Denisova, Ksenia; Barmettler, Anne
Purpose of review
Refractive surgery is one of the most popular elective procedures performed in the world. Given that dry eye is a common complaint following keratorefractive surgery, evaluation, and treatment of periocular conditions that further predispose the patient to dry eye symptoms is an important part of the presurgical assessment. Periocular conditions and surgeries can also affect the ocular surface and keratometry, and should be addressed. For example, ptosis, orbital fat herniation, ectropion, and eyelid masses have been shown to induce corneal topography changes and astigmatism. The oculoplastic considerations for refractive surgery include both the contribution of eyelid position on dry eye, ocular surface damage, refractive error, and outcomes, as well as the timing of oculoplastic surgery in relation to the refractive surgery. In this review, the recently published literature on eyelid and orbital surgery in relation to keratorefractive surgery is reviewed to elucidate the relationship of periocular factors with refractive surgery outcomes and complications. To improve keratorefractive surgery outcomes, a literature review is presented, discussing evaluation, management, and timing of management of oculoplastics conditions.
Dry eye syndrome is a well known complication of keratorefractive procedures. This is exacerbated with concurrent eyelid or orbital disorders, such as ectropion, lagophthalmos, and thyroid eye disease. In addition to impacting dry eye and ocular surface damage, eyelid surgeries can also affect corneal topography and refraction. Studies have found that patients with ptosis have topographic corneal aberrations from the eyelid exerting pressure on the cornea, while ptosis repair and blepharoplasty patients may undergo an astigmatic change postoperatively. Finally, the corneal flap created in laser-assisted in situ keratomileusis may be at risk for displacement or damage postoperatively with this risk changing, depending on method of flap creation, and time elapsed since keratorefractive surgery.
Eyelid and orbital conditions that predispose to dry eye syndrome and refractive changes should be evaluated and optimized prior to keratorefractive surgery. Patients electing to have oculoplastic surgery, like ptosis repair, should be fully healed prior to any refractive surgery to allow both refractive changes and eyelid positions to stabilize prior to the refractive surgery.
Prendes, Mark A.; Geng, June; Ediriwickrema, Lilangi S.; Areephanthu, Christopher; Burchell, Patrick; Kikkawa, Don O.; Nunery, William R.; Korn, Bobby; Harold Lee, H. B.
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.
Roberto Secondi, Juan Carlos Sánchez España, Johnny Castellar Cerpa & Nuria Ibáñez Flores
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.
Junhyung Kim, Sang Woo Park, Jaehoon Choi, Woonhyeok Jeong, Seongwon Lee
We evaluated the relationship between infraorbital fat herniation and age-related changes in the bony orbit and orbital fat density using computed tomography. Two hundred and sixty-five patients were enrolled (60 patients were evaluated for changes in the bony orbit and 205 for changes in orbital fat density). Five measurements using parasagittal sections and one measurement using three-dimensional images were obtained. Intraorbital fat herniation length was positively correlated with orbital rim inclination. Lowering of the inferior orbital rim, which is connected to the orbicularis retaining ligament, tear trough ligament and orbital septum, can cause mechanical stretching of the lower eyelid and may contribute to infraorbital fat herniation. A strong and significant negative correlation was observed between orbital fat density and age, indicating that existing orbital fat can accommodate an enlargement in bony orbit volume without orbital fat hyperplasia/hypertrophy. In other words, an increased orbital fat volume may be a by-product of the adaptation of orbital fat to changes in bony orbit volume. Mechanical stretching of the lower eyelid due to ageing of the bony orbit and weakening of the lower eyelid due to age-related factors such as dermal/fat/muscle atrophy and loss of muscle tone can together result in anterior drooping of the lower eyelid. Therefore, age-related changes in the bony orbit contribute to intraorbital fat herniation.
Raparia, Eva; Rafailov, Leon; Shinder, Roman
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.
M K Yang, N Kim, H-K Choung and S I Khwarg
To report long-term outcome of new surgical technique for prolapsed subconjunctival orbital fat.
Patients and methods
Retrospective study was conducted on 48 eyes of 37 patients who underwent excision of prolapsed subconjunctival orbital fat with conjunctival fixation to the sclera. Complications and recurrence were evaluated.
The mean follow-up period was 39 months (range, 8–101 months). Two eyes (4.4%) developed recurrence at 4 and 8 years after surgery. No long-term complication was found.
The new surgical technique to manage prolapsed subconjunctival orbital fat using conjunctival fixation to the sclera was very useful and effective, with few recurrence and no long-term complication.