of 228 orbital MR imaging examinations, 3 neuroradiologists independently assessed the presence of prolapse on high-resolution T1-weighted images. Discrepancies were resolved by consensus, and interobserver agreement was calculated. Patient demographics, indications for imaging, and pertinent clinical history were recorded. One-way analysis of variance and the Fisher exact test were used to assess possible associations between prolapse and specific patient characteristics. Orbital fat prolapse through the inferior orbital fissure was observed in 20/228 patients (9%). This finding was unilateral in 11 patients (55%) and bilateral in 9 patients (45%). There was no significant association with age, sex, obesity, Graves disease, hypercortisolism, prior orbital trauma, proptosis, or enophthalmos. Interobserver agreement was 90%. Prolapse of orbital fat into the infratemporal fossa via the inferior orbital fissure is a relatively common finding on orbital MR imaging that has no identified pathologic association. Neuroradiologists should recognize this finding so as not to report it as pathologic.