Elizabeth J. Rossin, MD, PhD1; Colleen Szypko, BS1; Isaiah Giese, MD2; Nathan Hall, MS1; Matthew F. Gardiner, MD1; Alice Lorch, MD, MPH1
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.
David C. Herman, MD1
Who should receive emergency assessment for serious ocular injury by an ophthalmologist in the setting of orbital fracture? This question is important on a variety of levels. The first and foremost is the care of the patient. Often, the physician to first assess the patient may have neither the expertise nor the equipment to perform the type of examination required to diagnose or rule out a sight-threatening ocular injury. Given that premise, all patients could reasonably be referred for a more detailed examination by an ophthalmologist.