Lower eyelid herniation of orbital fat may complicate periocular corticosteroid injection

doi:10.1016/S0002-9394(02)01412-5

American Journal of Ophthalmology

Volume 133, Issue 6, June 2002, Pages 845-847

https://doi.org/10.1016/S0002-9394(02)01412-5 Get rights and content

Abstract

PURPOSE: To report a case of lower eyelid herniation of orbital fat occurring after periocular corticosteroid injection.

DESIGN: Interventional case report.

METHODS: A 44-year-old man with asymmetrical pars planitis complicated by right cystoid macular edema was treated with multiple right orbital floor injections of triamcinolone through the lower eyelid.

RESULTS: Right lower eyelid orbital fat herniation occurred during the course of the treatment.

CONCLUSION: A herniation of orbital fat may complicate the injection of corticosteroid through the lower eyelid.

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Requests for cosmetic eyelid surgery are frequent. The surgeon must carry out a complete clinical examination in order to rule out any orbital pathologies responsible for eyelid pockets.
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The clinical examination allows to look for signs of alarms, such as medical history, unilateral involvement, pain and the presence of exophthalmos. These should lead to perform orbital imaging and surgical biopsy if an orbital mass has been identified for histological analysis which will make the diagnosis. We identified four cases of orbital lymphoma, one foreign body granuloma, chronic bilateral dacryoadenitis, sarcoidosis involvement, AAPOX syndrom, cavernous hemangioma, and simple fatty hernia.
These cases shows the importance of not ignoring an underlying orbital pathology before proposing cosmetic surgery for eyelid pockets.
Periocular corticosteroid injections in uveitis: Effects and complications
2014, Ophthalmology
Citation Excerpt :
However, the effectiveness with different routes of application seems to be comparable in previous reports.6,20 Other adverse effects associated with periocular corticosteroid injections such as hypopigmentation, ptosis, and inadvertent globe perforation42 could not be evaluated in this retrospective study. We also could not adjust for the severity of ME or the presence of various degrees of cataract at baseline, or a history of corticosteroid-responsive IOP elevation events (or a lack thereof) before baseline.
To evaluate the benefits and complications of periocular depot corticosteroid injections in patients with ocular inflammatory disorders.
Multicenter, retrospective cohort study.
A total of 914 patients (1192 eyes) who had received ≥1 periocular corticosteroid injection at 5 tertiary uveitis clinics in the United States.
Patients were identified from the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study. Demographic and clinical characteristics were obtained at every visit via medical record review by trained reviewers.
Control of inflammation, improvement of visual acuity (VA) to ≥20/40, improvement of VA loss attributed to macular edema (ME), incident cataract affecting VA, cataract surgery, ocular hypertension, and glaucoma surgery.
Among 914 patients (1192 eyes) who received ≥1 periocular injection during follow-up, 286 (31.3%) were classified as having anterior uveitis, 303 (33.3%) as intermediate uveitis, and 324 (35.4%) as posterior or panuveitis. Cumulatively by ≤6 months, 72.7% (95% CI, 69.1–76.3) of the eyes achieved complete control of inflammation and 49.7% (95% CI, 45.5–54.1) showed an improvement in VA from <20/40 to ≥20/40. Among the subset with VA <20/40 attributed to ME, 33.1% (95% CI, 25.2–42.7) improved to ≥20/40. By 12 months, the cumulative incidence of ≥1 visits with an intraocular pressure of ≥24 mmHg and ≥30 mmHg was 34.0% (95% CI, 24.8–45.4) and 15.0% (95% CI, 11.8–19.1) respectively; glaucoma surgery was performed in 2.4% of eyes (95% CI, 1.4–3.9). Within 12 months, among phakic eyes initially ≥20/40, the incidence of a reduction in VA to <20/40 attributed to cataract was 20.2% (95% CI, 15.9–25.6); cataract surgery was performed within 12 months in 13.8% of the initially phakic eyes (95% CI, 11.1–17.2).
Periocular injections were effective in treating active intraocular inflammation and in improving reduced VA attributed to ME in a majority of patients. The response pattern was similar across anatomic locations of uveitis. Overall, VA improved in one half of the patients at some point within 6 months. However, cataract and ocular hypertension occurred in a substantial minority.
Single perioperative triamcinolone injection versus standard postoperative steroid drops after uneventful phacoemulsification surgery. Randomized controlled trial
2006, Journal of Cataract and Refractive Surgery
Citation Excerpt :
The potential serious complications reported with posterior sub-Tenon's injection of corticosteroids include perforation of the globe with or without intravitreal injection, central artery occlusion, and inadvertent injection into the choroidal or retinal artery circulations.18–20 Other complications that have been reported infrequently are subconjunctival hemorrhages, orbital fat atrophy, conjunctival infections and ulceration, lower eyelid orbital fat herniation, and proptosis.21–24 One of the potential side effects of corticosteroid administration by any route is raised IOP, and because of this we chose to use a smaller dose (20 mg) of triamcinolone at the beginning of the trial.
To evaluate the safety and efficacy of a single perioperative sub-Tenon's injection of triamcinolone following cataract surgery and its effect on the incidence of early pseudophakic cystoid macular edema (CME).
Ophthalmology Department, Queen's Medical Centre University Hospital, Nottingham. United Kingdom.
This prospective randomized controlled trial included 54 eyes (54 patients) having routine cataract surgery. Twenty-seven eyes received the conventional postoperative care with steroid drops (drops group), whereas the other 27 were given a perioperative sub-Tenon's injection of triamcinolone (injection group); 10 of these received 20 mg, and the remaining 17 eyes had 30 mg triamcinolone. All patients were evaluated preoperatively and at days 1, 8, 30, and 90. The outcome measures evaluated were logMAR best corrected visual acuity (BCVA), anterior chamber flare (Kowa-500 flare meter), intraocular pressure, and slitlamp biomicroscopy. Oral fluorescein angiograms were performed at 30 and 90 days to detect angiographic CME.
The mean logMAR BCVA improved from a baseline of 0.38 ± 0.38 (SD) and 0.44 ± 0.26 to 0.02 ± 0.14 and 0.0 ± 0.07 at 90 days in the steroid drops and injection groups, respectively. (P = .59). The mean flare increased from a baseline of 8.9 ± 3.2 photons/ms and 8.3 ± 3.7 photons/ms in the steroid drops and injection groups, respectively, to a maximum of ±14.1 photons/ms and 25.8 ± 7.5 photons/ms at day 8. Mean flare decreased to 15.8 ± 9.7 photons/ms and 13.8 ± 10.1 photons/ms at 30 days (P = .48, difference between groups) and 10.4 ± 3.6 photons/ms and 9.8 ± 3.1 photons/ms at 90 days, respectively, in the 2 groups. Subanalysis revealed lowest peak flare (17.9 ± 7.9 photons/ms) at 8 days in the group that received 30 mg triamcinolone.
A single sub-Tenon's injection of 30 mg triamcinolone seem to be safe and effective as a route of steroid delivery after uneventful phacoemulsification surgery. Larger numbers in patients at high risk are required to assess its effectiveness in reducing the risk for pseudophakic CME.
Ptosis and orbital fat prolapse after posterior sub-Tenon's capsule triamcinolone injection
2005, Ophthalmology
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.
Anterior segment complications following periocular and intraocular injections
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: Supported by the National Institute of Health (J.T.R.: #EYO6484), Research to Prevent Blindness (J.T.R.). J.R.S. is the recipient of a Research to Prevent Blindess Career Development Award.

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Brief reportLower eyelid herniation of orbital fat may complicate periocular corticosteroid injection

Abstract

Am J Ophthalmol

J Cataract Refract Surg

Am J Ophthalmol

Brief report
Lower eyelid herniation of orbital fat may complicate periocular corticosteroid injection