Ophthalmic pathology can be a hidden secondary condition in orbital fracture

Rates of ophthalmic pathology and ocular injury in patients who present with orbital fractures have been known to vary widely. Since immediate interventions may be required to address ophthalmic pathology, knowing when to refer patients for ophthalmologic consultation is key.

Study design

This was a Canadian retrospective case-control study that evaluated incidence and presentation of ophthalmic pathology in 244 patients (278 orbits) with at least one orbital wall fracture diagnosed by computed tomography. Patients were initially seen by a primary care physician at a level I trauma center and then seen in follow-up clinics by a resident and an attending ophthalmologist. Ophthalmic pathology was defined as pathologic findings on examination that may be either acutely vision-threatening, such as orbital compartment syndrome, or may portend a significant risk to vision in the future. such as retinal tears.

Outcomes

Twenty-seven of the fractured orbits had associated ophthalmic pathology: 3 were categorized as urgent (requiring an exam immediately); 22 were classified as semi-urgent (able to be safely triaged to the following day); and 4 were classified as nonurgent (able to be safely triaged to several days later). Subjective vision loss and having an assault- or work-related injury were significantly correlated with ophthalmic pathology; there was no significant correlation between ophthalmic pathology and intoxication, anticoagulation or antiplatelet therapy alone or in combination, intubation or sedation, or any previous ocular surgery (including cataract surgery). Pupillary abnormalities other than corectopia were also significantly correlated with ophthalmic pathology.

Limitations

Although 278 orbits are included in this study, the relatively low number of reported orbits (n = 27) with associated ophthalmic pathology may limit the capacity to form clinically reliable correlations.

Clinical significance

To help optimize ophthalmology consultations for patients suffering from an orbital fracture, the initial history and physical examination by the primary care physician, emergency department clinician, or trauma provider should at least include mechanism of injury, subjective vision loss, pupil check, and extraocular motility. The report of the radiologist can be helpful when making a recommendation (with discretion) for ophthalmologic clinical correlation.

Financial Disclosures: Dr. Nikisha Richards discloses financial relationships with Horizon Therapeutics (Consultant/Advisor).