Evaluating Lower Lid Complications in Preseptal Versus Retroseptal Transconjunctival Approaches for Orbital Fractures: Systematic Review and Meta-Analysis

Purpose: The present study compares lower eyelid complication rates between preseptal and retroseptal transconjunctival approaches for orbital fracture repair. Methods: MEDLINE, Embase, Cochrane, and Web of Science were searched from inception to November 2024 in accordance with PRISMA 2020 guidelines. Studies were included if they reported original data (n > 1) on orbital or peri-orbital fracture repair using either preseptal or retroseptal transconjunctival approaches, with at least 1 postoperative lower eyelid complication. Both comparative and single-arm studies were included due to limited available evidence. Risk of bias was assessed using RoB 2.0, ROBINS-I, and MINORS tools as appropriate. Pooled proportions and risk ratios were calculated using random-effects meta-analysis. Results: Three hundred studies were screened and 39 studies (n = 2665 patients) met inclusion criteria. Of these, 1976 patients underwent preseptal and 689 underwent retroseptal approaches. For isolated orbital floor fractures, a retroseptal approach was used more often (59.9%) than a preseptal approach (34.9%). Scleral show was the most frequent complication overall (1.4%) and was more common in retroseptal cases (2.9%) than in preseptal cases (0.9%). Entropion occurred in 0.8% of preseptal and 0.9% of retroseptal cases; ectropion occurred in 0.4% and 0.7%, respectively. The pooled proportion of total eyelid complications was 2% (95% CI: 1-5) for preseptal and 3% (95% CI: 1-9) for retroseptal approaches. Meta-analysis of 5 comparative studies (n = 556) demonstrated no significant difference in complication risk (RR 0.80; 95% CI: 0.26-2.41). GRADE certainty of evidence was moderate. Conclusions: Both transconjunctival approaches associated with low complication rates, but they are not clinically interchangeable. Retroseptal access may be preferred in older patients or isolated fractures requiring minimal dissection, while preseptal incisions may benefit younger patients or complex fractures requiring broader exposure. Until stronger comparative evidence emerges, patient anatomy and fracture pattern should guide approach selection.