‘Frozen Eye’ ? Post Blowout Fracture Surgical Correction ? A Case Report

The Rationale: “Frozen Eye” is a very uncommon sequel after treatment of orbital blowout fractures requiring implant placement. Patient Concerns: The implant may faultily impinge on the ocular and extra?ocular muscle(s), causing the abnormality in the movement of the eye. Diagnosis: We present a 56?year?old male whose ocular implant impinged on muscle, causing “frozen eye” and had an infected implant. Treatment Outcomes: The same was removed and surgically corrected. The manuscript describes the details and discusses the possible mechanism that led to the “Frozen Eye”

Patient-Specific Implant for Primary Orbital Reconstruction: A Case Report

ABSTRACT @#The main aim of orbital fracture reconstruction is to restore the functional and aesthetic components of the eye. However, it is known that surgery for complex three-dimensional anatomy of the orbit is always a challenge. With recent advancements in technology, surgical predictability and outcomes have greatly improved. Several methods for orbital reconstruction surgery have been documented such as virtual surgical planning, intraoperative navigation, intraoperative imaging, and the use of patient-specific implant (PSI). PSI made of titanium can be designed by using a computer-aided design process and manufacturing (CAD-CAM) of CT-scan routinely used during diagnostic imaging. With precise analyses in shape and size followed by personalised implant design, the surgical precision can be alleviated further and at the same time, the surgical duration could be reduced with anticipation of better surgical outcomes. However, meticulous planning needs to be done preoperatively, with the timing of the surgery being an important factor. In the present case, pure orbital blowout fracture primarily treated with a personalised-implant solution derived from 3D-printing technology is described. Both pre-surgical and surgical workflow of this computer-assisted surgical method is elaborated. PSI for primary orbital reconstruction can be regarded as a viable alternative surgical solution including its working timeframe and adherence to the surgical protocol or algorithm.

Intraoperative Computed Tomography Image Fusion for Orbital Blowout Fracture Reconstruction

ABSTRACT@#Intraoperative computed tomography (CT) has been previously described and acknowledged for its use in orbital blowout fracture reconstructions. We described a clinical case series managed by this technique combined with intraoperative image fusion for accuracy in orbital implant position. In total, eight patients who sustained a total number of 19 orbital wall fractures were described. From the total number of 19 blowout orbital fracture reconstructions comprised of medial and inferior (floor) orbital fractures, malposition was identified in a total of four orbital implants by using image fusion. All cases of implant malposition were immediately revised intraoperatively. Subsequent fusion was carried out to confirm whether the revision was satisfactorily achieved. We found that the intraoperative image fusion technique utilised to determine orbital implant position, especially at the posterior ledge, further augmented the role of intraoperative CT scanning. Image fusion conceptually provides an immediate, real-time, and objective solution for intraoperative image analysis and potentially eliminates problems with misaligned CT images. It also reduces the need for the surgeon to ‘eye-ball’ the CT images acquired or the need for additional intraoperative time, since the patient’s head orientation is always axially at random during the acquisition of the CT. Conventional methods for CT image assessment are subjected to one’s own interpretation and may introduce inconsistent or longer intraoperative decision-making. The technique facilitates intraoperative decision-making and reduces the risk of orbital implant malposition in orbital blowout fracture reconstructions. Hence, surgical complication in relation to orbital implant malposition in orbital blowout fracture management could be minimised. In addition, no further postoperative imaging is required.

Clinical Manifestations and Computed Tomography Findings of Trapdoor Type Medial Orbital Wall Blowout Fracture

PURPOSE: To report the clinical manifestations and computed tomography (CT) findings of patients with a trapdoor type medial orbital wall blowout fracture.METHODS: From March 2009 to October 2016, the clinical records and computed tomography findings of patients who underwent surgical treatment for a trapdoor type medial orbital wall blowout fracture were retrospectively analyzed.RESULTS: A total of eight patients (six males and two females) were enrolled with a combined mean age of 14.4 years. Clinical manifestations were eyeball movement limitation (abduction and adduction) and ocular motility pain (eight patients, 100%), diplopia (seven patients, 87.5%), and nausea and vomiting (four patients, 50%). On CT, the distance from the orbital apex to the fracture site was an average of 22.0 mm and occurred in the middle position of the entire wall. Two patients had missed rectus completely dislocated into the ethmoid sinus through the fracture gap and six patients had definite involvement in the fracture gap and edema of the medial rectus muscle. The medial rectus muscle cross-sectional area was 47.7 mm² which was edematous compared to the contralateral eye (40.1 mm²). Orbital wall reconstruction was performed an average of 4.1 days after the injury. In all patients with oculocardiac reflex-like nausea and vomiting immediately improved after surgery. Six out of eight patients who had eyeball movement limitations (abduction and adduction) preoperatively showed adduction limitation after surgery. The eyeball movement limitation and diplopia disappeared 11.7 days and 46.7 days after surgery, respectively.CONCLUSIONS: Patients with trapdoor type medial wall blowout fracture showed characteristic computed tomographic findings and clinical manifestations such as eyeball movement limitation, ocular motility pain, diplopia, and oculocardiac reflex. An understanding of clinical findings and quick surgical treatment are therefore required. The type of eyeball movement limitation was abduction and adduction limitation preoperatively and adduction limitation postoperatively.

Outcome of posterior wall blowout in anterior cruciate ligament (ACL) reconstruction via anteromedial portal approach: A retrospective research in 20 patients with 6 years follow-up / 中华创伤杂志(英文版)

PURPOSE@#To evaluate the clinical outcome in patients who received anterior cruciate ligament (ACL) reconstruction via anteromedial portal with or without posterior wall blowout.@*METHODS@#Twenty patients with ruptured ACL, who have received ACL reconstruction via anteromedial portal between Apr 2012 and Oct 2013 were enrolled. According to the conditions of posterior wall, the patients were divided into 2 groups: posterior wall blowout group (10 patients) and posterior wall intact group (10 patients). The median follow up time were 63 (range 19-75) months and 60.5 (range 25-64) months in the 2 groups respectively. The clinical outcome was evaluated by knee joint physical examination, magnetic resonance imaging (MRI), the International Knee Documentation Committee (IKDC) 2000 subjective score, Lysholm score, Tenger score, difference of thigh circumference, KT-2000 and Biodex isokinetic dynamometer system.@*RESULTS@#No significant differences were found in terms of the IKDC score, Lysholm score, Tegner score, Lachman test positive rate or Pivot Shift test positive rate between the two groups. In KT-2000 and Biodex isokinetic dynamometer tests, the difference of muscle strength between affected knees and unaffected knees in posterior wall blowout group was not significant less than that of posterior wall intact group (p > 0.05). In addition, there is no statistical difference between the two groups in signal/noise quotient (SNQ) of the graft (p > 0.05) in post operative MRI.@*CONCLUSION@#Blowout of posterior wall in ACL reconstruction via anteromedial portal does not affect the clinical outcome as long as reliable fixation is taken intraoperatively.

Orbital wall restoring surgery with primary orbital wall fragments in blowout fracture

Most orbital surgeons believe that it's difficult to restore the primary orbital wall to its previous position and that the orbital wall is so thin that cannot be firmly its primary position. Therefore, orbital wall fractures generally have been reconstructed by replacing the bony defect with a synthetic implant. Although synthetic implants have sufficient strength to maintain their shape and position in the orbital cavity, replacement surgery has some drawbacks due to the residual permanent implants. In previous studies, the author has reported an orbital wall restoring technique in which the primary orbital wall fragment was restored to its prior position through a combination of the transorbital and transantral approaches. Simple straight and curved elevators were introduced transnasally to restore the orbital wall and to maintain temporary extraorbital support in the maxillary and ethmoid sinus. A transconjunctival approach provided sufficient space for implant insertion, while the transnasal approach enabled restoration of the herniated soft tissue back into the orbit. Fracture defect was reduced by restoring the primary orbital wall fragment to its primary position, making it possible to use relatively small size implant, furthermore, extraorbital support from both sinuses decreased the incidence of implant displacement. The author could recreate a natural shape of the orbit with the patient's own orbital bone fragments with this dual approach and effectively restored the orbital volume and shape. This procedure has the advantages for retrieving the orbital contents and restoring the primary orbital wall to its prior position.

Management of Orbital Blowout Fractures: ENT Surgeon's Perspective

A Meta-analysis of complications of orbital blowout fracture by surgical approaches / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM:To investigate the effect of conjunctival approach and skin approach on postoperative complications in orbital blowout fracture through Meta-analysis.<p>METHODS: Search literatures in PubMed, Web of Science, Cochrane library, OVID, Chinese biomedical literature database, Weipu, Wanfang and CNKI database from the establishment of the database to May 30, 2018. The main contents included randomized controlled trials and cohort studies about comparing the postoperative complications of orbital blowout fracture through the transconjunctival approach and subciliary approach. Meta-analysis of the incidence of complications was performed using Review Manager 5.3 statistical software.<p>RESULTS: A total of 7 cohort studies were included. The Newcastle Ottawa Scale(NOS)score showed that the quality of the included literature was above 6 points. Meta-analysis showed no significant difference in odds ratio(OR)between the transconjunctival approach group and subciliary approach group \〖<i>OR</i>=0.74, 95% <i>CI </i>(0.44-1.24),<i> P=</i>0.25\〗. Sensitivity analysis showed that the results of the Meta-analysis were stable and reliable. Funnel plot analysis showed that there might be publication bias in the included literature.<p>CONCLUSION: The effect of skin approach and conjunctival approach on the incidence of postoperative complications of orbital blowout fractures is not significant. The two approaches have their own advantages and disadvantages. It is necessary to combine the clinical practical considerations to select the most suitable surgical approach.

Research advances of clinical applications in repairing surgery for orbital fracture / 眼科新进展

As one of the common type of ocular injuries,orbital fracture can result in enophthalmos,diplopia and infraorbital nerve injury,which affects the physiological function of eyeball.Repairing surgery for orbital fracture should be treated for reconstructing the orbital anatomical structure in case of severe enophthalmos and diplopia,or infraorbital nerve injury.Meanwhile,it's crucial to identify the suitable surgery approach and implants because of the specificity and complexity of the orbit.What a clinician expected most is the ideal prognosis obtained easily with minimal operation complication.Transconjunctival approach should be applied as one of the standard approaches for repairing surgery of orbital fracture,offering good operative field with less complications.Titanium mesh and resorbable materials are the ideal implants at present,for their high level of stable quality and plasticity.More and more applications of 3D-printed rapid prototyping technique can guide the new directions of individualization and precision of repairing surgery for orbital fracture.

Treatment of orbtical blow-out fracture by surgical or conservative therapy: A retrospective study of 90 cases / 实用口腔医学杂志

Objective: To compare the effects of surgical and conservative therapy in the treatment of orbital blow-out fracture. Methods: 90 cases of obital blow-out fracture were treated by surgical(n = 40) and conservative(n = 50) trerapy respectively, the patients were fllowed up for 12 months. The treatment outcome was retrospectively analysed. Results: Of the 40 patients managed surgically 39 were with complete follow up data, 19 had diplopia in peripheral gaze before surgery, 13 (33％) had at 3-month and 12 (31％) had at 6-month follow-up. 31 had enophthalmus before surgery and 3(8％) had at 3-month and 6-month follow-up. Of the 50 patients managed conservatively 26 were with complete follow-up data, 11 had diplopia in peripheral gaze initially, 9(35％) had at 3-month and 8(31％) had at 6-month follow-up. 15 had enophthalmus initially and 13(50％) had at 3-month and 6-month followup. Conclusion: Surgical therapy is more effective for the treatment of enophthalmus. The effects tend to be stable 3 months after treatment, the ratio of diplopia in peripheral gaze after treatment by the 2 treatments is similar(about 30％ of the total cases).

Carotid blowout syndrome in patients treated by larynx cancer / Síndrome da ruptura da artéria carótida em pacientes tratados para câncer de laringe

Abstract Introduction: Carotid blowout syndrome is an uncommon complication for patient treated by head and neck tumors, and related to a high mortality rate. Objective: The aim of this study was to study the risk of carotid blowout in a large cohort of patients treated only by larynx cancer. Methods: Retrospective analysis of patients older than 18 years, treated by larynx cancer who developed a carotid blowout syndrome in a tertiary academic centre. Results: 197 patients met the inclusion criteria, 192 (98.4%) were male and 5 (1.6%) were female. 6 (3%) patients developed a carotid blowout syndrome, 4 patients had a carotid blowout syndrome located in the internal carotid artery and 2 in the common carotid artery. According to the type of rupture, 3 patients suffer a type I, 2 patients a type III and 1 patient a type II. Five of those patients had previously undergone radiotherapy and all patients underwent total laryngectomy. We found a statistical correlation between open surgical procedures (p = 0.004) and radiotherapy (p = 0.023) and the development of a carotid blowout syndrome. Conclusion: Carotid blowout syndrome is an uncommon complication in patients treated by larynx tumours. According to our results, patient underwent radiotherapy and patients treated with open surgical procedures with pharyngeal opening have a major risk to develop this kind of complication.

Resumo Introdução: A síndrome da ruptura da carótida é uma complicação incomum no paciente em tratamento para tumores de cabeça e pescoço, relacionada com uma alta taxa de mortalidade. Objetivo: O objetivo deste estudo foi estudar o risco de ruptura da carótida em uma grande coorte de pacientes tratados isoladamente por um câncer de laringe. Método: Análise retrospectiva de pacientes com mais de 18 anos, tratados por câncer de laringe em um centro de assistência terciária, que desenvolveram a síndrome da ruptura da carótida. Resultados: Ao todo, 197 pacientes atenderam aos critérios de inclusão, 192 (98,4%) eram do sexo masculino e 5 (1,6%) eram do sexo feminino. 6 (3%) desenvolveram síndrome da ruptura da carótida, 4 tiveram síndrome da ruptura da carótida localizada na artéria carótida interna e 2 na artéria carótida comum. De acordo com o tipo de ruptura, 3 pacientes apresentaram síndrome da ruptura da carótida tipo I, 2 pacientes, síndrome da ruptura da carótida Tipo III e um tipo II. Cinco desses pacientes haviam sido previamente tratados com radioterapia e todos os pacientes foram submetidos a laringectomia total. Encontrou-se uma correlação estatística entre procedimentos cirúrgicos abertos (p = 0,004) e radioterapia (p = 0,023) e o desenvolvimento de síndrome da ruptura da carótida. Conclusão: A síndrome de ruptura da carótida é uma complicação rara em pacientes tratados para tumores de laringe. De acordo com nossos resultados, pacientes submetidos a radioterapia e pacientes tratados com procedimentos cirúrgicos abertos com abertura da faringe apresentam um risco maior de desenvolver essa complicação.

Usefulness of Fibrin Glue in Transantral Orbital Floor Fracture Repair Using Bioresorbable Panel / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The purpose of this study was to evaluate the advantages and limitations of using fibrin glue for securing bioresorbable panels to reconstruct the fractured orbital floor by transantral approach. SUBJECTS AND METHOD: A retrospective study was conducted from July 2009 to July 2015 in 35 patients with pure orbital floor fractures. Nineteen patients underwent reduction surgery for inserting the bioresorbable panel and 16 patients underwent reduction surgery using fibrin glue for securing the bioresorbable panel via a transantral approach. In both groups, a chart review of preoperative and postoperative ocular symptoms, operation records, and complications was conducted. RESULTS: There was no significant difference between two groups in the demographic data of patients. Comparing the surgical outcomes between two groups, diplopia and mean discrepancy between fractured bone chip and intact orbital floor based on computed tomography scans showed much better results in the group that used bioresorbable panel secured by fibrin glue than in the bioresorbable only group. Furthermore, we carried out revision operations in six cases in the bioresorbable panel only group, where we found that the main cause of fracture to be the dislocation of bioresorbable panel. On the other hand, in the bioresorbable panel secured by the fibrin glue group, there were no reoperation and postsurgical complications. CONCLUSION: During the course of the study, we sensed orbital floor fracture repair using bioresorbable panel secured by fibrin glue via a transantral approach as an easy and effective technique with good postoperative results, and minimal implant related complications. This novel procedure is recommended as a surgical option for the reduction of orbital floor fractures, especially in large and posterior fractures.

The Reliability of the Transconjunctival Approach for Orbital Exposure: Measurement of Positional Changes in the Lower Eyelid

BACKGROUND: Lower eyelid incisions are widely used for the orbital approach in periorbital trauma and aesthetic surgery. In general, the subciliary approach is known to cause disposition of the lower eyelid by scarring the anterior lamella in some cases. On the other hand, many surgeons believe that a transconjunctival approach usually does not result in such complications and is a reliable method. We measured positional changes in the lower eyelid in blowout fracture repair since entropion is one of the most serious complications of the transconjunctival orbital approach. METHODS: To measure the positional changes in the lower eyelids, we analyzed preoperative and postoperative photographs over various time intervals. In the analysis of the photographs, marginal reflex distance 2 (MRD2) and eyelash angle were used as an index of eyelid position. Statistical analyses were performed to identify the significance in the positional changes. All patients underwent orbital reconstruction through a transconjunctival incision by a single plastic surgeon. RESULTS: In 42 blowout fracture patients, there was no statistical significant difference in the MRD2 and eyelash angle. Furthermore, there were no clinical complications, such as infection, hematoma, bleeding, or implant protrusion, during the follow-up periods. CONCLUSION: The advantages of the transconjunctival approach for orbital access include minimal scarring and a lower risk of eyelid displacement compared with other approaches. Based on these results, we recommend the transconjunctival approach for orbital exposure as a safe and reliable method.

Orbital blowout fracture reconstruction using titanium mesh pre-bent with computer-aided rapid prototy-ping technology / 医学研究生学报

Objective This study was to evaluate the clinical outcomes of orbital blowout fracture repair using the individual titanium mesh bent by computer-aided rapid prototyping . Methods The CT imaging data of 11 cases of orbital blowout fracture were analyzed.The subciliary approach was used for the exposure of the fractures .An appropriate 3D-printed titanium mesh pre-bent by computer-aided rapid prototyping was selected and implanted according to the characteristics of a given defect .The surgical results were analyzed by evaluating diplopia , eyeball movement , enophthalmos , and the position of the titanium mesh and comparing the orbital vol-ume before and after surgery . Results All the operations were successfully accomplished .No remolding or trimming was needed for the pre-bent titanium mesh and implanted titanium mesh was tightly fixed to the orbital wall .The patients were followed up for 3 -12 months, which revealed no symptoms of diplopia in any of the patients . Volumetric analysis showed a significantly reduced orbital volume difference from (2.60 ±0.43) mL preoperatively to (-0.07 ±0.62) mL postoperatively (P<0.01).Enophthalmos was desirably correc-ted, with the enophthalmos difference decreased from (2.35 ±0.81)mm preoperatively to (-0.10 ±0.52) mm postoperatively (P<0.01).No extra-ocular muscle limitation was observed . Conclusion The individual titanium mesh bent with computer-aided rapid prototyping technology can be applied to orbital blowout fracture repair , which may achieve a high success rate of anatomic restoration of the orbital volume and effective prevention of enophthalmos .

Analysis of Ocular Complications and Blowout Fracture in Orbital Blunt Trauma

PURPOSE: To help predict the severity of ocular complications in orbital blunt trauma by analyzing clinical features of ocular complications and orbital wall fracture. METHODS: A retrospective survey consisting of 169 eyes of 168 patients with orbital blunt trauma who visited Kosin University Gospel Hospital was performed. The patients' age, gender, height, weight, cause of accident, and ocular complications were investigated. The patients were imaged using computer tomography and divided into two groups according to whether they had orbital wall fracture: the orbital contusion group and the orbital wall fracture group. Variables of orbital wall fracture, including the location, length, width, and area were measured using computer tomography in the orbital wall fracture group. RESULTS: The incidence of ocular complication was 27 of 67 eyes (40.2%) in the orbital wall fracture group and 75 of 102 eyes (73.5%) in the orbital contusion group; ocular complications were found significantly more often in the orbital contusion group than in the orbital wall fracture group (p < 0.001). Among causes of the accident, 'flying object' showed the highest incidence of ocular complication at 40 of 48 eyes (85.1%). In the orbital wall fracture group, there was no significant difference in orbital fracture location, length, width or area between the ocular complication group and the non-ocular complication group. CONCLUSIONS: Ocular complications were found significantly more often in the orbital contusion group than in the orbital wall fracture group, and 'flying object' showed the highest incidence of ocular complication among causes of the accident.

Orbital Wall Reconstruction with Osteoconductive Unsintered Hydroxyapatite/Poly L-Lactide

PURPOSE: To evaluate the effect of orbital wall reconstruction with absorbable osteoconductive unsintered hydroxyapatite/poly L-lactide by assessment of the orbital volume via orbital computed tomography. METHODS: 24 patients who followed up at least 6 months after orbital wall reconstruction with unsintered hydroxyapatite/poly L-lactide were included. Retrospective clinical chart reviews for clinical manifestations and complications were performed, and orbital volume measurements were taken using the Eclipse Treatment Planning System (ver.13.0, Varian Medical System Inc., Palo Alto, CA, USA) through orbital computed tomography, which were taken before operation, right after operation, and at last follow up. RESULTS: Fourteen patients (58.3%) showed diplopia and extraocular muscle movement limitation preoperatively. Diplopia was resolved at last follow up and extraocular muscle movement limitation was improved at postoperative 6 months for all cases. The mean volumes of the fractured orbit and the unaffected orbit before operation were 23.62 ± 0.45 cm3 and 21.95 ± 1.01 cm3, respectively (p = 0.003). The mean volumes of the fractured orbit and the unaffected orbit right after operation were 21.65 ± 0.91 cm3 and 21.78 ± 0.83 cm3, respectively (p = 0.542). The mean volumes of the fractured orbit and the unaffected orbit at last follow up were 21.84 ± 0.93 cm3 and 21.81 ± 0.91 cm3, respectively (p = 0.889). CONCLUSIONS: Absorbable osteoconductive unsintered hydroxyapatite/poly L-lactide was effective for clinical improvement and orbital volume assessment in cases of orbital wall reconstruction and it can be used safely without definite implant related complications.

Orbital Wall Reconstruction with Osteoconductive Unsintered Hydroxyapatite/Poly L-Lactide

PURPOSE: To evaluate the effect of orbital wall reconstruction with absorbable osteoconductive unsintered hydroxyapatite/poly L-lactide by assessment of the orbital volume via orbital computed tomography. METHODS: 24 patients who followed up at least 6 months after orbital wall reconstruction with unsintered hydroxyapatite/poly L-lactide were included. Retrospective clinical chart reviews for clinical manifestations and complications were performed, and orbital volume measurements were taken using the Eclipse Treatment Planning System (ver.13.0, Varian Medical System Inc., Palo Alto, CA, USA) through orbital computed tomography, which were taken before operation, right after operation, and at last follow up. RESULTS: Fourteen patients (58.3%) showed diplopia and extraocular muscle movement limitation preoperatively. Diplopia was resolved at last follow up and extraocular muscle movement limitation was improved at postoperative 6 months for all cases. The mean volumes of the fractured orbit and the unaffected orbit before operation were 23.62 ± 0.45 cm3 and 21.95 ± 1.01 cm3, respectively (p = 0.003). The mean volumes of the fractured orbit and the unaffected orbit right after operation were 21.65 ± 0.91 cm3 and 21.78 ± 0.83 cm3, respectively (p = 0.542). The mean volumes of the fractured orbit and the unaffected orbit at last follow up were 21.84 ± 0.93 cm3 and 21.81 ± 0.91 cm3, respectively (p = 0.889). CONCLUSIONS: Absorbable osteoconductive unsintered hydroxyapatite/poly L-lactide was effective for clinical improvement and orbital volume assessment in cases of orbital wall reconstruction and it can be used safely without definite implant related complications.

Orbital Floor Fracture

The medial wall and floor of the bony orbit are frequently fractured because of the delicate anatomy. To optimize functional and aesthetic results, reconstructive surgeons should understand the anatomy and pathophysiology of orbital fractures. Appropriate treatment involves optimal timing of intervention, proper indications for operative repair, incision and dissection, release of herniated tissue, implant material and placement, and wound closure. The following review will discuss the management of orbital floor fractures, with the operative method preferred by the author. Special considerations in operation technique and the complication are also present in this article.

A Case of Pediatric Medial-Orbital Wall Fracture with Extraocular Muscle Entrapment

PURPOSE: To report a case of pediatric medial wall blowout fracture with entrapment of medial rectus muscle which can be easily misdiagnosed as a cerebral lesion. CASE SUMMARY: A 16-year-old male visited our clinic with headache, severe restriction of his right eye movement, and diplopia after a head injury due to falling occurring 1 day before evaluation. The patient was inebriated at the time of the accident and could not recall the event but occipital hematoma was palpable. Periorbital ecchymosis or edema was not observed with minimal soft tissue injury except mild conjunctival injection on slit-lamp examination. The patient had an 18 prism diopter exodeviation at primary position and severe medial and mild lateral gaze limitation in his right eye. Brain magnetic resonance imaging (MRI) showed no specific cerebral findings although trapdoor orbital medial wall fracture with incarceration of soft tissue and medial rectus muscle at the medial wall fracture site of his right eye was observed. Within 48 hours from the first evaluation, the blowout fracture was repaired and 50 days postoperatively, right eye gaze limitation and diplopia were nearly recovered. CONCLUSIONS: A case of pediatric blowout fracture with uncertain injury location, periocular ecchymosis, or edema absent could be misdiagnosed as a cerebral lesion. If a pediatric patient is experiencing gaze limitation, diplopia, nausea, or vomiting after trauma, neurological examination as well as evaluation for blowout fracture should be performed.