Fat Prolapse Research Articles

Clinicoradiologic Relationships in Case of Grave's Orbitopathy

Purpose. To evaluate the relationship of clinical and radiologic findings in improving of diagnostics and amendment of the outcome.Material and methods. 52 patients (104 orbial cavities) in the age of 18–61 years were examined. Patients with the clinical symptoms of Grave’s orbitopathy were examined using ophthalmological evaluation and MSCT-visualization of orbial cavities.Results. The most significant MSCT-parameters for the determination of severity are: prolapse of orbital fat (р = 0.0009), protrusion of eye bulb (р = 0.001), apical inspissations (р = 0.019), density of RBCmin (р = 0.004), size of external terminal membrane (р = 0.001), size of LRM (р = 0.002), size of MRM (р = 0.006), length of optic nerve (р = 0.0001), diameter of optic nerve in 1 cm from the macula (р = 0.01), width of lacrimal gland (р = 0.0002).Conclusions. There is significant relationship between clinical and radiologic (MSCT) features. It lets develop the protocolof examination for diagnostics and treatment of Grave’s orbitopathy.

The Blepharochalasis Syndrome

Blepharochalasis is a rare eyelid disorder that often presents in childhood or early adolescence. It is characterized by exacerbations and remissions of painless edema of the upper and occasionally lower eyelids. Although the average duration of attack is only two days, multiple attacks eventually lead to atrophic, wrinkled, and discolored periorbital skin. Other clinical manifestations include ptosis, acquired forms of blepharophimosis, lower lid retraction, pseudoepicanthal folds, proptosis, prolapse of orbital fat, and lacrimal tissue. The etiology of blepharochalasis has yet to be fully elucidated, but histpathologic examinations indicate that elastolytic activity, immunoglobulin A (IgA), and other inflammatory processes might play a substantial role in the pathogenesis of the disease. The treatment of blepharchalasis is primarily surgical, and therefore understanding the natural history is essential to avoid overcorrection and recurrences after surgery. In this review we present the clinical characteristics, differential diagnosis, and treatment options of blepharochalsis.

Graves Ophthalmopathy: The Bony Orbit in Optic Neuropathy, Its Apical Angular Capacity, and Impact on Prediction of Risk

Optic neuropathy (ON), a serious complication of Graves ophthalmopathy, is often subclinical and masked by symptoms of orbitopathy. We examined herein bony and soft-tissue CT features associated with ON, including an angular assessment of orbital apex capacity, and their usefulness in the risk prediction of ON. The CT scans of 41 patients with Graves ophthalmopathy (17 men, 24 women; mean age, 49.1 years) clinically diagnosed with (19 patients, 32 orbits) or without ON were evaluated by 2 independent raters. Quantitative linear and angular measurements of the orbital structures and bony walls and categoric scores of apical crowding and intracranial fat prolapse were assessed on a clinical workstation. Inter- and intrarater variability of these features was determined. The CT features of the 2 patient groups were compared, and multivariate logistic regression analysis was performed to evaluate the predictive features of ON. Bony orbital angles (P < .005), length of the lateral orbital wall (P < .05), muscular diameters (P < .0005), muscular bulk of the medial rectus muscle relative to the bony orbit (P < .05), and apical crowding (P < .0005) were associated with clinical ON. Stepwise multivariate logistic regression analysis revealed the muscle diameter index and medial and lateral wall angles to be independent predictors. Combining these in a single multivariate equation yielded sensitivity, specificity, and positive and negative predictive values of 73%, 90%, 82%, and 85%, respectively. Orbital wall angles, especially the medial wall, and muscular enlargement are independent risk predictors.

Prolapsed orbital fat: 15 consecutive cases

Prolapsed orbital fat has rarely been described and is often confused with other conjunctival tumours, such as dermolipoma. We describe the clinical features and treatment of 15 patients with prolapsed orbital fat. We report here our experience in 15 consecutive patients who presented to the Vision Institute of Federal University of São Paulo, Brazil, between July 2004 and December 2007. Age, sex, presenting complaint, physical findings, associated local and systemic diseases, type of treatment, and complications were recorded. Ten patients were men, and ages ranged from 44-86 (mean 68). Eleven patients presented with unilateral disease. Thirteen had superotemporal prolapse, and two atypical superonasal prolapse. Two gave a history of trauma. All patients had the prolapsed fat excised for cosmetic reasons. There were no complications. Orbital fat prolapse is usually superotemporal, mainly in men, and is easily differentiated from other lesions, such as prolapsed lacrimal gland. Excision is always indicated, usually for cosmetic reasons.

Fornix Fat Prolapse as a Sign for Involutional Entropion

To compare horizontal and vertical laxity of lower eyelids in patients with unilateral lower eyelid involutional entropion, introduce a reliable and common finding in involutional entropion, and review the literature. Prospective, comparative observational case series. Eighty patients with unilateral involutional entropion. Horizontal laxity was measured by recording the distance between the globe and the lower eyelid margin when pulled anteriorly with the eye in primary position (digital subtraction test). Vertical laxity was gauged by recording lower lid excursion between extreme up- and downgaze. Forniceal preaponeurotic fat prolapse was assessed by pulling the lower lid margin to the level of the inferior orbital rim and comparing the meniscus of protruding fat in each fornix. Forniceal fat pad height of <2 mm was graded as grade 1, and that of >or=2 mm as grade 2. Fornix fat prolapse. There were 43 males and 37 females, with a mean age of 77.70 years (range, 57-93 years) (standard deviation, 7.79). There were 47 patients with right-sided and 33 with left-sided entropion. The range of horizontal lid laxity was between 7.5 and 11 mm. The amount of vertical laxity assessed by lower lid excursion between extreme up- and downgaze ranged from 2 to 5 mm. Comparison between the affected and nonaffected sides failed to show a statistical difference in horizontal or vertical laxity (0.19<P<0.49). However, grade 2 forniceal fat height was observed to be significantly more on the affected than unaffected side (P = 0.000). Increased forniceal fat height is associated with lower lid entropion. Forniceal fat height represents a more accurate assessment tool for either lower lid retractor laxity or disinsertion than the lid excursion test.

Clinical Consideration of Uncinectomy for Endonasal Dacryocystorhinostomy

Purpose: To evaluate the effects of uncinectomy for osteotomy method during endonasal dacryocystorhinostomy (DCR). Methods: This retrospective review study comprised 102 nasolacrimal duct obstruction patients that underwent endonasal dacryocystorhinostomy with uncinectomy at our hospital between 2003 and 2006. The patients were classified into two groups based on records of preoperative endoscopic examination. Group A consisted of patients who had no nasal cavity abnormality, and Group B comprised patients who had a nasal cavity abnormality but received no treatment. Results: Sixty-four patients were included in Group B. The success rates of endonasal DCR were 89.5% in Group A and 90.6% in Group B, with no statistically significant difference between the two groups (p>0.99). There were no cases of mucosal burn, orbital fat prolapse, spinal fluid leak, maxillary sinusitis, or delayed bleeding. Conclusions: Anterior resection of the uncinate process is the most important surgical step to expose the medial aspect of the lacrimal fossa and to form the precise location of osteotomy during endonasal dacryocystorhinostomy. J Korean Ophthalmol Soc 49(6):871-877, 2008

Floretlike Cells in In Situ and Prolapsed Orbital Fat

Orbital pleomorphic lipoma has been rarely reported in the literature. Although floretlike cells are characteristic of pleomorphic lipoma, they are not pathognomonic. We reviewed cases of prolapsed orbital fat and exenteration specimens to determine the significance of presence of these cells in the diagnosis of orbital pleomorphic lipoma. Retrospective interventional case series with clinicopathologic correlation. Seventy-two specimens of 45 patients with prolapsed orbital fat and 74 exenteration specimens as controls. Histologic review of the specimens including light microscopy, Masson trichrome staining, immunostaining for S100, CD34, CD68, terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) assay, and transmission electron microscopy and review of clinical records and analysis of the data with generalized estimation equation. Evidence of histologic abnormalities in histologic specimens and clinical and demographic data. Floretlike cells were present in 31 of 72 (43%) specimens of prolapsed orbital fat and in 12 of 74 (16%) orbital exenterations. Fewer than 6 florets were present in twenty 40x high-power fields in 15 (48%), 6 to 10 in 9 (29%), and >10 in 7 (23%) specimens. The florets stained positive for CD34 but not for S100 or CD68. TUNEL assay revealed significant nuclear pyknosis, and transmission electron microscopy disclosed spindle-shaped cells with abundant rough endoplasmic reticulum and no basement membrane. The mean age of patients with prolapsed orbital fat with florets was 67 years (range, 52-86). Of 31 samples, 29 (94%) were from males. Of 30 samples, 29 (97%) were located in the superotemporal conjunctiva; only one was located in the lower lid. There was significant association between the presence of florets and location of the prolapsed orbital fat (P = 0.0013) and gender (P = 0.0015). Floretlike cells may be present in in situ and prolapsed orbital fat as a degenerative process. What some have called "orbital pleomorphic lipoma" is in fact only age-related orbital fat prolapse.

Traumatic orbital compartment syndrome: importance of prompt recognition and management

The orbit is a cone-shaped structure formed by rigid bony walls within which the globe and retrobulbar contents are encased. Anteriorly, the orbital septum and eyelids form another relatively inflexible boundary. The medial and lateral canthal tendons attach the eyelids to the orbital rim and also limit any anterior displacement of the globe. Although small increases in orbital volume can be compensated for by forward displacement of the globe and prolapse of fat, a rapid rise in intraorbital pressure normally ensues. This increase in pressure within the confined space of the orbit causes decreased perfusion with associated ischaemic damage not unlike that seen in other compartment syndromes. We report a case of traumatic orbital compartment syndrome successfully decompressed by means of a lateral canthotomy.

Subconjunctival Herniated Orbital Fat: A Benign Adipocytic Lesion That may Mimic Pleomorphic Lipoma and Atypical Lipomatous Tumor

Prolapse of subconjunctival intraconal orbital fat is a rare cause of an intraorbital mass lesion. Over the past several years, we have seen a number of cases in which this prolapsed fat was confused pathologically with a neoplasm of adipocytic lineage, specifically pleomorphic lipoma and atypical lipomatous neoplasm (well-differentiated liposarcoma). We report the clinical, histopathologic, and immunohistochemical findings in 21 specimens from 17 patients, all of whom presented with prolapsed intraconal orbital fat. All specimens were routinely examined and processed for light microscopy. Immunohistochemistry for CD34, CD68, S100 protein, vimentin, alpha-smooth muscle actin, and Ki-67, and Giemsa, Masson trichrome, and alcian blue histochemical stains were performed. Clinical and follow-up information was extracted from a chart review. The mean age (+/-SD) of the patients was 65.6+/-11.9 years (range: 41 to 85 y); 2 were women and 15 were men. Subconjunctival prolapsed orbital fat was localized in the superotemporal quadrant or lateral canthus around the rectus muscle below the lacrimal gland. The lesions were unilateral in 10 and bilateral in 7 patients. No recurrence was clinically evident over a mean (+/-SD) follow-up time of 2.5+/-3.2 years (range: 1 mo to 13.5 y). Histopathologically, all specimens showed an admixture of mature fat, fibrous septae lacking hyperchromatic cells, adipocytes with intranuclear vacuoles (Lochkern cells), multinucleated giant cells with a wreathlike configuration of normochromatic nuclei (floret cells), and varying numbers of histiocytes, lymphocytes, plasma cells, and mast cells. "Control" sections of normal orbital fat showed occasional Lochkern cells but lacked floret cells. By immunohistochemistry, the floret cells expressed only CD34 and vimentin, whereas the Lochkern cells expressed CD34, S100 protein, and vimentin. We conclude that subconjunctival herniated orbital fat commonly contains multinucleated floretlike giant cells, fibrous septae, and Lochkern cells, features that may result in diagnostic confusion with pleomorphic lipoma and atypical lipomatous neoplasms. Importantly, specific diagnostic features, such as aggregates of bland spindled cells associated with wiry collagen, as seen in pleomorphic lipoma, and enlarged hyperchromatic cells within fibrous septae, as in atypical lipomatous neoplasms, are entirely absent in herniated orbital fat. Multinucleated floret cells present in prolapsed orbital fat likely represent a reactive phenomenon, as they are not present in normal orbital fat.

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

Abstract Subconjunctival orbital fat prolapse is an uncommon benign entity. In addition to insufficient information concerning the mechanisms of the prolapse, detailed surgical methods that can be followed are uncommon in the literature. We prospectively studied six consecutive eyes in four males who were to undergo our novel surgical sequence, attempting to avoid postoperative complications by reconstructing intermuscular septa on the basis of the assumption that the spontaneous prolapsed fat at the superior temporal quadrant stemmed from intraconal fat. Intraoperative findings were in agreement with our hypothesis that the anterior part of the herniated fat is covered by both the intermuscular septum and Tenon's capsule. All the surgeries were uneventful and cosmetic improvement without postoperative complications was obtained. Our early results indicated the safety and efficacy of this newly developed technique for spontaneous orbital fat prolapse.

Prolapso de gordura orbitária bilateral associado a pterígio: relato de caso

Orbital fat prolapse is an uncommon benign entity that can cause esthetic defects. The authors present a 63-year-old patient with bilateral temporal orbital fat prolapse associated with a bilateral nasal pterygium. Clinical and surgical features are described. The clinical, imaging and histopathological diagnoses are discussed.

Spontaneous Subconjunctival Orbital Fat Prolapse: Presentation of Four Cases

Subconjunctival orbital fat prolapse is a benign entity characterized by orbital fat herniation through a dehiscence in Tenon's capsule, usually between the superior and lateral recti muscles. It is often associated with ocular trauma or surgery, although spontaneous cases have also been reported with a predilection for obese individuals. A retrospective study of four subconjunctival orbital-fat prolapse cases with no history of ocular surgery or trauma was performed. A trans-conjunctival surgical approach with Tenon's capsule repair was offered to all subjects. Differential diagnosis is discussed. The diagnosis of subconjunctival orbital fat prolapse was confirmed in all cases by histopathological examination. Functional and aesthetic postoperative results were excellent, with no recurrences during follow-up, for all cases. Although rare, subconjunctival orbital fat prolapse should be recognized. Surgical management offers excellent results.

Periorbital and midfacial rejuvenation via blepharoplasty and sub-periosteal midface rhytidectomy

The stigmata of midfacial ageing are the malar descent, lateral orbital festoon formation, tear-through deformity, deep melojugal sulcus, buccal fat pad and sub-orbicularis oculi fat (SOOF) prolapse, deep nasolabial folds and cutaneous and muscular descent. The signs of periorbital ageing include dermatochalasis, skin hooding of the upper eyelids, lacrimal gland prolapse, adipose prolapse, and lateral canthal descent and orbital septum diastasis. All of these deformities can be addressed through upper and lower blepharoplasties with arcus marginalis release, lateral canthopexy, sub-periosteal midface rhytidectomy with temporal suspension of the malar mound and SOOF repositioning. The same technique can be utilized for the restoration of facial symmetry after Bell's palsy. In the following report the technique and the authors’ experience in the rejuvenation of the periorbital and midface region are presented. There were a total of 20 patients in this series. Sixteen were female and 4 were male. All the patients were followed-up on a monthly basis after surgery for the first 6 months. They were then seen at 1 year post-surgery. All of the patients were evaluated by the senior author. In the beginning of the study there was 1 Asian female patient with mild postoperative ectropion, which resolved and did not require operative intervention. The patients experienced prolonged postoperative oedema. The patients were satisfied with their postoperative outcomes. In all patients, the goals of periorbital and midfacial rejuvenation were achieved with the above technique. Simultaneous periorbital and midfacial rejuvenation can be achieved via upper and lower blepharoplasties, lateral canthopexies and sub-periosteal midface rhytidectomy.

Orbital fat prolapse in a Persian cat. Case report

A two and a half-year-old female Persian cat was presented with a history of bilateral chronic ocular discharge. Epiphora bilateral mucous ocular discharge and a volume increase in bulbar conjunctiva on the dorsolateral quadrant of the right eye were noticed during routine ophthalmic examination. Ophthalmic examination and the aspiration cytology showed the presence of adipose tissue at the right eye dorsolateral quadrant indicating orbital fat prolapse.

Surgical resection of an orbital fat prolapse in a California sea lion (Zalophus californianus)

A 23-year-old captive female California sea lion (Zalophus californianus) developed an inferiotemporal subconjunctival swelling of the right eye. Surgical excision of the mass was performed and a diagnosis of orbital fat prolapse was confirmed histopathologically. There was no recurrence of orbital fat prolapse at 15 months post operatively. This is the first known case of orbital fat prolapse in the California sea lion.

Alterações palpebrais após a idade de 50 anos

To quantify the palpebral alterations occurring in subjects after the age of 50 years. An observational study was done with 325 subjects older than 50 years. The data comprised measurements of intercantal distance, palpebral fissure length and height, external and internal eyelid angles, margin reflex distance (MRD) and total palpebral fissure area. Digital images were obtained with a Sony Lithium movie camera at the frontal view in ocular primary position, with the object of observation being located at the height of the pupil. The images were saved on tape, transferred to a McIntosh G4 computer and processed with the NIH 1.58 program. The data were submitted to statistical analysis. The subjects presented dermochalasis (96.5%), eyebrow ptosis (60.8%), orbital fat prolapse (50.0%) or eyelid ptosis (39.1%). The alterations were bilateral in 68.8% of the subjects. The intercantal distance was higher with age; the eyelid fissure length, the margin reflex distance and the external angle decreased in the elderly. The differences were more important on evaluating each eye separately. Intercantal distance increase and palpebral fissure length, margin reflex distance and total eyelid area decrease with age.

Ptosis and Orbital Fat Prolapse after Posterior Sub–Tenon’s Capsule Triamcinolone Injection

To describe the occurrence of orbital fat prolapse and blepharoptosis after posterior sub-Tenon (PST) triamcinolone injection. Retrospective review of consecutive case series. Patients with ptosis and orbital fat herniation after PST triamcinolone injection. Charts of all patients with ptosis and orbital fat herniation presenting after PST triamcinolone injection to the oculoplastics service of the Cole Eye Institute between 1999 and 2003 were reviewed. Charts were reviewed for patient age, indication, dates of injections, time to patient complaint or time to referral for ptosis, and marginal reflex distance (MRD1). Ptosis and orbital fat herniation after PST triamcinolone injection. Eleven patients with a history of ipsilateral PST triamcinolone injections were seen with ptosis and orbital fat prolapse. Ten charts were available for review. Mean patient age was 64 years (range, 45-78 years). Patients underwent 1 to 9 ipsilateral injections, and 2 patients underwent bilateral injections. Patients were seen for ptosis evaluation on average 22.5 months (range, 3-56 months) after the initial injection, and 6.6 months (range, 0-20 months) after the most recent injection. All patients demonstrated significant orbital fat prolapse in conjunction with statistically significant ptosis (P = 0.016). Tissue was obtained in 3 cases. Histologic findings in 1 case showed orbital fat infiltrated by histiocytes that seemed to contain phagocytosed material. Posterior sub-Tenon triamcinolone injection may cause ptosis associated with orbital fat prolapse. This finding may be a relatively common complication of PST triamcinolone injection. We recommend counseling patients about this risk before PST triamcinolone injection.

What Causes Eyelid Bags? Analysis of 114 Consecutive Patients

The purpose of this study was to identify the anatomical basis for perception of lower eyelid bags in patients seeking aesthetic surgery and to evaluate the cumulative contribution of different anatomic characteristics before surgery. The histories and photographs of patients whose motivation for aesthetic consultation was lower eyelid bags were analyzed. Six categories of anatomic basis for the lower eyelid bags were identified. For each patient, a score from 0 to 4 was given in each category. The cumulative contribution score for each category was calculated as total points for that category for all patients, divided by the 456 total available points. The authors also developed a "uniqueness score" to reflect the percentage contribution of the worst identified anatomic problem compared with the other problems. This was calculated for each patient as the maximum score in one category, divided by total points for that patient. A total of 114 consecutive cases were evaluated (67 men and 47 women; mean age, 52 +/- 11 years; age range, 23 to 76 years). The cumulative contribution score for each anatomic variable was as follows: cheek descent and hollow tear trough, 52 percent; prolapse of orbital fat, 48; skin laxity and sun damage, 35; eyelid fluid, 32; orbicularis hyperactivity, 20; and triangular cheek festoon, 13. Prolapsed orbital fat and tear trough deformity both received the higher score and were more common in men as compared with women. The average uniqueness score was 38 percent, with a range of 20 to 75 percent. No one category played a dominant role for most patients. Tear trough depression, skin laxity, and triangular malar mound were significantly more common in patients older than 50 years. Linear regression analysis showed that recommendation for surgery is based on the extent of fat prolapse, skin elasticity, and midface descent. Significant positive correlations were found in all six categories and in uniqueness scores calculated by different observers (r values ranged from 0.31 to 0.73; p < 0.001, Pearson correlation), with the highest score in agreement with the contribution of eyelids fat (r = 0.73) and skin laxity (r = 0.66); the uniqueness score correlation was r = 0.45 (p < 0.001). Eyelid bags do not have a single anatomic basis. For different anatomic problems, different treatments are recommended.

Combined Arcus Marginalis Release, Preseptal Orbicularis Muscle Sling, and SOOF Plication for Midfacial Rejuvenation

Improvements have been made throughout the history of medicine, causing physicians to abandon a technique or medications clearly shown to be suboptimal. Unfortunately, this has not happened with rejuvenative surgery. Conventional lower eyelid procedures continue to include removal of orbital fat in most cases, and facelift procedures remain primarily a lateral vector pull. The unfortunate results of these traditional procedures are becoming easy to recognize. Optimal rejuvenation of the lower eyelid complex should be based on the principle that the contour changes characterizing aging involve not only prolapse of orbital fat, but also descent of the cheek tissues, resulting in accentuation of the orbital rim and tear trough groove. Although the necessity of preserving fat and repositioning the soft tissues of the midface has been widely accepted, there still is wide disagreement among authors as to the best approach and surgical technique. This report describes a surgical technique for lower lid midfacial rejuvenation that is a composite of several previously published approaches with some modifications, particularly in the way the Sub-Superficial Musculo Aponeurotic System (SMAS) fat pad is plicated and the midfacial tissues suspended. The technique is simple and safe, resulting in a pleasing natural midface contour.

Blépharoplastie esthétique supérieure et sourcil

Upper cosmetic blepharoplasty allows to treat cutaneo-orbicularis excess of the upper eyelid, which is often associated with fat prolapse. Using the same surgical way, it is also possible to treat external heaviness of the brow, mild brow ptosis and glabellar wrinkles. We will describe the most important stages of these different surgical techniques.