Pediatric orbital floor trapdoor fractures: outcomes and CT-based morphologic assessment of the inferior rectus muscle

An 11-year multicentric surgical experience on pediatric orbital floor trapdoor fracture: A World Oral Maxillofacial Trauma (WORMAT) project

INTRODUCTION

Trapdoor fractures of the orbital floor occur almost exclusively in the paediatric population. Despite being widely discussed in the literature, their management remains controversial. The objective of this retrospective study was to analyse the surgical experiences on paediatric trapdoor fractures in the maxillofacial centres participating in the WORMAT project.

MATERIALS AND METHODS

14 centres collected data for patients aged ≤16 years operated between January 2011 and December 2022. The demographic, cause and type of fracture, timing from injury to surgery, surgical approach, type of floor repair and outcomes were recorded. Diplopia, surgical wound infection, hardware loosening and dysesthesia in the infraorbital nerve area were recorded at follow-up.

RESULTS

43 patients were included: 25 children (0-12 y) and 18 adolescents (13-16 y) (mean age, 11.1 years). Surgical treatment was performed within 24 h in 51 % of the patients, within 24-72 h in 33 %, and beyond 72 h in the remaining. The orbital floor was repaired with a resorbable implant/membrane in 63 % of the patients, open reduction without an implant in 30 %, a titanium mesh implant in 3 adolescent patients. At follow-up (mean 16.3 months), 14 patients had residual diplopia in the upper fields, only two of these resolved within 6 months.

DISCUSSION

A tendency toward an increased incidence of postoperative diplopia with longer intervals between trauma and surgery was observed. This study showed different choices regarding the material placed on the floor, with a preference for open reduction without implants in children, compared to the use of resorbable implants or membranes in adolescents.

Diagnostic pitfalls in pediatric orbital entrapment fractures

Prompt diagnosis and management of orbital entrapment fractures in the pediatric patient have been advocated. This retrospective study analyzed a cohort of orbital entrapment fractures in pediatric patients with regard to diagnostic pitfalls, treatment and outcomes in a Level I trauma center in Germany. Based on medical records and radiological imaging, patients under the age of 18 years who presented with orbital fractures during 2009-2021 were analyzed. Overall, 125 patients presented with orbital fractures, of whom 29 patients (23.2%) had orbital entrapment fractures. The majority of patients presented with monocle hematoma (n = 23), diplopia (n = 20), and/or restricted extraocular eye movement (n = 14). While all patients with orbital entrapment fractures underwent three-dimensional imaging, 10 radiological reports (34.5%) did not include findings on orbital entrapment fractures. All patients underwent surgical exploration in less than 24 h. In 12 patients, clinical symptoms such as diplopia and restricted ocular elevation were documented upon postoperative evaluation before discharge. Considering the significant proportion of orbital entrapment fractures that are not noted on radiological imaging, prompt clinical examination should be initiated in pediatric patients at risk for orbital fractures. Urgent surgical intervention should be recommended in entrapment fractures.

Outcome Analysis of Surgical Timing in Pediatric Orbital Trapdoor Fracture with Different Entrapment Contents: A Retrospective Study

Orbital trapdoor fracture occurs more commonly in pediatric patients, and previous studies suggested early intervention for a better outcome. However, there is no consensus on the appropriate timing of emergent intervention due to the insufficient cases reported. In the current retrospective study, we compared the outcomes of patient groups with different time intervals from injury to surgical intervention and entrapment content. Twenty-three patients who underwent surgery for trapdoor fracture between January 2001 and September 2018 at Chang Gung Memorial Hospital were enrolled. There was no significant difference in diplopia and extraocular muscle (EOM) movement recovery rate in patients who underwent surgery within three days and those over three days. However, among the patients with an interval to surgery of over three days, those with muscle entrapment required a longer period of time to recover from EOM movement restriction (p = 0.03) and diplopia (p = 0.03) than those with soft tissue entrapment. Regardless of time interval to surgery, patients with muscle entrapment took longer time to recover from EOM movement restriction (p = 0.036) and diplopia (p = 0.042) and had the trend of a worse EOM recovery rate compared to patients with soft tissue entrapment. Hence, we suggested that orbital trapdoor fractures with rectus muscle entrapment should be promptly managed for faster recovery.

Does Early Treatment of Paediatric Orbital Fracture Offer Any Advantage in Terms of Post-Operative Clinical Outcomes

Background

Trapdoor fractures commonly occur in children below 6 years of age. The high resiliency of bone, pneumatisation of sinuses and other factors lead to entrapment of muscle and/or soft tissue which undergoes ischaemic changes leading to residual diplopia. The timing of intervention in children ranges from 24 h to greater than 2 weeks. Early surgical intervention is particularly indicated in cases of Oculocardiac reflex.

Methods

A Prisma guided systematic review of literature was conducted with no filters on language till September 2020. Studies on paediatric orbital fractures with data on timing of intervention and clinical outcomes were considered eligible for the review. The Oxford Level Of Evidence was used to assess the strength of individual studies.

Results

A total of 19 studies (18 English, 1 French) were selected; except for one study all were retrospective series. The timing of intervention ranged from 24 h to more than 1 month. Most of the studies agreed that orbital fractures in children should receive early intervention preferably within 2 weeks. In case of white-eyed blowout fracture, oculocardiac reflex and trapdoor fractures with muscle entrapment surgical intervention should be carried out within 24-48 h.

Discussion

Children presenting with facial injuries should be thoroughly examined for signs of muscle entrapment, diplopia, nausea, vomiting and bradycardia. If present these should receive early intervention. In cases with no signs of oculocardiac reflex and muscle entrapment a treatment within 2 weeks is recommended. If diplopia is mild or resolving with minimal hypoglobus and enophthalmos a wait and watch policy should be carried out.

White-eyed blowout fracture: A 10 days delayed surgical intervention and outcomes: A case report

The basis of the problem: Craniomaxillofacial trauma in pediatric group is less common with an incidence rate of 15% and the most commonly involved site is the fracture of orbital floor. Blow out fractures can either be pure or impure with trauma being the most predominant etiology. Method: Our case report present a 15 year old patient with a diagnosis of white eye blow out fracture reported ten days post trauma. The case was surgically dealt by releasing the entrapped inferior rectus muscle and placement of titanium mesh in the orbital floor with a postoperative follow up period of 6 months. Results: In the present report, although the eye movements i were evident without any restriction, the authors were unable to achieve a full range of eye movements due to delayed surgical intervention. Conclusion: Inferior rectus muscle entrapment is the most common entity encountered in cases of white eye blow out fractures, due to its close proximity with the orbital floor and lack of periodontal fat. Early diagnosis and immediate surgical intervention would bring about a best positive outcome in the management of white eye blow out fractures.

White-Eyed Blowout Fracture

White-eyed blowout fracture is often found in pure orbital floor blowout fracture among pediatric patients. Unlike common orbital blowout fractures with apparent clinical signs, the diagnosis of white-eyed orbital blowout fractures is difficult because of minimal soft-tissue signs. This report describes an early missed-out diagnosis of a white-eyed blowout fracture in a 7-year-old child, due to negligible soft-tissue manifestation.

Management of White-Eyed Blowout Fracture in the Pediatric Population

Aims and objectives

Diplopia in children is uncommon. However a small group of patients present with diplopia and severe restriction of upward globe movement which requires early diagnosis and prompt intervention. This study aims to evaluate the timing of intervention and functional outcome in the management of white-eyed blowout fractures.

Methodology

The study was conducted in a tertiary level trauma center. There were a total of 46 orbital floor injuries over a period of 2 years out of which 4 patients with white-eyed blowout fractures were identified. Details of each case were entered on a standard data base and analysed with respect to age, mode of injury, extent of limitation of gaze, timing of intervention, pre and post-operative diplopia. Minimum follow up period for every case was 1year.

Results

All of them had sports related injuries. Three of the four patients had complete recovery from diplopia with full range of eye movements. However one child with delayed presentation didn't recover fully and had persistence of symptoms within the functional range.

Conclusion

White-eyed orbital blowout fracture in kids though uncommon need prompt diagnosis and management for complete recovery. The initial clinical presentation mimics that of head injury and hence can be missed, leading to a delay in diagnosis resulting in incomplete recovery.

Clinical Outcome Following Surgical Repair of Small Versus Large Orbital Floor Fractures Using Polyglactin 910/Polydioxanone (Ethisorb®)

The aim of this retrospective study was to evaluate the clinical outcome of surgical management of small versus large, isolated orbital floor fractures (OFFs) using polyglactin 910/polydioxanone (Ethisorb®). Covering a four-year period (2010-2013), all records concerning midfacial fractures with involvement of the orbit were screened. Isolated fractures of the orbital floor as well as combined injuries of the orbital floor and medial wall that had been treated surgically using polyglactin 910/polydioxanone (Ethisorb®) were included. Patients underwent a preoperative, a postoperative, and a late ophthalmologic assessment. The clinical outcomes of surgically managed small OFFs up to 2 cm2 were statistically analyzed and compared to clinical results in larger defects. The final sample included 61 patients (25 women, 36 men). Fractures up to 2 cm2 were found in 33 patients (54.1%), whereas 28 patients (45.9%) suffered from OFFs larger than 2 cm2. The clinical outcomes did not significantly differ between both sample categories, and statistical analysis showed a power of 0.91 to detect a potentially existing difference. On final examination, 52 patients were free of any clinical symptoms, whereas minor issues were found in seven subjects, and two patients suffered from severe impairment. In conclusion, polyglactin 910/polydioxanone (Ethisorb®) seems to be a suitable material for surgical repair of both small and large OFFs.

Pure Orbital Trapdoor Fractures in Adults: Tight Entrapment of Perimuscular Tissue Mimicking True Muscle Incarceration with Successful Results from Early Intervention

Orbital trapdoor fractures (OTFs) entail entrapment of intraorbital soft tissues with minimal or no displacement of the affected bones and are almost exclusively seen in children. This article aimed to report the diagnosis and treatment of an OTF of the floor in an adult patient and to critically review the literature regarding the management aspects of this specific subset of orbital blowout fractures in adults. A 29-year-old man presented with limitations of vertical right eye movements owing to blunt orbital trauma. The patient mainly complained of double vision in upper gazes and some episodes of nausea. Neither floor defect nor significant bone displacement found on orbital computed tomography, while edema of inferior rectus muscle was apparent. The patient underwent surgical repair 5 days later; a linear minimally displaced fracture of the floor was recognized and complete release of the entrapped perimuscular tissues was followed. Within the first week postoperatively, full range of ocular motility was restored, without residual diplopia. This case was the only identified pure OTF over a 6-year period in our department (0.6% of 159 orbital fractures in patients >18 years). By reviewing the literature indexed in PubMed, a very limited number of either of isolated case reports or retrospective case series of pure OTFs has been reported in adults. Contrary to the typical white-eyed blowout fractures, the literature indicates that OTFs in adults seem to not always constitute absolute emergency conditions. Although such fractures need to be emergently/ immediately treated in children, in the absence of true muscle incarceration, adults may undergo successful treatment within a wider but either early or urgent frame of time. Adults frequently exhibit vagal manifestations and marked signs of local soft tissues injury.

Pediatric orbital wall fractures: Prognostic factors of diplopia and ocular motility limitation

OBJECTIVES

To investigate the factors affecting recovery of diplopia and limited ocular motility in pediatric patients who underwent surgery for orbital wall fracture.

DESIGN

Retrospective observational case series.

METHODS

In this retrospective observational case series, 150 pediatric patients (1-18 years old) who were diagnosed with orbital medial wall or floor fracture and underwent corrective surgery between 2004 and 2016 at Seoul National University Bundang Hospital were included. The medical records of patients with orbital medial wall or floor fracture were reviewed, including sex, age, diplopia, ocular motility, preoperative computed tomographic finding, and surgical outcomes. Factors affecting recovery of diplopia and ocular motility limitation were analyzed.

RESULTS

Of the 150 patients (134 boys; mean age, 14.4 years) who underwent corrective surgery for orbital wall fracture, preoperative binocular diplopia was found in 76 (50.7%) patients and limited ocular motility in 81 (54.0%). Presence of muscle incarceration or severe supraduction limitation delayed the recovery of diplopia. In case of ocular motility limitation, presence of muscle incarceration and retrobulbar hemorrhage were related with the delayed resolution. Multivariate analysis revealed supraduction limitation (Hazard ratio [HR] = 1.74, 95% confidence interval [CI] = 1.19-2.55), larger horizontal orbital floor defects (HR = 1.22, 95% CI = 1.07-1.38), and shorter time interval to first visit (HR = 0.73) as negative prognostic factors for the recovery of diplopia. In addition, muscle incarceration (HR = 3.53, 95% CI = 1.54-8.07) and retrobulbar hemorrhage (HR = 3.77, 95% CI = 1.45-9.82) were found as negative prognostic factors for the recovery of motility limitation.

CONCLUSIONS

Presence of muscle incarceration and retrobulbar hemorrhage, horizontal length of floor fracture, supraduction limitation, and time interval from trauma to first visit were correlated with the surgical outcomes in pediatric orbital wall fracture patients. These results strengthen that the soft tissue damage associated with bony fracture affects the orbital functional unit. When managing children with orbital wall fracture, meticulous physical examination and thorough preoperative computed tomography based evaluation will help physicians to identify damage of orbital functional unit.

Pediatric Orbital Floor Fractures: Clinical and Radiological Predictors of Tissue Entrapment and the Effect of Operative Timing on Ocular Outcomes

Orbital floor fractures can produce acute constitutional symptoms and poor ocular outcomes. This study aims to determine the clinical and radiological predictors of tissue entrapment in pediatric orbital floor fractures and to explore the effect of operative timing on ocular outcomes. The authors reviewed medical records from pediatric patients with orbital floor fractures from 2007 to 2015. One hundred fifty-two patients with 159 orbital floor fractures were included. One hundred twenty-two (80.3%) patients were male, and the mean age was 12.2 years. Twelve patients sustained orbital floor fractures with tissue entrapment. At presentation extraocular movement (EOM) restriction, diplopia, nausea, and vomiting were all associated with tissue entrapment (P < 0.001). Among patients with trapdoor fractures (determined by facial computed tomography), the presence of nausea and/or vomiting was predictive of tissue entrapment: positive predictive value 80%, negative predictive value 100%. For all the patients, regardless of fracture configuration, the presence of nausea and/or vomiting was valuable in ruling out tissue entrapment: sensitivity 83.3%, negative predictive value 98.1%. In tissue entrapment patients, poorer ocular outcomes (EOM restriction and diplopia) were associated with the length of operation (P = 0.007), but not the time interval to operation (P = 0.146). The authors conclude that nausea and vomiting are valuable predictors of tissues entrapment, particularly when EOM restriction and diplopia are equivocal. In the authors' study, radiological findings were also predictive of entrapment, but inconsistent language in this area limits the external validity of these results. The authors' study draws attention to the relationship between operation length and poorer ocular outcomes, suggesting that case severity/complexity and surgeon technique/experience may influence outcomes.

Pediatric Orbital Medial Wall Trapdoor Fracture with Normal Computed Tomography Findings

With advances in diagnostic technology, radiologic diagnostic methods have been used more frequently, and physical examination may be neglected. The authors report a case of pediatric medial orbital trapdoor fracture in which the surgery was delayed because computed tomography (CT) findings did not indicate bone displacement, incarceration of rectus muscle, or soft tissue herniation. A healthy 6-year-old boy was admitted to the emergency room for right eyebrow laceration. We could not check eyeball movement or diplopia, because the patient was irritable. Thus, we performed facial CT under sedation, but there was normal CT finding. Seven days later, the patient visited our hospital due to persistent nausea and dizziness. We were able to perform a physical examination this time. Lateral gaze of right eye was limited. CT still did not show any findings suggestive of fracture, but we decided to perform exploratory surgery. We performed exploration, and found no bone displacement, but discovered entrapped soft tissue. We returned the soft tissue to its original position. The patient fully recovered six weeks later. To enable early detection and treatment, thorough physical examination and CT reading are especially needed when the patient shows poor compliance, and frequent follow-up observations are also necessary.

Forced duction training: A potential key point for recovery in pediatric patients with trapdoor fracture

Trapdoor fracture is a type of orbital fracture frequently observed in pediatric patients after facial trauma. The treatment options and surgical outcomes associated with this fracture are controversial.This study investigated the surgery principles and strategies as well as the functional training for the recovery and prognosis of pediatric patients with trapdoor fracture.A retrospective study was conducted on 21 pediatric patients with orbital trapdoor fracture who received the transconjunctival approach for orbital defect reconstruction surgery between 2009 and 2014 at the Department of Ophthalmology, Shanghai Ninth People's Hospital. The minimum follow-up period was 1 year, and the average follow-up time was 2.5 years. These data included surgery principles and strategies, functional training for recovery, and patient prognosis.Of all the numerical variables, interval to surgery was the only parameter that affected the recovery of ocular movement and diplopia grades [ΔLEMSG (6 m:pre) = -2.689 + 0.015 • interval to surgery, P = 0.018; ΔLEMSG (last:pre) = -3.171 + 0.026 • interval to surgery, P = 0.033; Δdiplopia (6 m:pre) = -3.266 + 0.026 • interval to surgery, P = 0.047; Δdiplopia (last:pre) = -2.518 + 0.019 • interval to surgery, P = 0.031], whereas recovery was not affected by age or preoperative ocular movement or diplopia grades (P > 0.05). According to the categorical variable analysis, patient prognosis grouped by coordination to forced duction training varied across the different groups (P < 0.05); however, male and female patients did not differ with regard to prognosis (P > 0.05).To judge the prognosis of pediatric patients with trapdoor fracture, cooperation to forced duction training and interval to surgery are most likely key points. Correct surgical approaches and functional training are of great importance for faster recovery.

Prognostic CT findings of diplopia after surgical repair of pure orbital blowout fracture

PURPOSE

Diplopia is a common sequela of blowout fracture even after proper surgical management. We investigated the prognostic factors of diplopia after surgery of pure blowout fracture.

MATERIALS AND METHODS

We retrospectively reviewed CT images of 181 patients with pure orbital blowout fracture who underwent at least six months of postoperative follow-up. We evaluated the following CT factors: (1) fracture site (orbital floor, medial wall of the orbit, or both), (2) fracture type (closed flap, open flap), (3) fracture size, (4) volume of herniated orbital soft tissue, (5) ratio of volume of herniated orbital soft tissue to fracture size, (6) number of points of contact between extraocular muscle (EOM) and bony edge, (7) presence of EOM thickening, (8) EOM swelling ratio, (9) presence of displacement of EOM, (10) presence of deformity of EOM, (11) presence of tenting of EOM, and (12) presence of entrapment of EOM. The associations between diplopia at six months after surgical repair and various risk factors were analyzed using logistic regression models for univariable and multivariable analyses.

RESULTS

EOM tenting and deformity and ratio of volume of herniated orbital soft tissue to fracture size were found to be statistically significant risk factors of diplopia at six months after repair on univariable analysis (all P < 0.05). Patients who showed EOM tenting or deformity on CT images had 5.22 and 10.85 times greater probability of diplopia after surgery, respectively (P-value, <0.001 and 0.026; 95% confidence interval of odds ratio, 2.071-13.174 and 1.323-88.915, respectively). On the other hand, ratio of volume of herniated orbital soft tissue to fracture size was not significant on multivariable analysis (P = 0.472).

CONCLUSION

The prognosis of patients was predicted by CT evaluation. Patients who have tenting or deformity of EOM on CT scan are more likely to have postoperative diplopia.

Inaugural Survey on Practice Patterns of Orbital Floor Fractures for American Oral and Maxillofacial Surgeons

PURPOSE

In recent years, several studies have reported on practitioners' preferences for the treatment of orbital floor fractures, showing widely varying practice patterns. The purpose of the present study was to identify the practice patterns among oral and maxillofacial surgeons involved in the management of orbital floor fractures in the United States and compare them with the available published data.

MATERIALS AND METHODS

An anonymous survey was created and electronically mailed to surgeons. We also reviewed the published data on orbital floor fractures using a PubMed and MEDLINE search. The responses to the survey were analyzed using descriptive statistics.

RESULTS

The factors that had the greatest influence on the surgeon's decision to operate were a defect size > 2 cm2, enophthalmos, entrapment, and persistent diplopia. The most common surgical approach reported was a preseptal transconjunctival approach (32.0%), followed by the subciliary (27.9%) and postseptal transconjunctival (26.2%) approaches. The most commonly reported implant for orbital reconstruction was titanium (65.4%), followed by Medpor (43.7%) and composite Medpor and titanium (26.4%). The review of the published data showed a consensus among many of the operative indications mentioned, including a large defect size, enophthalmos, clinical entrapment, and persistent diplopia.

CONCLUSIONS

Oral and maxillofacial surgeons in the United States have a wide range of practice habits in the management of orbital floor fractures. Although the quality of the available evidence is poor, it supports a consistent approach to the management of orbital floor fractures in terms of the indications and surgical approach. The choice of reconstructive material and timing of repair remain more controversial. A clear need exists for improvement in the available data to help guide and set standards of care for the specialties managing orbital floor fractures.

White-eyed blowout fracture: Diagnostic pitfalls and review of literature

White-eyed blowout fracture was first termed by Jordan et al. in individuals sustaining a blow to the periocular area and presenting with ocular symptoms, although with minimal soft tissue signs of trauma. It is often found in pure orbital floor blowout fractures among paediatric patients, and it could manifest as a linear or hinge-like trapdoor deformity. Unlike the more common open orbital blowout fractures with distinct diagnostic clinical signs, white-eyed blowout fractures are rarer and their diagnoses can be easily missed, subsequently costing an optimal time window for surgical intervention. This is critical as better outcomes are found with earlier release of entrapments. This report describes a case of a white-eyed blowout fracture in a 10-year-old child faced with its diagnostic challenges. The current literature review discusses the types of fracture pattern, signs and symptoms, mechanism of action, as well as timing of surgery. In view of the common complication of persistent diplopia, clinical pitfalls in achieving this diagnosis are emphasized to prevent any delay of treatment. Current literature evidences are weighted towards urgent surgical intervention, as positive outcomes are found to correlate with earlier release of entrapments.

Complete reduction with traction of the infraorbital neurovascular bundle in a delayed patient with white-eyed blow-out fracture

In case of delayed surgery, if an orbital floor fracture involves the infraorbital canal, adhesions may form between the infraorbital neurovascular bundle and herniated muscle, and manipulations to reduce the fracture may lead to unexpected bleeding due to injury of the infraorbital artery. The author reports a case of a white-eyed blow-out fracture patient, who visited our clinic one-and-a-half months after the injury. Exploration of the fracture confirmed intensive fibrosis of the infraorbital neurovascular bundle and the entrapped inferior rectus muscle at the fracture site. The author was able to reduce the muscle completely with the release of the fibrotic tissue around the nerve bundle by using a vessel loop to safely retract the neurovascular bundle upwards, and obtained good results.

Surgical outcomes of orbital trapdoor fracture in children and adolescents

PURPOSE

Orbital trapdoor fractures are uncommon but more frequent in children and adolescents. Orbital trapdoor fractures have been discussed in many previous reports, early treatment has been advocated but there is controversy over treatment policy and surgical outcomes. Our retrospective study analyzed the surgical outcomes of orbital trapdoor fracture in children and adolescents to investigate the appropriate timing of treatment and the relationship between severity of extraocular muscle movement (EOM) limitation before the operation and the period of recovery after operation.

METHODS

A total of 44 children and adolescents with orbital wall fractures were operated on from 2009 to 2013. This study included 25 patients who underwent surgery for orbital trapdoor fractures; age range 9-18 years (mean age 14.0). We investigated the interval from trauma to surgery, the period of full EOM recovery after operation and the correlation between these factors, retrospectively.

RESULTS

The mean follow-up duration was 90.2 days. At follow-up, nine out of ten patients who underwent surgery within 24 h (Group 1) had full EOM recovery, with a mean recovery time of 25.1 days; five out of six patients who underwent surgery within 24-72 h (Group 2) had full EOM recovery with a mean recovery time of 60.2 days; and seven out of nine patients who underwent surgery after 72 h (Group 3) had full EOM recovery with a mean recovery time of 67.6 days. There was no statistical difference in the operation success rates between the groups. Also, the four patients that not completely recovered EOM had a mild EOM limitation below grade -1.

CONCLUSION

In our study, we found that patients with orbital trapdoor fractures can recover full EOM regardless of the interval from trauma to surgery. Therefore, we suggest that appropriate surgical technique is important in the treatment of patients with orbital trapdoor fractures, in addition to the urgent surgery recommended for these fractures in a pediatric population. Furthermore, we expect a good prognosis following the treatment of orbital trapdoor fractures if appropriate surgical techniques are used, even if a relatively long time has passed after the trauma.

Correlation between the Time to Surgery and That to Recovery from Postoperative Diplopia Based on a Single-Center, Retrospective Experience: A Case Series of 11 Patients

Background

We conducted this study to identify the correlation between the time to surgery and that to recovery from postoperative diplopia.

Methods

In the current single-center, retrospective study, we enrolled a total of 11 patients (n=11) who were diagnosed with white-eyed blowout fracture and underwent surgical operation at our institution between January 2009 and January 2013. To identify the correlation between the time to surgery and that to recovery from postoperative diplopia, we divided our patients into the three groups: the group A (time to surgery, <2 days) (n=4), the group B (time to surgery, 3-7 days) (n=4) and the group C (n=3) (time to surgery, 8-60 days). Then, we compared such variables as sex, age, signs of soft tissue injury, preoperative nausea/vomiting, the degree of preoperative diplopia and the side of the fracture on computed tomography scans between the three groups.

Results

In our series, mean age at the onset of trauma was nine years (range, 5-16 years); the mean time to surgery was 30 days (range, 2-60 days); and the mean follow-up period was one year (range, 6 months-2 years). Our results showed that the time to recovery was shorter in the patients with a shorter time to surgery.

Conclusions

We found that the degree of recovery from impaired ocular motility and diplopia was the highest in the patients undergoing surgical operations within 48 hours of the onset of trauma with the reconstruction of the fracture sites using implant materials.

Traumatic lysis of the inferior rectus muscle

BACKGROUND

The study aims to report a rare case of traumatic lysis of inferior rectus muscle after a traffic accident.

METHODS

This is a case report wherein the clinical features, computed tomographic findings, and surgical treatment were presented.

RESULTS

A 42-year-old woman complained of double vision and upward deviation of the left eye for 13 months after being involved in a traffic accident. The alternate prism and cover test both at distance and near testing showed an exotropia of 18 prism diopters (PD) and hypertropia of 50 PD of the left eye. The left eye had complete restriction of downward movement, and the forced duction test was negative. Computed tomography disclosed that the middle portion of the left inferior rectus muscle was absent. Diagnosis was traumatic lysis of left inferior rectus muscle. The deviation of the left eye was corrected by left superior rectus muscle recession and partial transposition of the medial and lateral rectus muscles. Six months after surgery, no deviation at the primary position both at distance and near testing was present; however, the left eye remained at a -3 restriction of downward movement.

CONCLUSIONS

Paralysis of the inferior rectus muscle may have resulted from the traumatic lysis, a rare clinical feature that can be confirmed by computed tomography.

Orbital trapdoor fractures

Orbital trapdoor fractures are commonly encountered in children. Awareness of trapdoor fractures is of particular importance. This is because early recognition and treatment are necessary to prevent permanent motility abnormities. In this article, we will provide a brief overview of orbital fractures. The clinical and radiographic features of trapdoor fractures will then be reviewed, followed by a discussion on their proper management.