The white-eyed blowout fracture in the child: beware of distractions
A 14-year-old boy was playing soccer, when he sustained a blow from a knee to his left orbit. He sustained no loss of consciousness. He presented to his nearest emergency department. He was assessed and, as he was nauseous and vomited once, a decision was made to admit him under the paediatric services to monitor his head injury.\nHe had minimal periorbital bruising, and his visual acuity was 6/6; however, his ability to move his eye was reduced over the next 24h, and his diplopia worsened. His nausea and vomiting continued, and he had a head CT scan performed. This showed no brain injury; however, the scan discovered a left orbital floor fracture with entrapment of the inferior rectus muscle (Fig. ).\nHe was subsequently transferred to our unit, and when he arrived 60h after his initial injury, his left eye showed no vertical movement and very limited downward gaze and some preserved lateral and medial movement. Movements were painful. There was no subconjunctival haemorrhage; 6/6 visual acuity; his pupils were equal and reactive to light and he had marked diplopia in upward gaze. The patient kept the eye habitually closed to avoid diplopia.\nHe was urgently taken to theatre, where an open exploration of his left orbit was performed. This was performed via a second crease incision, and his Inferior rectus was successfully released.\nAt 1 month following surgery, his diplopia and range of ocular movement has improved significantly but has not completely returned to normal. He continues to be monitored under review.