Chung Stella Y, Langer Paul D
Institute of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
Curr Opin Ophthalmol. 2017 Sep;28(5):470-476. doi: 10.1097/ICU.0000000000000407.
The current study reviews the recent literature on pediatric orbital blowout fractures and provides guidelines on their management.
The most common problem among patients requiring surgical revision of a previously repaired orbital floor fracture is an improperly placed orbital floor implant, usually erroneously placed under the posterior bony ledge. Although the transconjunctival incision can be combined with a lateral canthotomy and cantholysis, excellent surgical exposure can be obtained without the need for these latter relaxing maneuvers. In surgically repaired pediatric orbital blowout fractures with preoperative diplopia (both trapdoor and nontrapdoor), approximately 85% of patients recover completely over time. Delayed orbital tissue atrophy may play a role in the development of late enophthalmos.
Most cases of pediatric orbital fracture can initially be followed conservatively to determine if disabling diplopia, when present, resolves without surgery. A notable exception is the trapdoor fracture, in which herniated tissue becomes entrapped by a recoiled bone fragment, causing marked or complete reduction in motility and/or an oculocardiac reflex; we recommend that these fractures be repaired within 24 h from the time of diagnosis. Enophthalmos resulting from an orbital floor fracture does not need to be prevented with early surgery. Enophthalmos can be allowed to develop over time to determine if it is noticeable, and then repair undertaken, if necessary, at that time. When surgery is indicated, a simple transconjunctival incision is preferred over a cutaneous incision, and care should be taken to insure that the implant is placed on the bony ledge at the posterior edge of the defect. Many children with blowout fractures will not require surgery, and those that do usually have excellent outcomes provided the recommendations are closely followed.
本研究回顾了小儿眼眶爆裂性骨折的近期文献，并提供了治疗指南。
在需要对先前修复的眶底骨折进行手术翻修的患者中，最常见的问题是眶底植入物放置不当，通常错误地放置在后部骨嵴下方。虽然经结膜切口可与外眦切开及外眦松解术联合使用，但无需这些后期的松解操作即可获得良好的手术暴露。在术前存在复视（包括活板门型和非活板门型）的手术修复小儿眼眶爆裂性骨折中，约85%的患者随时间推移可完全恢复。延迟性眼眶组织萎缩可能在晚期眼球内陷的发生中起作用。
大多数小儿眼眶骨折病例最初可采用保守治疗，以确定存在的致残性复视是否可在不手术的情况下自行缓解。一个显著的例外是活板门骨折，其中疝出的组织被退缩的骨碎片卡住，导致活动度明显或完全降低和/或眼心反射；我们建议这些骨折在诊断后24小时内进行修复。眶底骨折导致的眼球内陷无需早期手术预防。可允许眼球内陷随时间发展，以确定是否明显，如有必要，届时再进行修复。当需要手术时，经结膜简单切口优于皮肤切口，应注意确保植入物放置在缺损后缘的骨嵴上。许多眼眶爆裂性骨折的儿童不需要手术，而那些需要手术的儿童，只要严格遵循建议，通常会有良好的预后。
