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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 and Reconstructive Surgery: March 2017 - Volume 139 - Issue 3 - p 804e–805e
doi: 10.1097/PRS.0000000000003122

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,

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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.

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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.

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