Editorial

Orbital “Blowout” Fractures: Time for a New Paradigm

Robert C. Kersten, MD - San Francisco, California
M. Reza Vagefi, MD - San Francisco, California
George B. Bartley, MD - Rochester, Minnesota

With the exception of pediatric trapdoor floor fractures (the recommendation for operating within 2 weeks was based on
so-called white-eyed blowout), which warrant immediate the putative belief that surgery would be more difficult and
repair to prevent sequelae of oculocardiac reflex and muscle less successful if delayed.14 Notably, this 14-day window
fibrosis, 1e3
the optimal management of so-called routine has been questioned because it is too long of a delay for
orbital blowout fractures remains controversial. Two issues repair of a tightly entrapped muscle, but too soon to allow
lie at the heart of the debate: the indications for repair and for the usual spontaneous resolution of diplopia that
the timing of repair. Unfortunately, there are no prospective, typically occurs in fractures other than the trapdoor
randomized clinical trials to guide decision making. variety. The formative study by Putterman et al6 regarding
4
More than 15 years ago, Burnstine assessed the the natural history of unoperated blowout fractures found
published literature, seeking to define the indications and that diplopia resolved in all patients within 6 months.
timing of repair for orbital blowout fractures. The study Similarly, Kasaee et al15 found in 72 patients with
reviewed relevant articles from 1983 to 2000, 31 of which blowout fractures followed up without surgery that
were selected to develop guidelines. All studies were diplopia resolved in all but 1 patient (1.4%) by 6 months
noncomparative, retrospective reports or case series, but after injury. In a more recent prospective study by Nishida
the criteria derived from them have been the standard of et al,16 diplopia resolved in all unoperated patients by an
care since that time. Burnstine advocated urgent repair for average of 7 weeks after injury, with a range of 19 to 143
trapdoor fractures with days.
entrapment of an extraocular Two issues lie at the heart of the Multiple authors have found
muscle by the fracture fragment that late enophthalmos is rare,
and marked restrictions of debate: the indications for repair and even in the case of large fractures.
vertical gaze, significant nausea the timing of repair. However, it is difficult to predict
and vomiting, or bradycardia from imaging studies in which
resulting from the oculocardiac reflex. He proposed patients it will develop.17e19 The study by Young et al20 (see
observing all other orbital fractures for 2 weeks before page 938) in this issue provides additional insight to the
repair. Such fractures can be categorized into 3 groups: ultimate outcome of such patients. They observed that the
(1) those associated with symptomatic diplopia and size of an unoperated fracture on imaging often decreases
positive forced ductions, computed tomographic evidence over time as the initial traumatic edema resorbs and bone
of entrapped perimuscular soft tissue, and minimal clinical remodels. Silverman et al21 recently presented a prospective
improvement; (2) fractures associated with significant multicenter trial in which large fractures were observed for
hypo-ophthalmos or enophthalmos; and (3) large floor up to 6 months after injury. Of 46 patients enrolled, 37
fractures (more than one half of the orbital floor displaced patients did not demonstrate enophthalmos of 2 mm or
more than 5 mm). more. Of the 9 patients who did demonstrate “significant”
Not included in the analysis were seminal studies from enophthalmos, only 50% were sufficiently concerned with
the 1970s by Emery et al5 and Putterman et al6 of orbital their appearance to choose delayed surgical repair. In those
blowout fractures that demonstrated no significant patients who opted for eventual surgical repair, there was
difference between surgical and nonsurgical groups in the no difference in outcomes between those having surgery
frequency of clinically significant enophthalmos or within 2 weeks’ time and those who underwent surgery at a
symptomatic diplopia when patients were observed for a later time.
prolonged interval without surgical repair. Our How about patients with persistent double vision?
understanding of the natural history of orbital fractures Although some studies have found that delayed operation
and the success of delayed surgical intervention has may have a lower chance of curing symptomatic
improved over the past decade. As mentioned previously, diplopia,14,22,23 other studies from several surgical disci-
although most surgeons agree on the need for urgent plines have found similar rates of resolution of double vision
repair of pediatric trapdoor fractures with an entrapped in early versus delayed intervention.7e13 All of these studies
extraocular muscle, it has been well established that good are retrospective and confounded by the inclusion of 2
results can be obtained when operating on fractures with groups of patients: (1) patients with trapdoor fractures that
persistent diplopia or enophthalmos, even when surgery is may not present immediately after injury and thus will bias
delayed well beyond the 2-week window.7e13 The the seemingly delayed surgical outcomes and (2) patients

796 ª 2018 by the American Academy of Ophthalmology https://doi.org/10.1016/j.ophtha.2018.02.014

Published by Elsevier Inc. ISSN 0161-6420/18
 Editorial

who underwent routine early surgery whose diplopia would repair. Trans Am Acad Ophthalmol Otolaryngol. 1971;75:
have cleared with observation over time. 802e812.
Further insight into the outcomes of these 2 groups of 6. Putterman AM, Stevens T, Urist MJ. Nonsurgical management
patients was provided by Biegi et al12 in their series of 79 of blow-out fractures of the orbital floor. Am J Ophthalmol.
orbital fractures. Although they advocated for early repair 1974;77:232e239.
7. Roncevic R, Stajcic Z. Surgical treatment of posttraumatic
of all fractures with documented extraocular muscle enophthalmos: a study of 72 patients. Ann Plast Surg.
entrapment, 2 of their patients sought treatment on a 1994;32:288e294.
delayed basis and both experienced persistent diplopia after 8. Dal Canto AJ, Linberg JV. Comparison of orbital fracture
surgical repair. They chose to observe all fractures with repair performed within 14 days versus 15 to 29 days after
diplopia and tissue incarceration at presentation, but no trauma. Ophthal Plast Reconstr Surg. 2008;24:437e443.
frank extraocular muscle entrapment, for 6 to 8 weeks 9. Simon GJ, Syed HM, McCann JD, Goldberg RA. Early versus
before deciding whether repair was necessary. They found late repair of orbital blowout fractures. Ophthalmic Surg La-
that, in most fractures with tissue incarceration but no frank sers Imaging. 2009;40:141e148.
trapdoor entrapment, initial diplopia cleared spontaneously 10. Amrith S, Almousa R, Wong WL, Sundar G. Blowout frac-
(24 of 42 patients). Importantly, in the 17 patients with tures: surgical outcome in relation to age, time of intervention,
and other preoperative risk factors. Craniomaxillofac Trauma
persistent diplopia after the period of observation, all were Reconstr. 2010;3:131e136.
successfully operated 4 to 5 months after injury with 11. Shin KH, Baek SH, Chi M. Comparison of the outcomes of
resolution of diplopia in all fields except extreme upgaze. non-trapdoor-type blowout fracture repair according to the
With these observations in mind, we believe it is time to time of surgery. J Craniofac Surg. 2011;22:1426e1429.
abandon the old paradigm of performing surgical repair of 12. Beigi B, Khandwala M, Gupta D. Management of pure orbital
large fractures or those associated with persistent diplopia floor fractures: a proposed protocol to prevent unnecessary or
within 2 weeks of injury. It has been our practice for many early surgery. Orbit. 2014;33:336e342.
years to follow the protocol advocated by others.12,24 We 13. Scawn RL, Lim LH, Whipple KM, et al. Outcomes of orbital
propose dividing patients into 2 groups: those (usually chil- blow-out fracture repair performed beyond 6 weeks after
dren) with trapdoor fractures and marked vertical limitation of injury. Ophthal Plast Reconstr Surg. 2016;32:296e301.
14. Hawes MJ, Dortzbach RK. Surgery on orbital floor fractures.
ductions, and all others. Patients with trapdoor fractures and Influence of time of repair and fracture size. Ophthalmology.
marked limitation of vertical gaze are taken to surgery as soon 1983;90:1066e1070.
as practicable. In such cases, surgical repair is inevitable, and 15. Kasaee A, Mirmohammadsadeghi A, Kazemnezhad F, et al.
delaying the operation risks greater morbidity and less satis- The predictive factors of diplopia and extraocular movement
factory postoperative outcomes. In the remainder of patients limitations in isolated pure blow-out fracture. J Curr Oph-
(the large majority), we advocate more prolonged observation thalmol. 2016;29:54e58.
to allow resolution of diplopia or development of cosmeti- 16. Nishida Y, Hayashi O, Miyake T. Quantitative evaluation of
cally significant enophthalmos. In those patients with ocular motility in blow-out fractures for selection of nonsurgically
diplopia, but without frank muscle entrapment, we are able to managed cases. Am J Ophthalmol. 2004;137:777e779.
reassure them that the diplopia typically resolves without 17. Vicinanzo MG, McGwin Jr G, Allamneni C, Long JA. Inter-
surgical intervention, but that should it persist, delayed sur- reader variability of computed tomography for orbital floor
fracture. JAMA Ophthalmol. 2015;133:1393e1397.
gery is still likely to achieve full restoration of functional
18. Goggin J, Jupiter DC, Czerwinski M. Simple computed
motility. Patients with large fractures also can be reassured tomography-based calculations of orbital floor fracture defect
that the development of late enophthalmos is uncommon, but size are not sufficiently accurate for clinical use. J Oral
that should it occur, subsequent repair can be pursued with no Maxillofac Surg. 2015;73:112e116.
increased risk of surgical complications. 19. Gilbard SM, Mafee MF, Lagouros PA, Langer BG. Orbital
blowout fractures. The prognostic significance of computed
tomography. Ophthalmology. 1985;92:1523e1528.
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1. Wachler BS, Holds JB. The missing muscle syndrome in 21. Silverman N, Nakra T, Schinder R. Large orbital floor fractured
blowout fractures: an indication for urgent surgery. Ophthal indication for surgery or not? In: 46th Annual Fall Scientific
Plast Reconstr Surg. 1998;14:17e18. Symposium of the American Society of Ophthalmic Plastic and
2. Jordan DR, Allen LH, White J, et al. Intervention within days Reconstructive Surgery; 2015 Nov 12e13; Las Vegas, NV.
for some orbital floor fractures: the white-eyed blowout. 22. Harris GJ, Garcia GH, Logani SC, Murphy ML. Correlation of
Ophthal Plast Reconstr Surg. 1998;14:379e390. preoperative computed tomography and postoperative ocular
3. Sires BS, Stanley Jr RB, Levine LM. Oculocardiac reflex motility in orbital blowout fractures. Ophthal Plast Reconstr
caused by orbital floor trapdoor fracture: an indication for Surg. 2000;16:179e187.
urgent repair. Arch Ophthalmol. 1998;116:955e956. 23. Liu SR, Song XF, Li ZK, et al. Postoperative improvement of
4. Burnstine MA. Clinical recommendations for repair of isolated diplopia and extraocular muscle movement in patients with
orbital floor fractures: an evidence-based analysis. Ophthal- reconstructive surgeries for orbital floor fractures. J Craniofac
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5. Emery JM, Noorden GK, Sclernitzauer DA. Orbital floor frac- 24. Chung SY, Langer PD. Pediatric orbital blowout fractures.
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 Ophthalmology Volume 125, Number 6, June 2018

Footnotes and Financial Disclosures

Financial Disclosure(s): The author(s) have no proprietary or commercial Correspondence:
interest in any materials discussed in this article. Robert C. Kersten, MD, Division of Oculofacial Plastic Surgery, Depart-
Supported in part by unrestricted grants to the authors’ institutions. ment of Ophthalmology, University of California, San Francisco, 10 Koret
Way, Room 301, San Francisco, CA 94143. E-mail: Robert.Kersten@ucsf.
edu.

Pictures & Perspectives

Bilateral Periorbital Impetigo Inducing Significant

Dermatitis and Cicatricial Eyelid Changes in an Adult
A 23-year-old man with history of eczema was referred for
evaluation of acute bilateral periorbital dermatitis. Examination
revealed bilateral upper and lower eyelid crusting (Fig 1A),
cicatricial ectropion (Fig 1B), and lagophthalmos. Cultures
grew Staphylococcus aureus, conferring a diagnosis of impe-
tigo. Oral clindamycin and antibiotic/steroid ointment yielded
dramatic clinical improvement in 1 week (Fig 1C). Impetigo is
a cutaneous infection most commonly seen in children and
caused by S. aureus and may present as secondary “impetigi-
nization” of recurrent eczema. It should be considered in adults
with a known history of eczema. Treatment with systemic
antibiotics and topical steroids is recommended in severe cases.
(Magnified version of Fig 1A-C is available online at
www.aaojournal.org).
NATALIE HOMER, MD
LARISSA HABIB, MD
NAHYOUNG GRACE LEE, MD
Massachusetts Eye and Ear Infirmary, Boston, Massachusetts

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