Controversies in the Principles for Management of Orbital Fractures in the Pediatric Population

Dorafshar, Amir H. F.A.C.S., F.A.A.P.; Davidson, Edward H. M.A.(Cantab.), M.B.B.S.; Manson, Paul N. M.D.

Plastic & Reconstructive Surgery:
doi: 10.1097/PRS.0000000000003122
Letters
Author Information

Department of Plastic and Reconstructive, Surgery Johns Hopkins Hospital, Baltimore, Md.

Correspondence to Dr. Dorafshar, Johns Hopkins Outpatient Center, 601 North Caroline Street, Suite 8161, Baltimore, Md. 21287, adorafs1@jhmi.edu

Article Outline
Back to Top | Article Outline

Sir:

There are three large-scale studies in the plastic surgery literature, including the one presented by Coon et al.1–3 and others,4–6 that have evaluated the management of pediatric orbital fractures. Initially, it may appear that these studies have differing conclusions regarding when operative management is necessary; however, there is consensus that the absolute indications for operative repair are muscular entrapment and acute enophthalmos.

Differences between these studies can be attributed to a third group of patients—those who have large orbital floor defects, without clinical entrapment or acute enophthalmos (group 3 in Coon’s study, n = 46). Indeed, operative management of these injuries remains controversial in both adults and children.4,7,8 Coon et al. define broader indications for operative management in this subgroup of patients (volume change and persistent central gaze diplopia), and they report excellent outcomes in patients treated with surgery. Conversely, Losee et al. managed 88 percent of similar injuries nonoperatively, with clinically insignificant enophthalmos (i.e., not noticed by the family or documented in pediatric ophthalmology assessment) noted in only three of 22 patients. Losee et al. went further and identified a subgroup of patients with fractures involving more than 50 percent in length or width of the floor or displacement of three cortical thicknesses and found no incidence of clinically significant enophthalmos among the patients managed nonoperatively (n = 10).3 All of these patients have undergone continued pediatric ophthalmologic follow-up without any evidence of sequelae to date (personal communication). Interestingly, Broyles et al. found patients with some acute enophthalmos who were ultimately managed nonoperatively, and did not go on to have clinically significant enophthalmos as documented by patients’ families or treating providers. They also had no serious ophthalmologic sequelae such as amblyopia, strabismus, or persistent diplopia identified during long-term pediatric ophthalmologic follow-up.2 The study by Coon et al., however, did have substantially better follow-up data than the other two studies mentioned.

In this group of patients, the question of nonoperative versus surgical management remains controversial. Although Coon et al. have provided us their general indications for operative repair, prediction of enophthalmos, diplopia, and other negative sequelae in pediatric patients is complex and not clearly defined. There exists no single indicator or group of indicators that reliably define the complex interplay of fracture size, fracture pattern, fracture location, periorbita involvement, ligamentous sling condition (including rounding of the inferior rectus), level of prolapsed/displaced soft tissue, amount of fat atrophy, and degree of diplopia in each field of gaze to guide management for each individual age group, and perhaps Coon et al. can be more specific about giving objective criteria that define operative intervention for them.

The likelihood of implementing a large-scale randomized clinical trial in this population is low; however, this would be the ideal way to further analyze the mentioned variables to better define specific indications for operative management. Until then, meticulous assessment, interdisciplinary evaluation, and follow-up with a pediatric ophthalmologist and pediatric plastic/craniofacial surgeon with expertise in trauma are recommended, with detailed collection of these variables to allow for continued retrospective study and analysis.

Back to Top | Article Outline

DISCLOSURE

Dr. Dorafshar receives indirect research support and is entitled to royalties from KLS Martin. Dr. Dorafshar also receives research support from De Puy Synthes. Drs. Davidson and Manson have no financial interest to declare in relation to the content of this communication.

Amir H. Dorafshar, F.A.C.S., F.A.A.P.

Edward H. Davidson, M.A.(Cantab.), M.B.B.S.

Paul N. Manson, M.D.

Department of Plastic and Reconstructive Surgery

Johns Hopkins Hospital

Baltimore, Md.

Back to Top | Article Outline

REFERENCES

1. Coon D, Kosztowski M, Mahoney NR, Mundinger GS, Grant MP, Redett RJPrinciples for management of orbital fractures in the pediatric population: A cohort study of 150 patients.Plast Reconstr Surg20161371234–1240
2. Broyles JM, Jones D, Bellamy J, et alPediatric orbital floor fractures: Outcome analysis of 72 children with orbital floor fractures.Plast Reconstr Surg2015136822–828
3. Losee JE, Afifi A, Jiang S, et alPediatric orbital fractures: Classification, management, and early follow-up.Plast Reconstr Surg2008122886–897
4. Hink EM, Wei LA, Durairaj VDClinical features and treatment of pediatric orbit fractures.Ophthal Plast Reconstr Surg201430124–131
5. Hatton MP, Watkins LM, Rubin PAOrbital fractures in children.Ophthal Plast Reconstr Surg200117174–179
6. Brucoli M, Arcuri F, Cavenaghi R, Benech AAnalysis of complications after surgical repair of orbital fractures.J Craniofac Surg2011221387–1390
7. Luce EADiscussion: Pediatric orbital floor fractures: Outcome analysis of 72 children with orbital floor fractures.Plast Reconstr Surg2015136829–830
8. Putterman AM, Stevens T, Urist MJNonsurgical management of blow-out fractures of the orbital floor.Am J Ophthalmol197477232–239
Back to Top | Article Outline
GUIDELINES

Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.

Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.

Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/.

We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.

©2017American Society of Plastic Surgeons