RESUMO
BACKGROUND: Conjunctival prolapse (CP) is an uncommon but challenging condition following maximal levator resection (MLR) and other extensive periorbital procedures. MLR extending beyond the Whitnall's ligament is frequently performed to address severe blepharoptosis with poor levator function (LF). Patients with CP may encounter symptoms such as ocular discomfort, tearing, vision impairment, persistent conjunctival chemosis, lagophthalmos, or exposure keratopathy. Typically, surgical intervention becomes necessary if conservative measures prove to be ineffective; nevertheless, there is no consensus regarding the optimal treatment approach. OBJECTIVES: This study aimed to propose a simple sutureless direct excision method and explore the surgical advancements in CP correction through a systematic review. METHODS: Patients with recurrent CP after MLR who underwent sutureless direct excision of the conjunctiva using loupe magnifiers at a tertiary hospital were included in this study. The clinical evolution and surgical results were recorded. PubMed, MEDLINE, EMBASE, and Web of Science databases were queried following The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. RESULTS: The comprehensive analysis of 1858 articles identified 88 patients from 24 studies, highlighting that blepharoptosis surgery is predominantly associated with CP (36.6%). Surgically treated CP showed a higher resolution rate compared to those managed conservatively (54.8% vs. 45.2%; p = 0.034). No relapse was observed in patients treated with sutureless direct excision of CP in long-term follow-up. CONCLUSION: We proposed a simple sutureless direct excision technique that offers a straightforward and efficient approach in treating CP, which is particularly suitable for cases requiring excision lengths >16 mm during MLR. Furthermore, stitch removal can be obviated after surgery.
RESUMO
Diplopia is a common symptom after blowout fractures, with an incidence of 43.6%-83%. Although there is some consensus toward surgical correction, diplopia is not always resolved by surgery. Thus, there is a clinical dilemma for surgeons with regard to performing surgery at a specific time. This review aimed to create an algorithm to support accurate and effective decision-making. Methods: We reviewed articles published on PubMed during 2013-2020 regarding orbital fractures. Articles discussing surgical treatment for blowout fractures and diplopia were included. Five reviews, six prospective cohort studies, and 33 retrospective studies were identified. After reviewing and summarizing these articles, a step-by-step algorithm was created. Results: Most authors advise immediate surgery when a patient presents with either a positive oculocardiac reflex or a "trapdoor" fracture. Early surgical correction is recommended in children to prevent profound muscle damage. In other scenarios, most authors recommend performing surgery within 2 weeks. The algorithm begins with the aspect of motility, including muscle entrapment assessed by computed tomography or limited movement of the extraocular muscle. When there is no abnormality in motility, the algorithm continues to the aspect of position. Generally, an orbital floor defect of more than 50% or 2 cm2 or an enophthalmos of more than 2 mm is indicated for surgery. However, diplopia may also gradually resolve after improvement of periorbital edema or swelling. Conclusion: We proposed a step-by-step approach to help surgeons make effective decisions concerning surgical correction for patients suffering from blowout fractures with diplopia at different time points.