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Subconjunctival orbital fat herniation: repair with a new technique in one case/Subkonjontival orbital yag fitiklasmasi: bir olguda yeni bir teknikle onarim.

Summary

Spontaneous subconjunctival intraconal herniated orbital fat is a rare clinical condition. The common approach to herniated orbital fat treatment is excise the "excess fat". This paper discusses the possible explanations for spontaneous herniated orbital fat and offers a newly detailed surgical technique of relocating and repression rather than excision in a case. (Turk J Ophthalmol 2013; 43: 208-10)

Key Words: Herniated orbital fat, surgery

Ozet

Kendiliginden olan subkonjonktival intrakonal fitiklasmis orbital yag nadir bir klinik durumdur. Fitiklasmis orbital yag tedavisinde yaygin yaklasim asiri yagin eksizyonudur. Bu yazi kendiliginden olan fitiklasmis orbital yag icin olasi aciklamalari tartisacaktir ve yeni, detayli, eksizyondan ziyade yeniden yerlestirme ve baskilama cerrahi teknigini sunacaktir. (Turk J Ophthalmol 2013; 43:208-10)

Anahtar Kelimeler: Fitiklasmis orbital yag, cerrahi

Introduction

Orbital fat is divided into two compartments by the extraocular muscles and the intermuscular septum. Intraconal fat lies inner to this layer, and extraconal fat is external to it. (1) The outer surface of intraconal fat anterior to equator is enveloped by intermuscular septum; the inner surface is coated by Tenon's capsule lying between the fat and the sclera. (2) Extraconal fat is bordered by the orbital periosteum (outside), extraocular muscles and Tenon's capsule (inside), and the orbital septum (anterior). (3)

With aging, orbital septum becomes thinner and weaker, and extraconal fat may herniate, causing the well-known palpebral bags. Besides, surgery, trauma, or disease may cause a rent in the surrounding connective tissue including Tenon's capsule, the orbital septum, and Lockwood ligament allowing the extraconal fat to herniate into the eyelids or the intraconal fat to herniate into the subconjunctival space, medial to the lacrimal gland. (3)

The intraconal herniated orbital fat (HOF) may be confused with other lesions, such as lacrimal gland ptosis, lacrimal gland tumors, lipodermoids, and lymphoid tumors. The clinical, histopathological and computed tomographic findings are helpful in the differential diagnosis.

The common approach to HOF treatment is excise the 'excess' fat. (1,4,5) We report the case of a patient with unilateral spontaneous superotemporal subconjunctival HOF who was treated by relocating and repression rather than excision.

Case Report

A 74-year-old, non-obese (Body mass index <25 kg/[m.sup.2]) male patient presented with a unilateral epibulbar mass in the superotemporal quadrant of right eye. The patient had no history of systemic disease, orbital trauma, inflammation, infection, hemorrhage, or ocular surgery. The mass had a superficial vascular pattern and the well-defined anterior border was soft, yellow, slightly elevated, convex-shaped, easily repositioned into the orbit with a cotton tip applicator, and it could be made more prominent by retropulsion of the globe. The presumed diagnosis was subconjunctival HOF (Figure la). The palpebral lobe of the normal lacrimal gland could be distinguished from the fat prolapse by elevating the upper eyelid.

Preoperative magnetic resonance imaging (MRI) showed characteristic findings of low-density (fat compatible) areas between the sclera and the overlying lateral eyelid and conjunctiva (Figure 2). No abnormal lacrimal gland or an orbital mass was seen.

Local anesthesia was injected subconjunctivally directly into the area of HOF. An incision was made through the overlying conjunctiva. In this area, the conjunctiva was bluntly separated from the Tenon's capsule. It was observed that HOF was surrounded by a sheet of connective tissue (between Tenon's capsule and intermuscular septum) that was derived from both the conjunctiva and the sclera; the septum and the anterior Tenon's capsule were intact (Figure 3a). It was macroscopically evident that the revealed tissue was orbital fat. The HOF was pushed posteriorly. The intermuscular septum was sutured to the Tenon's capsule in the area of the HOF with interrupted 6-0 absorbable monofilament suture (6-0 polyglycolic acid suture, Steinberg, Belgium) and an average of five sutures was placed (Figure 3b). The HOF was retained postetiorly by this approximation of the intermuscular septum to the Tenon's capsule. The conjunctiva was closed with a continuous 8-0 absorbable monofilament suture (8-0 polyglycolic acid absorbable suture, Jestetten, Germany) (Figure 3c). Surgery was uncomplicated and cosmetic improvement was obtained. Figure 1 illustrates the preoperative, perioperative, and postoperative photographs of this patient.

During the follow-up period (18 months), any postoperative complications including recurrence, dry-eye symptoms or impairment of ocular motility caused by possible muscle restriction were not observed.

Discussion

Subconjunctival HOF is an uncommon clinical condition, in contrast to the extraconal fat, which is a frequent finding such as herniated fat pads of the lower eyelids in patients over 60 years of age. (3) It usually occurs in elderly (average onset of 65 years) obese men, unilaterally or bilaterally in the superotemporal quadrant of the eye. (3) Clinically, (an elevated, soft, yellowish mass with superficial blood vessels and a convex well demarcated anterior border), distinction from other ocular pathologies including dermoid cysts, dermolipoma, lacrimal gland abnormalities, and subconjunctival lipomas is usually possible. (1) In this case report, the patient was male but not obese, and was diagnosed clinically by its typical local findings. Also, orbital imaging was helpful for the diagnosis.

Sires et al (6) demonstrated that supetotemporal fat was not usually included in extraconal space. Furthermore, Koornneef reported that the thinnest intermuscular septum was in the superotemporal region. (7) In the light of this knowledge, because of slimming of the supetotemporal intermuscular septum with ageing, the intraconal fat may come forward without trauma, and the HOF may be surrounded by stretched intermuscular septum.

The approach to treatment of HOF has frequently been to excise the "herniated fat" (1,2,4,5), but excision of the orbital fat may be difficult, and postoperative bleeding from the pedicle of the removed fat is a potential risk for a retrobulbar hematoma. (1)

Otaka and Kyu exhibited their surgical procedure lacking a conjunctival opening: The HOF was pushed back, and the conjunctiva was fixed to the sclera with several stitches. (8) Howevet, in this technique, serious complications such as choroidal hemorrhage or rhegmatogenous retinal detachment by an accidental scleral perforation or restriction of eye movements by deeper (more posterior) sutures may occur.

In our technique, conjunctiva was opened and the intermuscular septum was fixed to the Tenon's capsule with several shallow stitches to preclude damage to the globe. This fixation limits additional fat herniation with minimal trauma to the intetmuscular septum.

We preferred this modification in the fat conserving technique to avoid serious complications and recurrence. Although further studies with many cases and long-term follow-up are needed to ascertain the safety and efficacy of this technique; relocating father than removing of HOF seems to be more favorable in selected cases.

In view of the fact that we observed a lasting excellent result, we recommend the procedure in similar patients.

DOI: 10.4274/tjo.43.21043

References

(1.) Monner J, Benito JR, Zayuelas J, Paloma V, Castro V, Serra JM. Transconjuctival herniation of orbital fat. Ann Plast Surg. 1998;41:658-61.

(2.) Sato K, Yamaguchi T, Yokota H. A surgical technique with connective tissue repair for the management of subconjunctival orbital fat prolapse. Clin Experiment Ophthalmol. 2006;34:841-5.

(3.) Schmack I, Patel RM, Folpe AL, et al. Subconjunctival herniated orbital fat: a benign adipocytic lesion that may mimic pleomorphic lipoma and atypical lipomatous tumor. Am J Surg Pathol. 2007;31:193-8.

(4.) Jordan DR, Tse DT. Herniated orbital fat. Can J Ophthalmol. 1987;22:173-7.

(5.) Glover AT, Grove AS Jr. Subconjunctival orbital fat prolapse. Ophthal Plast Reconstr Surg. 1987;3:83-6.

(6.) Sires BS, Lemke BN, Dortzbach RK, Gonnering RS. Characterization of human orbital fat and connective tissue. Ophthal Plast Reconstr Surg. 1998;14:403-14.

(7.) Koornneef L. Eyelid and orbital fascial attachments and their clinical significance. Eye. 1988;2:130-4.

(8.) Otaka I, Kyu N. A new surgical technique for the management of orbital fat prolapse. Am J Ophthalmol. 2001;131:67-9.

Melike Balikoglu-Yilmaz, Emine Sen *, Sule Yenigun *, Golge Acaroglu *, Faruk Ozturk *

Torbali Stare Hospital, Department of Ophthalmology, Izmir, Turkey

* Ulucanlar Eye Education and Research Hospital, Ankara, Turkey

Address for Correspondence/Yazisma Adresi: Melike Balikoglu-Yilmaz MD, Torbali State Hospital, Department of Ophthalmology, Izmir, Turkey Phone: +90 232 856 62 70 E-mail: drmelkebalkoglu@yahoo.com Received/Gelis Tarihi: 09.06.2012 Accepted/Kabul Tarihi: 18.09 2012
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Title Annotation:Case Report / Olgu Sunumu
Author:Balikoglu-Yilmaz, Melike; Sen, Emine; Yenigun, Sule; Acaroglu, Golge; Ozturk, Faruk
Publication:Turkish Journal of Ophthalmology
Article Type:Case study
Geographic Code:7TURK
Date:May 1, 2013
Words:1343
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