Ptosis and orbital fat prolapse secondary to posterior sub–Tenon's triamcinolone injection

Abstract

Abstract: : Purpose: To describe a previously unreported complication of posterior sub–Tenon’s (PST) triamcinolone injection: orbital fat prolapse with or without blepharoptosis. Methods: Consecutive case series of patients with ptosis and orbital fat herniation presenting to the oculoplastics service of the Cole Eye Institute between 1999 and 2003. Charts were reviewed for age, dates of injections, time to patient complaint or time to referral for ptosis, and preoperative MRD₁. Photos were studied for evidence of orbital fat prolapse. Results: Eleven patients presented with ptosis and orbital fat prolapse having a history of ipsilateral PST triamcinolone injections. Patient age ranged from 52–80yo. Patients underwent between 1 and 7 ipsilateral injections and two patients underwent bilateral injections. Eight patients (73%) reported a history of new onset ptosis 1 to 36 months after injection. Patients presented to the oculoplastic service for ptosis evaluation on average 15 months (range, 3–36 months) after injection. All patients demonstrated significant orbital fat prolapse in conjunction with ptosis. The fat prolapse was typically easily identified as a fullness of the upper lid and lower brow. One patient demonstrated transconjunctival orbital fat prolapse. One patient developed a large mass inferior to the lateral canthus consistent with prolapsed fat. Tissue was obtained in two cases; one showed a histiocytic infiltrate within the orbital fat. The histiocytes appeared to contain phagocytosed material, perhaps representing the kenalog vehicle. Conclusions: PST triamcinolone injection may cause orbital fat prolapse into the anterior orbital space in addition to inducing ptosis. To our knowledge, orbital fat prolapse represents a previously undescribed complication of PST triamcinolone injection. Inflammation induced by the particulate kenalog vehicle may result in rarification of the orbital septum and levator aponeurosis, thereby producing the finding of fat prolapse in addition to ptosis. Patients should be counseled prior to PST triamcinolone injection that treatment may result in fat prolapse, ptosis, or both.

Keywords: eyelid • corticosteroids • injection