2017 Sec 1 Green Book

Plastic and Reconstructive Surgery • April 2016

(2) early enophthalmos; (3) persistent restrictive strabismus or diplopia in central gaze suggestive of restriction of orbital contents; and (4) anatomi- cally or functionally significant loss of orbital sup- port. Using these principles, early intervention to restore normal orbital volume and support can provide good long-term outcomes in visual acuity, globe position, and binocular eye function, with an acceptably low complication profile. Richard J. Redett, M.D. Department of Plastic Surgery Johns Hopkins Medical Institutions 1800 Orleans Street, 7314B Baltimore, Md. 21287 rredett1@jhmi.edu REFERENCES 1. Stotland MA, Do NK. Pediatric orbital fractures. J Craniofac Surg . 2011;22:1230–1235. 2. Losee JE, Afifi A, Jiang S, et al. Pediatric orbital fractures: Classification, management, and early follow-up. Plast Reconstr Surg . 2008;122:886–897. 3. Gerber B, Kiwanuka P, Dhariwal D. Orbital fractures in children: A review of outcomes. Br J Oral Maxillofac Surg . 2013;51:789–793. 4. Grant JH, Patrinely JR, Weiss AH, Kierney PC, Gruss JS. Trapdoor fracture of the orbit in a pediatric population. Plast Reconstr Surg . 2002;109:482–489; discussion 490–495. 5. Grant MP, Iliff NT, Manson PN. Strategies for the treatment of enophthalmos. Clin Plast Surg . 1997;24:539–550. 6. Wolfe SA, Ghurani R, Podda S, Ward J. An examination of posttraumatic, postsurgical orbital deformities: Conclusions drawn for improvement of primary treatment. Plast Reconstr Surg . 2008;122:1870–1881. 7. Escaravage GK Jr, Dutton JJ. Age-related changes in the pediatric human orbit on CT. Ophthal Plast Reconstr Surg . 2013;29:150–156. 8. Grunwaldt L, Smith DM, Zuckerbraun NS, et al. Pediatric facial fractures: Demographics, injury patterns, and associ- ated injuries in 772 consecutive patients. Plast Reconstr Surg . 2011;128:1263–1271. 9. Chapman VM, Fenton LZ, Gao D, Strain JD. Facial fractures in children: Unique patterns of injury observed by computed tomography. J Comput Assist Tomogr . 2009;33:70–72. 10. Coon D, Yuan N, Jones D, Howell LK, Grant MP, Redett RJ. Defining pediatric orbital roof fractures: Patterns, sequelae, and indications for operation. Plast Reconstr Surg . 2014;134:442e–448e. 11. Hawes MJ, Dortzbach RK. Surgery on orbital floor fractures: Influence of time of repair and fracture size. Ophthalmology 1983;90:1066–1070. 12. Hatton MP, Watkins LM, Rubin PA. Orbital fractures in chil- dren. Ophthal Plast Reconstr Surg . 2001;17:174–179. 13. Bansagi ZC, Meyer DR. Internal orbital fractures in the pediatric age group: Characterization and management. Ophthalmology 2000;107:829–836. 14. Egbert JE, May K, Kersten RC, Kulwin DR. Pediatric orbital floor fracture: Direct extraocular muscle involvement. Ophthalmology 2000;107:1875–1879. 15. KoltaiPJ,AmjadI,MeyerD,FeustelPJ.Orbitalfracturesinchil- dren. Arch Otolaryngol Head Neck Surg . 1995;121:1375–1379.

physical examination and important because late enophthalmos is a highly challenging prob- lem. Less appreciated is extraocular muscle func- tion and preservation of binocular stereo vision. Although it is not uncommon in the literature to see conclusions that “all diplopia resolved,” continued diplopia in children can lead to the development of compensatory mechanisms that may go unappreciated. We have seen a number of secondary referral patients whose diplopia has resolved despite detectable heterotropia because they have suppressed vision from the affected eye. The development of strabismus can be par- ticularly problematic in the context of younger children with a developing visual system and sig- nificant neuroplasticity. All children in this series had routine ophthal- mologic examinations, and only four patients had any detectable degree of heterotropia. By restoring orbital symmetry and addressing any restrictions in ocular movement, excellent visual acuity out- comes and maintenance of conjugate gaze can be obtained. Overall, operative intervention was well tolerated, with a 4.7 percent complication rate, including two patients with detectable hyperglobus and one that had inadequate enophthalmos correc- tion. Two patients required reoperation for removal of infected hardware. Only one patient desired correction of their globe malposition, which was addressed by plate removal to improve hyperglo- bus. Equally important, although impaired visual acuity was common on initial presentation, nearly all patients recovered excellent vision by the con- clusion of follow-up. Only two patients had worse than 20/40 visual acuity at the end of the follow-up, both of whom had sustained serious ophthalmo- logic injuries during their trauma (retinal injury and traumatic optic neuropathy, respectively) and had poor vision on initial presentation. CONCLUSIONS Orbital fractures are among the most common sequelae after blunt facial trauma in children. Many different criteria have been suggested to identify the need for operative intervention. In the largest series of isolated orbital fractures with good follow-up, we had a less than 5 percent complica- tion rate from reduction and internal fixation. Concomitant ophthalmologic injuries can often be predicted based on associated fracture patterns and should prompt delay in intervention until sur- gery is unlikely to aggravate the condition. Indi- cations for surgery can be divided into four main criteria: (1) entrapment of extraocular muscles;

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