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Plastic and Reconstructive Surgery • April 2016
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;
(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
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