Outcomes of orbital blowout fracture surgery in children and adolescents

Stuart C Carroll; Stephen G J Ng

doi:10.1136/bjo.2008.155143

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Outcomes of orbital blowout fracture surgery in children and adolescents

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Re:Response to Outcomes of orbital blowout fracture surgery in children and adolescents
Stephen G J Ng
Published on: 21 January 2011
Response to Outcomes of orbital blowout fracture surgery in children and adolescents
Stephanie K West
Published on: 26 July 2010

Published on: 21 January 2011
Re:Response to Outcomes of orbital blowout fracture surgery in children and adolescents
- Stephen G J Ng, Consultant Ophthalmologist
- Other Contributors:
  Stuart C Carroll
Dear Editor, we thank West et al. for their interest in our paper. Firstly, we wish to point out that as stated in our paper's conclusion, we fully endorse early surgery in all cases of paediatric & adolescent blowout fracture. We are committed to educating referrers and colleagues in other specialities to recognize & refer these patients as soon as possible. Secondly, West et al claim that we did not adequatel...
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Dear Editor, we thank West et al. for their interest in our paper. Firstly, we wish to point out that as stated in our paper's conclusion, we fully endorse early surgery in all cases of paediatric & adolescent blowout fracture. We are committed to educating referrers and colleagues in other specialities to recognize & refer these patients as soon as possible. Secondly, West et al claim that we did not adequately highlight patients with white-eyed blowout fractures who they presume have muscle ischaemia and poorer outcomes. Jordan et al's paper on white-eyed blowout fractures postulated that perimuscular soft tissue entrapment causes muscle ischaemia due to a "compartment-type syndrome"1. This remains unproven. Iliff et al's clinical and experimental animal study could not confirm the existence of orbital compartment syndromes in blowout fractures2. They identified direct muscle damage, nerve contusion and incarceration of the muscular fascial network as more likely causes of postoperative diplopia. If muscle ischaemia was present, urgent surgery (within hours) to prevent muscle necrosis would be indicated. Other causes of muscle damage may not require the same degree of urgency. Further information on the causes of diplopia and prospective randomized trials comparing outcomes after various intervals to surgery are required. Until more is known, our stance on white-eyed blowout fractures is not dogmatic: each case is considered individually and surgery is performed as soon as practicable. This approach does not preclude urgent surgery if it is required.
West et al. also stated that our results may have been better if our patients with white-eyed blowout fractures had undergone earlier surgery. They compared our results with three studies 3-5. Unfortunately, each study presents its results differently. We described diplopia on extreme gaze as self-reported or elicited on examination. We consider these children did not have significant diplopia. Ethanadan et al describe a similar group with diplopia as not "relevant" for day to day activites3. Gerbino et al describe three motility outcomes: full extraocular muscle recovery, diplopia in supraduction & vertical diplopia4. They did not state if postoperative diplopia in their cases was functionally significant or elicited on examination only. Bansagi et al used a numerical scale for comparing supraductions before and after surgery instead of reporting on diplopia5. Comparison of our results and those of other studies is difficult. We do not accept that our results are necessarily inferior to other studies' results when consensus on describing motility outcomes is lacking.
1. Jordan DR, Allen LH, White J et al: Intervention within days for some orbital floor fractures: The white-eyed blowout. Ophthal Plast Reconstr Surg 1998;14(6):379-390.
2. Iliff N, Manson PN, Katz J et al. Mechanisms of extraocular muscle injury in orbital fractures. Plast Reconstr Surg 1999;103:787-99
3. Ethunandan M, Evans BT. Linear trapdoor or "white-eye" blowout fracture of the orbit: not restricted to children Br J Oral Maxillofac Surg. 2010 May 12 [Epub ahead of print]
4. Gerbino G et al. Surgical Management of Orbital Trapdoor Fracture in Pediatric Population. J Oral Maxillofac Surg 2010; 68: 1310-1316.
5. Bansagi ZC, Meyer DR. Internal orbital fractures in the pediatric age group: characterization and management. Ophthalmology 2000; 107(5): 829-836.
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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Published on: 26 July 2010
Response to Outcomes of orbital blowout fracture surgery in children and adolescents
- Stephanie K West, specialist registrar
- Other Contributors:
  Julia E Hale, Richard W Lee, Sachin M Salvi, Helen M Herbert
Dear Editor, We thank Authors S.C. Carroll et al for their interesting paper on the Outcomes of orbital blowout fracture surgery in children and adolescents.1 We agree that autonomic symptoms of nausea and vomiting should alert the clinician to the high likelihood of significant orbital trauma. This study shows that the overall outcomes for all patients under the age of 20 were good despite delays. However, this is a hete...
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Dear Editor, We thank Authors S.C. Carroll et al for their interesting paper on the Outcomes of orbital blowout fracture surgery in children and adolescents.1 We agree that autonomic symptoms of nausea and vomiting should alert the clinician to the high likelihood of significant orbital trauma. This study shows that the overall outcomes for all patients under the age of 20 were good despite delays. However, this is a heterogeneous group of patients with orbital floor fractures with and without entrapment. We are concerned that young patients with muscle entrapment (white eye blow out fracture) who are at risk of ischemia are not being highlighted in this paper. The data in this series does support early intervention for the two subgroups of trapdoor fractures. These groups included 6 patients with open trapdoor fractures and 6 patients with linear closed trapdoor and in which there is a greater risk of presumed muscle ischemia and poorer outcome. Follow up data was only available for 4 of the 6 linear closed trapdoor fractures, all of whom received their surgical intervention within 2 weeks (2 within 2 days); the one that fully recovered did not have entrapment of their inferior rectus in the fracture and the other 3 were left with residual diplopia in extreme gaze. Those patients with open trapdoor fractures all had surgery within 8 days and all but 1 regained full ductions but not all were symptom free. As per your comments in the discussion, the depressed plate fractures are lower risk and indeed did have good outcomes despite delayed surgery. In fact, in this series the significant delays were in this patient group and the trapdoor fractures were all operated on within 2 weeks. Previous studies have shown that intervention within 14 days results in complete recovery of supraductions 2. More recent studies have shown intervention within 7 days3 or within 24 hours4 also gives complete resolution of any symptoms of diplopia. We, therefore, feel it important to highlight that your data does support intervention for trapdoor fractures within 2 weeks (median 4 days) and we feel it is possible that some of these patients may have been completely symptom free if operated on earlier. We would encourage colleagues to operate on these patients as soon as possible to not only maximise potential recovery but also to alleviate any vagal symptoms.
1. Carroll SC, Ng SGJ. Outcomes of orbital blowout fracture surgery in children and adolescents. Br J Ophthalmol 2010; 94: 736-739
2. Bansagi ZC, Meyer DR. Internal orbital fractures in the pediatric age group: characterization and management. Ophthalmology 2000; 107(5): 829-836.
3. Ethunandan M, Evans BT. Linear trapdoor or "white-eye" blowout fracture of the orbit: not restricted to children Br J Oral Maxillofac Surg. 2010 May 12. [Epub ahead of print]
4. Gerbino G et al. Surgical Management of Orbital Trapdoor Fracture in Pediatric Population. J Oral Maxillofac Surg 2010; 68: 1310-1316.
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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