The 'White-eyed' Orbital Blowout Fracture: An Easily Overlooked Injury in Maxillofacial Trauma

Pediatric Orbital Floor Reconstruction Using a Nonresorbable Polypropylene-Based Hernia Mesh: A Case Report

Orbital floor fracture is the most common type of orbit-related injury seen in pediatric age groups. It is also called a white-eyed blowout fracture when the usual signs of orbital fracture-periorbital edema, ecchymosis, and subconjunctival hemorrhage are absent. Several materials are used for orbital defect reconstruction. The most popular and widely used material is titanium mesh. We present a case of a 10-year-old boy with a white-eyed blowout fracture of the floor of the orbit of the left side. The patient had a history of trauma, after which he developed diplopia in the left eye. On examination, his upward gaze was restricted in the left eye, which was suggestive of inferior rectus muscle entrapment. The orbital floor reconstruction was done using a hernia mesh made up of nonresorbable polypropylene material. This case demonstrates the utility of nonresorbable materials in orbital defect reconstruction in pediatric patients. Further studies are needed to better understand the scope of polypropylene-based materials in the floor of orbit reconstruction and their benefits and shortcomings in the long run.

Combined Subciliary/Transantral Approach for Reconstruction of Orbital Floor Fracture

Orbital floor fracture, especially with constriction of orbital soft tissue, should be reconstructed surgically. Although various approaches to treat the orbital floor have been reported, procedures have not been unified among hospitals or surgeons. Since 2009, we have adopted a procedure combining a transorbital approach via subciliary incision with a transantral approach through upper gingival incision. The combined approach compensates for the shortcomings of each approach, leading to successful reconstruction. It is applicable safely for trapdoor fracture of the orbital floor in children, which more frequently constricts orbital soft tissue and which leaves permanent diplopia. This report retrospectively assessed clinical preoperative findings and postoperative outcomes of patients who received reconstruction of orbital floor fracture with the combined approach in our department from August 2009 through March 2021. Data of 21 patients with orbital floor fracture were analyzed, only one (4.8%) of whom had postoperative diplopia. Specifically, we describe children with trapdoor fracture treated with the combined approach, resulting in complete recovery. The combined approach stands as an excellent procedure for reconstruction of orbital floor fracture in adults and even in children.

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.

Repair of orbital floor fractures via the transantral approach with osteosynthesis plate

INTRODUCTION

The most common surgical access techniques employed in patients with orbital floor fractures are associated with a risk of complications, such as implant infection, migration, epiphora, lower eyelid retraction, ectropion, diplopia worsening, retrobulbar hematoma, emphysema, "white-eyed" syndrome, enophthalmia relapse, hypoglobus, and persistent diplopia due to periorbital atrophy. Consequently, alternative access techniques precluding these complications have to be found.

STUDY OBJECTIVE

To assess the efficacy of transantral approach in the surgical treatment of patients with orbital floor fractures based on results of retrospective analysis of our clinical experience.

MATERIALS AND METHODS

We performed a retrospective study of medical records and X-ray data of 52 patients with fractures of the floor of the orbit, 18 to 68 years old, treated using transantral approach as described in the article. Titanium plates of special shape were used for orbital floor reconstruction.

RESULTS

In 94.2% of the cases, adequate restoration of the floor of the orbit was achieved. It led to regression of the ocular signs. In 4 patients, diplopia remained in extreme gaze positions, which did not require surgical correction. The failed cases were related to incorrect positioning of the plate or fixing screws. No inflammatory complications were observed.

CONCLUSION

Transantral access approach may be a technique of choice in treating patients with orbital floor fractures; it is safe, minimally traumatic, and effective in the early posttraumatic period when the injured area is located in the posterior parts of the floor of the orbit.