Screening Criteria for Detecting Severe Ocular Injuries in the Setting of Orbital Fractures

Are Orbital Fracture Location, Visual Disturbances, and Head Injury Associated With Severe Ocular and Periocular Injuries? A Retrospective Cohort Study

BACKGROUND

Cranio-maxillofacial fractures involving the orbits are common and may be associated with severe ocular and periocular injuries (OPOIs) requiring prompt management.

PURPOSE

The purpose of the study was to measure the association between orbital fracture (OF) location, visual disturbances (VDs), head injury (HI), and OPOI severity.

STUDY DESIGN, SETTING, AND SAMPLE

A retrospective cohort study was conducted at the University Hospital of Geneva (2008-2021). Inclusion criteria are as follows: subjects ≥18 years with OF due to blunt trauma, who underwent head computed tomography, comprehensive ophthalmological assessment, and had ≥1-year follow-up.

EXCLUSION CRITERIA

subjects <18 years, prior orbital/ophthalmic surgery, penetrating trauma, prior monocular or nonstereoscopic vision, lack of ophthalmological assessment, insufficient clinical data, or follow-up <1 year.

PREDICTOR VARIABLES

Predictors included OFs (categorized by anatomic location), VD (subjective/objective visual acuity decrease or diplopia), and HI, defined as (a) loss of consciousness, (b) Glasgow Coma Scale score, and/or (c) intracranial hemorrhage.

MAIN OUTCOME VARIABLE

The primary outcome was OPOI severity. Severe OPOI was defined as requiring immediate ophthalmic treatment (performed without delay or within 6 hours), while nonsevere OPOI did not require immediate intervention.

COVARIATES

Covariates included demographic and injury-related parameters.

ANALYSES

Descriptive, bivariate, and multivariate multinomial logistic regression analyses were performed to identify factors associated with OPOIs. Statistical significance was set at P ≤ .05.

RESULTS

The study included 824 patients (mean age: 47.2 ± 23.6 years), the majority of whom were male (n = 580; 70.4%). Adjusted analysis showed severe OPOIs were associated with medial orbital wall fractures (odds ratio [OR], 3.54; 95% CI, 1.78-7.07; P < .01); VD (OR, 3.57; 95% CI, 1.92-6.66; P < .01); HI (OR, 1.99; 95% CI, 1.06-3.74; P = .03) and older age (OR: 1.02; 95% CI: 1.01-1.03; P < .01).

CONCLUSION AND RELEVANCE

Within the limitations of the study, it appears that medial OFs, VD, HI, and older age are associated with severe OPOIs. These findings may help guide early risk assessment and management in patients with OFs.

Predictors of higher pain in possible open globe injury emergency medical services activations

PURPOSE

To determine predictors of high pain in open globe injury (OGI) cases treated and transported by Emergency Medical Services.

METHODS

The National Emergency Medical Services Information System database was queried for activations of OGI between 2017 and 2021. Demographic, location, medication, and date and time information was collected. Cases were divided based on the intensity of maximum pain reported (low pain: below 5/10, high pain: above 5/10). Logistic regression was used to identify significant predictors of high maximum pain.

RESULTS

Of 53,589 cases of OGI, 20,766 reported high levels of pain. Females were more likely to report high pain than males (OR 1.24, CI 1.195-1.285). All age groups between 16 and 75 years old were more likely to report high pain than patients below 15, while all age groups above 75 were less likely. American Indians/Alaska Natives, Black, and Hispanic Americans were all more likely to report high pain than White Americans (American Indian, OR 1.249, CI 1.067-1.461; Black, OR 1.332, CI 1.277-1.390; Hispanic, OR 1.133, CI 1.064-1.207). OGI cases in the Midwest and South regions were less likely to report high pain than those in the West (Midwest, OR 0.868, CI 0.807-0.933; South, OR 0.800, CI 0.748-0.855). Compared to low pain patients, a greater percentage of high pain patients received opioid analgesia (10.04% vs. 0.44%).

CONCLUSIONS

Demographic factors and location may contribute to higher pain in OGI patients. This information may prove useful in the management of OGI and may warrant further investigation into the nature of open globe trauma.Kindly check and confirm the inserted city is correct for affiliation 3.Correct.

Incidence of ophthalmologic pathology and associated risk factors in orbital fractures at a level I trauma centre

OBJECTIVE

To estimate the incidence of ophthalmologic pathology at presentation of patients with orbital fracture to a level I trauma centre and the most significant associated risk factors.

METHODS

A total of 244 patients with 278 fractured orbits over a 2-year period at a level I trauma centre were reviewed. The primary outcome was the incidence of urgent ophthalmologic pathology, defined as requiring attention without delay. Patient demographics, history, findings on radiographic imaging, and physical examination findings at initial and follow-up examinations were recorded. Odds ratios with 95% confidence intervals were calculated.

RESULTS

On initial examination and follow-up, 9.7% of orbits had ophthalmologic pathology. Only 3 patients (1.1%) had urgent pathology, including orbital compartment syndrome and globe rupture, whereas 22 patients (7.9%) had semiurgent pathology and 4 patients (1.4%) had nonurgent pathology. Subjective decreased vision (odds ratio [OR] = 3.5; p = 0.021), assault-related injuries (OR = 2.4; p = 0.036), work-related injuries (OR = 7.7; p = 0.004), afferent pupillary defect (OR = 19.2; p = 0.017), anisocoria (OR = 7.8; p = 0.001), and symmetrical extraocular movement limitation (OR = 5.2; p = 0.003) and fixed pupil (OR = 16.9; p < 0.001) had statistically significant odds ratios associated with pathology. Patient sex, eye involved, intoxication, anticoagulation, and antiplatelets, as well as previous ocular surgery, were not associated with pathology.

CONCLUSIONS

Most orbital fractures do not present with ophthalmologic pathology. Subjective vision loss, history of assault or work trauma, and pupil abnormalities on examination were the greatest risk factors for pathology. Our results highlight the most important factors on patient presentation that should prompt first responders to seek urgent ophthalmologic consultation.

Prediction of substantial closed-globe injuries in orbital wall fractures

PURPOSE

To determine risk factors for substantial closed-globe injuries in orbital fractures (SCGI) and to develop the best multivariate model for the prediction of SCGI.

METHODS

A retrospective study was performed on patients diagnosed with orbital fractures at Farabi Hospital between 2016 and 2022. Patients with a comprehensive ophthalmologic examination and orbital CT scan were included. Predictive signs or imaging findings for SCGI were identified by logistic regression (LR) analysis. Support vector machine (SVM), random forest regression (RFR), and extreme gradient boosting (XGBoost) were also trained using a fivefold cross-validation method.

RESULTS

A total of 415 eyes from 403 patients were included. Factors associated with an increased risk of SCGI were reduced uncorrected visual acuity (UCVA), increased difference between UCVA of the traumatic eye from the contralateral eye, older age, male sex, grade of periorbital soft tissue trauma, trauma in the occupational setting, conjunctival hemorrhage, extraocular movement restriction, number of fractured walls, presence of medial wall fracture, size of fracture, intraorbital emphysema and retrobulbar hemorrhage. The area under the curve of the receiver operating characteristic for LR, SVM, RFR, and XGBoost for the prediction of SCGI was 57.2%, 68.8%, 63.7%, and 73.1%, respectively.

CONCLUSIONS

Clinical and radiographic findings could be utilized to efficiently predict SCGI. XGBoost outperforms the logistic regression model in the prediction of SCGI and could be incorporated into clinical practice.

Retrospective Optimization of the Hawkeye Orbital Fracture Prioritization and Evaluation Algorithms for Triaging Ophthalmic Care

Objectives

Many orbital fracture patients are transferred to tertiary care centers for immediate ophthalmology consultation, though few require urgent ophthalmic evaluation or intervention. This overutilizes limited resources and overburdens patients and the health care system with travel and emergency department (ED) expenses. A simple, easy-to-use, clinical decision-making tool is needed to aid local EDs and triage services in effectively identifying orbital fracture patients who need urgent ophthalmic evaluation.

Design

Single center, retrospective cohort study.

Subjects

Orbital fracture patients aged ≥ 18 years who presented to the study institution's emergency department and received an ophthalmology consultation.

Methods

Ocular injuries that required close monitoring or an intervention within the first few hours after presentation were termed urgent. Two Hawkeye Orbital Fracture Prioritization and Evaluation (HOPE) algorithms were developed to identify orbital fracture patients needing urgent evaluation; including 1 algorithm incorporating computerized tomography (CT) scans interpreted by ophthalmology (HOPE+CT). Algorithms were compared with 3 previously published protocols: the University of Texas Health Science Center at Houston (UTH), the South Texas Orbital Fracture Protocol (STOP), and Massachusetts Eye and Ear (MEE) algorithms.

Main Outcome Measures

Correct triage of patients with orbital fractures who have urgent ocular or orbital conditions.

Results

In the study institution's ED, 134 adult patients (145 orbits) were seen with orbital fractures in 2019. Eighteen (13.4%) had ocular or orbital conditions categorized as urgent. The HOPE tool resulted in 100% sensitivity and 78.4% specificity. The HOPE+CT tool resulted in 100.0% sensitivity and 94.0% specificity. The UTH algorithm was 91.7% sensitive and 76.5% specific. South Texas Orbital Fracture Protocol and MEE were both 100% sensitive but only 35.1% and 32.8% specific, respectively.

Conclusions

The HOPE and HOPE+CT algorithms were superior or equal to the UTH, STOP, and MEE algorithms in terms of specificity while detecting all urgent cases. Implementation of a triage protocol that uses the HOPE or HOPE+CT algorithms could improve resource utilization and reduce health care costs through identification of orbital fracture patients needing urgent evaluation. An online tool that deploys the HOPE+CT algorithm in a user-friendly interface has been developed and is undergoing prospective validation before public dissemination.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Orbital fractures and concurrent ocular injury in a New Zealand tertiary centre

Background

Orbital fractures are a common presentation to acute care and carry an associated risk of ocular injury, however, previous research has not investigated injury rates by fracture category. These patients are frequently assessed by non-ophthalmic clinicians, however, limited data exists regarding referral patterns and how this impacts recorded injury rates (1-3).

Methods

We performed a retrospective review of all orbital fractures presenting to a tertiary hospital in Christchurch, New Zealand between March 2019 and March 2021. Data including mechanism of injury, fracture type, demographic characteristics, and associated ocular injury were recorded.

Results

284 patients with orbital fractures were identified. 41% of patients had isolated wall fractures, while 59% had complex orbitofacial fractures. Fractures were more common in males, and occurred more frequently in young individuals. The most common mechanism of injury was interpersonal violence (32%), followed by falls (23%). 41% of patients were reviewed by ophthalmology (n = 118). Of those, 33% had an associated ocular injury. Severe ocular injury (defined as vision threatening, requiring globe surgery or acute lateral canthotomy and cantholysis) occurred in 4.9% of those with formal ophthalmic review. 0.7% of patients required intraocular surgery or lateral canthotomy due to their orbital fracture.

Conclusion

Orbital fractures have a high rate of concurrent ocular injury in our study population, though rates of subsequent intraocular surgery are low. There was no significant difference in injury rates between isolated and complex fracture categories. Vision-threatening ocular injury occurred in 4.9% of fractures.

Clinical correlations of extraocular motility limitation pattern in orbital fracture cases: a retrospective cohort study in a level 1 trauma centre

PURPOSE

Ocular pathology (OP) following orbital fracture can vary vastly in complexity and severity. Extra-ocular motility (EOM) limitations are frequently present in orbital trauma cases, with patterns of duction limitations being symmetrical or asymmetrical. The aim of this study was to identify if there was any association between increased OP following orbital fracture cases based on the pattern of EOM deficits.

METHODS

This is a retrospective cohort study of patients with fractured orbits presenting with or without EOM limitations to a level 1 trauma center between August 2015 to January 2018. All pertinent elements of the ophthalmic examination were recorded. Outcome measures: Chi-square analyses assessed for association between symmetrical or asymmetrical EOM limitation and OP. Odds ratios were calculated with 95% confidence interval.

RESULTS

278 orbits with wall fractures were included in this study. A significant correlation between EOM limitation and increased OP following orbital trauma was found (p = 0.000081). Cases with symmetrical and asymmetrical EOM limitation were 7.9 (95%CI: 2.3-27.2) and 5.22 (95%CI: 1.9-13.9) times more likely to have OP than cases with no EOM limitation, respectively. With extraocular muscle entrapment excluded, cases with symmetrical limitations had a significantly higher incidence of OP than cases with asymmetrical limitations (p = 0.0161).

CONCLUSIONS

OP is frequently observed in cases of orbital fracture. While any EOM limitations should prompt the clinicians to anticipate OP, intra-ocular injury may be more likely in cases of symmetrical EOM limitation. Future prospective studies are needed to further elucidate the relationship between EOM symmetricity and OP following orbital trauma.

Utilization of Ophthalmic Management in Patients with Head-and-Neck Trauma Secondary to Firearms

Introduction

This retrospective cohort study presents the epidemiology of severe firearm-related ophthalmic injury and the level of ophthalmology involvement in the multidisciplinary management of head-and-neck gunshot injuries.

Methods

A retrospective study identified 207 patients with firearm-related injuries involving the head and neck treated at an Academic Tertiary Care Institution from 2010 to 2020.

Results

Ophthalmology consulted on 29% of patients with head-and-neck firearm injuries. At least one of the services managing facial trauma (plastic surgery and otolaryngology) consulted on 71.5% of cases (P < 0.001). Of patients evaluated by ophthalmology, 93.3% survived to discharge; 78.2% of patients who were not evaluated survived to discharge (P = 0.009). Ophthalmology consulted on all patients with open globe injury (10.6%) (P < 0.001), all of which were evaluated by the facial trauma service (P = 0.002), 77.3% by otolaryngology (P = 0.42), 50% by neurosurgery, 36.4% by plastic surgery, 13.6% by orthopedic surgery, and 4.5% by vascular surgery. Ophthalmology consulted on 76.5% of patients with orbital fracture (32.9%) (P < 0.001); 83.8% were evaluated by the facial trauma service (P = 0.006), 69.1% by otolaryngology (P = 0.014), 54.4% by neurosurgery, 27.9% by plastic surgery, 10.3% by orthopedic surgery, and 2.9% by vascular surgery. For patients with orbital fractures, 92.3% survived when ophthalmology was consulted (P = 0.698); 43.8% survived when not consulted (P = 0.001).

Conclusions

Firearm-related injuries of the head and neck frequently involve ocular and orbital structures, often causing serious vision-threatening injuries. Multispecialty management is common and early ophthalmology specialist evaluation and co-management are indicated to best identify ophthalmic injuries.

Assault-related Orbital Trauma at an Urban Level I Trauma Center: Racial Segregation and Other Neighborhood-level Social Determinants

PURPOSE

To report the demographics of assault-related orbital fractures over a 7-year period treated at a level I urban trauma center, as well as describe and analyze the variation in assault rates across different racial/ethnic neighborhoods for patients residing in Milwaukee County.

METHODS

A retrospective chart review was conducted for patients who sustained assault-related orbital fractures from January 1, 2013, through December 31, 2019, at the Froedtert & Medical College of Wisconsin, in Milwaukee, Wisconsin. A series of negative binomial regression models evaluating the association of neighborhood (i.e., US census tract) racial/ethnic composition, poverty, unemployment, percentage female head-of-household, and education level with neighborhood rate of orbital trauma was conducted.

RESULTS

A total of 410 adult patients with orbital fractures attributed to assault were identified during the seven-year period, of whom 326 (80%) resided in Milwaukee County. Among these patients, 242 (74%) were male, 260 (81%) were single, and 206 (63%) were non-Hispanic Black. Majority non-Hispanic Black, Hispanic, and Other-type minority neighborhoods have 5.30, 3.35, and 3.94 times higher incidence rates of orbital assault, respectively, compared with the majority of non-Hispanic White neighborhoods. The elevated incidence rates were significantly attenuated across all minority neighborhoods after accounting for neighborhood factors of poverty, unemployment, and low education level. Low education had the strongest association with the incidence of assault-related orbital fractures, followed by unemployment.

CONCLUSIONS

Results indicate that minority neighborhoods suffer from compounded burdens of both social and economic disadvantage as well as violent assaults. Additional resources allocated to poor minority communities are needed.

Orbital Wall Fractures and Ocular Injury: Impact on Management

Background: Orbital wall fractures are often associated with concomitant ocular injury. In some cases, detection and treatment of such injuries requires ophthalmology evaluation. Study Objective: To identify a change in ocular management as a result of ophthalmology evaluation in patients with orbital wall fractures. Materials and Methods: Retrospective cohort, patients >18 years of age with orbital wall fracture, and prompt evaluation by an ophthalmologist from 2012 to 2020 in a tertiary Level 1 trauma center. Results: Fifty percent of patients had a moderate and/or severe ocular injury. Ophthalmology evaluation led to an ocular management change in 27% of patients. Patients with eyelid laceration, extra-ocular motion (EOM) abnormality, and pupillary defect were more likely to have a change in management. There was no delay of surgical bony fracture management. Conclusion: In patients with midface trauma including orbital wall fractures those with eyelid laceration, EOM abnormality, and pupillary defect were likely to undergo ocular management change as a result of ophthalmology consultation.

Orbital Fractures and Risk Factors for Ocular Injury

Purpose

To identify factors predictive of serious ocular injury requiring urgent consultation by ophthalmology in patients presenting with blunt trauma orbital fractures.

Methods

This is a retrospective study of adult patients diagnosed with orbital fractures after blunt trauma at a university medical center emergency room. Patient records were examined over a three-year period. Data including mechanism of injury, fracture location, ocular symptoms, and examination findings were recorded. Ocular injuries were divided into three levels of severity: mild, moderate, and severe. Fracture characteristics, patient demographics, and examination findings were analyzed using multinomial regression to identify risk factors for more severe injury.

Results

One hundred and eighty-six patients met inclusion criteria. For 29.6% of patients, urgent ophthalmologic consultation was required. Ruptured globes occurred in 2.2% of injuries. There was a statistically significant association between severe ocular injury and three examination findings: poor vision (OR 14.5; p < 0.001), afferent pupillary defect (OR 44.8; p < 0.001), and abnormal pupillary reaction (OR 28.0; p < 0.001). Likewise, blurry vision (OR 3.6; p = 0.018), ocular pain (OR 3.7; p = 0.011), and facial pain (OR 4.4; p = 0.031) were also associated with an increased risk of severe ocular injury. Abnormal pupillary reaction was associated with moderate injury (OR 4.5; p = 0.041). Demographic factors, mechanism of injury, anti-coagulant use, fracture location, diplopia, no documented vision, subconjunctival hemorrhage, chemosis, and motility restriction were not associated with injury severity.

Conclusion

Most patients who presented to the emergency room with an orbital fracture did not require urgent ophthalmologic consultation. The presence of blurry vision, ocular pain, facial pain, poor vision, and afferent pupillary defect significantly increased the odds of severe injury. Abnormal pupillary reaction was associated with both moderate and severe injury.

Evaluation of commotio retinae in orbital fractures

PURPOSE

This study aimed to evaluate the mechanisms of injury and types of orbital fractures and their relation to concurrent commotio retinae.

METHODS

This retrospective study evaluated the records of patients with orbital fractures whose diagnoses had been confirmed by computer tomography between July 2017 and September 2019. Patient demographics, the circumstances of injury, ophthalmic examination results, and radiological findings were tabulated. Statistical analysis of the data used two-tailed student's t-tests, chi-squared tests, and odds ratio calculations. Statistical significance was set at p<0.05.

RESULTS

Of the 204 patients with orbital fractures included in this study, 154 (75.5%) were male. The mean age was 42.1 years. Orbital fractures involving one orbital wall (58.8%) were more common than those affecting multiple walls (41.2%). The majority of fractures affected the inferior wall (60.3%), with the medial walls being the next most frequently affected (19.6%). The most common cause of injury was assault (59.3%), and the second most common was falls (24%). Commotio retinae was observed in 20.1% of orbital fracture cases and was most associated with injuries caused by assault (OR=5.22, p<0.001) and least associated with those caused by falls (OR=0.06, p<0.001). Eye movement restrictions were more common in central than peripheral commotio (OR=3.79, p=0.015) and with medial wall fractures than fractures to other orbital walls (OR=7.16, p<0.001). The odds of commotio were not found to be higher in patients with multi-walled orbital fractures than in those with single-walled fractures (p=0.967).

CONCLUSIONS

In the study population, assault was the most common cause of orbital fractures and resulted in commotio retinae than other causes. Ophthalmologists should be aware of the likelihood of commotio retinae in patients with orbital fractures resulting from assault, regardless of the extent of the patient's injuries.

Significance of subconjunctival hemorrhage in predicting ocular pathology for patients with orbital fracture

OBJECTIVE

Subconjunctival hemorrhage (SCH) is a common presentation in patients with orbital trauma and often warrants investigation of underlying ocular pathology. Our study aims to assess the significance of SCH severity, graded in a spatial 0-360° manner, as a predictor for ocular pathology in patients with orbital fracture.

DESIGN

Retrospective chart review.

PARTICIPANTS

Patients with fractured orbits (n = 265) presenting to a level 1 trauma centre between August 2015 and January 2018.

METHODS

Key elements of ophthalmic assessment, including visual acuity, SCH (0-360°), anterior- and posterior-segment examination, Hertel exophthalmometry, and ocular pathology, were recorded. Simple logistic regression assessed for association between SCH severity and ocular pathology. Odds ratios (ORs) were calculated with 95% CI.

RESULTS

Among the 265 fractured orbits, 158 (59.6%) presented with no SCH, and 107 (40.4%) had some degree of SCH. Ocular pathology was noted in 24 fractured orbits (9%). Most common pathologies included entrapment (22.2%), hyphema (16.7%), traumatic optic neuropathy (8.3%), and commotio retinae (8.3%). Simple logistic regression revealed a higher incidence of ocular pathology with increasing severity of SCH from 0-360° (OR = 1.004; 95% CI 1.001-1.007; p = 0.0085). In addition, χ² analysis demonstrated a higher proportion of ocular pathology in 181-270° (25.0%; p = 0.0466) and 271-360° SCH subgroups (26.3%; p = 0.0031) compared with the 0° SCH subgroup (6.3%).

CONCLUSIONS

Our findings suggest that there is some correlation between the extent of SCH and ocular pathology. However, patient care and investigations should continue to be directed by a full clinical assessment of patients with orbital trauma.

Factors Associated With Increased Risk of Serious Ocular Injury in the Setting of Orbital Fracture

Importance

Orbital fractures are common in ocular trauma, and there is a need to develop predictive tools to estimate risk of concurrent ocular injury.

Objective

To identify clinical and radiographic features that are associated with increased risk of substantial ocular injury in the setting of orbital fracture.

Design, Setting, and Participants

Retrospective consecutive case series of patients who sustained orbital fractures between 2012 and 2018. Examinations were done at 1 of 2 level 1 trauma centers in the emergency or inpatient setting. A total of 430 consecutive patients (500 eyes) between 2012 and 2017 met inclusion criteria for the training sample. After building a predictive model, 88 additional consecutive patients (97 eyes) between 2017 and 2018 who met inclusion criteria were collected as a test sample.

Main Outcomes and Measures

The primary outcome measure was substantial ocular injury distinct from orbital fracture.

Results

The mean age of our patient population was 53.5 years (range, 16-100 years). The overall rate of substantial ocular injury was 20.4%, and the rate of injury requiring immediate ophthalmic attention was 14.4%. Five variables were found to be associated with increased risk of substantial ocular injury: blunt trauma with a foreign object (odds ratio [OR], 19.4; 95% CI, 6.3-64.1; P < .001), inability to count fingers (OR, 10.1; 95% CI, 2.8-41.1; P = .002), roof fracture (OR, 9.1; 95% CI, 2.8-30.0; P = .002), diplopia on primary gaze (OR, 6.7; 95% CI, 1.7-25.1; P = .003), and conjunctival hemorrhage or chemosis (OR, 4.2; 95% CI, 2.2-8.5; P < .001). The results were translated into a bedside tool that was tested in an independent group of eyes (n = 97) and found to be associated with substantial ocular injury with a 95% sensitivity (95% CI, 77.2-99.9), 40% specificity (95% CI, 28.9-52.0), 31.8% positive predictive value (95% CI, 27.5-36.5), and 96.8% negative predictive value (95% CI, 81.3-99.5).

Conclusions and Relevance

A minority of patients with an orbital fracture had a substantial ocular injury. Certain radiographic and clinical findings were associated with substantial ocular injury. Testing of the algorithm in prospective longitudinal settings appears warranted.

Review of Ocular Injuries in Patients with Orbital Wall Fractures: A 5-Year Retrospective Analysis

Purpose

The purpose of this study was to determine the incidence of minor and major ocular injuries in patients with orbital wall fractures at Loma Linda University Health, a level-one trauma center, to help determine the most appropriate setting for the initial dilated fundus examination by ophthalmologists.

Methods

A retrospective study was performed from January 2008 to January 2013 of patients diagnosed with orbital wall fracture secondary to trauma. Exclusion criteria included unknown mechanism of injury, the absence of ophthalmology consultation, or absence of imaging. Data collected included age, gender, mechanism of injury, visual acuity, and anterior/posterior segment findings. Ocular injuries were categorized as either minor or major.

Results

Of 567 charts reviewed, 460 met criteria and were included for analysis. In the analysis, 86.5% of patients were male, and 81.3% were Caucasian. The most common mechanism of orbital fracture was blunt injury. Visual acuity was better than 20/100 in 82.4% of patients. On chart review, 81.1% of patients were found to have either a minor injury, a major injury, or both. The most common injury was subconjunctival hemorrhage (53.5%). Globe rupture (2.9%) and vision-threatening posterior segment findings such as retinal tear and choroidal rupture (1.3%) were relatively rare. Only one retinal detachment (0.2%) was found, specifically in the setting of severe injury with concomitant globe rupture.

Conclusion

Knowledge of the common ocular injuries associated with orbital fractures will help emergency department (ED) physicians and ophthalmologists provide the dilated fundus exam in the most appropriate setting. The most frequent injuries identified were non-vision threatening, and visually significant posterior segment findings were relatively rare (1.3%). Thus, for the majority of patients presenting to the ED with orbital fracture, a dilated fundus exam can be performed at a later date in the outpatient clinic setting, unless urgent orbital fracture surgery is planned.

Eyelid and orbital trauma for the primary care physician

Patients who experience trauma to the eyelid or the orbit may present to their primary care providers or directly to the emergency room for evaluation of their injuries. These patients will often be in pain and may have bleeding around the eye, which can make evaluation of these patients difficult. Many traumatic injuries to the eye require quick and immediate intervention. In this article, we will review the background, anatomy, exam and management of some of the most common eye traumas including eyelid lacerations, orbital hemorrhages, intraorbital foreign bodies, and orbital fractures.

Occurrence of ocular injury and orbital fracture in orbital blunt trauma patients at tertiary care center emergency room

PURPOSE

To analyze the prevalence and association of ocular injury and orbital fracture in orbital trauma patients METHODS: Patients with periocular trauma who visited the emergency room at the referral center from 2014 to 2016 were screened. Patients examined by ophthalmologists and evaluated by CT scan were included. Patients' age, gender, cause of trauma, and injury patterns were retrieved. The location of the fracture and morphologic parameters were reviewed. The patients were divided into groups based on the presence of orbital fracture and/or the presence of ocular injury and clinical data were compared.

RESULTS

Two hundred patients were included and 158 presented with fracture. Ocular injuries occurred in 129 of 158 (81.6%) in the fracture group, and in 40 of 42 (95.2%) in the no fracture group; ocular injuries were found more often in the no fracture group (p = 0.031). Open globe injuries occurred in 5 of 158 (3.2%) in the fracture group and in 6 of 42 (14.3%) in the no fracture group; open globe injuries were found more often in the no fracture group (p = 0.012). Patients with ocular injuries showed shorter depth of the orbit (41.9 vs. 44.1 mm; p = 0.003) compared to the patients without ocular injuries. Logistic regression revealed that short orbit was associated with the presence of ocular injury (p = 0.004).

CONCLUSION

The incidence of ocular injuries was significantly higher in patients without orbital fracture than in those with fractures of the orbit. The orbital fracture may play a protective role against ocular injury by providing a decompressive effect on the orbital tissue.