a b s t r a c t

Purpose: facial trauma and orbital fractures are common reasons for ophthalmology consultation in the emergency department (ED). The purpose of this study is to assess intervention rates and evaluate the acuity of ophthalmology consultation for orbital fractures in the ED.

Basic procedures: A retrospective chart review of orbital fractures was conducted over a 23-month period. 379 cases of orbital fractures were identified in a single-center study. All patients that received an ophthalmology consultation in the ED were included. Demographics, mechanism and location of orbital fracture, ophthalmic complications, and surgical and non-surgical ophthalmic interventions were recorded. The primary study out- come was the rate of ophthalmic consultation and intervention with and without retrospective application of our proposed South Texas Orbital Fracture Protocol (STOP).

Results: Immediate ophthalmic intervention was performed in 18.7% of patients. Statistically significant subjec- tive, radiographic, and physical exam features correlating with ophthalmic intervention were identified and in- cluded globe rupture, concern for entrapment, orbital roof fractures, and retrobulbar hematoma. Retrospective application of our proposed South Texas Orbital Fracture Protocol (STOP) would have resulted in 186 of 379 patients requiring ophthalmology consultation, thus reducing consultation rate by 51% with an improved rate of intervention from 18.7% to 37.6%.

Conclusions: Orbital fractures can be associated with severe Ocular complications. Most cases, however, do not re- quire emergent evaluation by an ophthalmologist. We propose the South Texas Orbital Fracture Protocol (STOP) for proper assessment and triaging of orbital fractures in the ED. While this clinical decision-making tool requires validation, it may offer improved healthcare efficiency, reduced costs, fewer unnecessary inter-facility transfers, and less burnout for ophthalmology residents.

Published by Elsevier Inc.

1. Introduction

Orbital fractures are a common facial injury, often due to trauma, that can be managed by ED physicians as well as multiple surgical specialties. In the United States, trauma to the eye, orbit, and/or periorbita accounts for roughly 3% of ED visits annually [1]. The most common etiologies for orbital fractures include assault, Motor vehicle collisions , sports, falls, and machinery [2]. Signs of an orbital

Abbreviations: ED, Emergency Department; STOP, South Texas Orbital Fracture Protocol; MVC, motor vehicle collision; MCC, Motorcycle collision; BAMC, Brooke Army Medical Center; FFS, fall from standing; FFH, fall from height; IOP, Intraocular pressure; EOM, extraocular muscle; OCR, oculocardiac reflex; OR, operating room.

* Corresponding author at: Brooke Army Medical Center, 3551 Roger Brooke Dr., Fort Sam Houston, TX 78234, USA.

E-mail address: [email protected] (J. Jeffrey).

fracture include, but are not limited to, restricted motility, orbital emphysema, enophthalmos (i.e., posterior displacement of the eye), infraorbital (V2) hypoesthesia, and point tenderness [3]. Upon presen- tation to the ED and following stabilization, examination of the eye is required to assess for ocular injuries. Often, ophthalmology is consulted to assist in this examination and determine any need for surgical inter- vention.

Indications for emergent repair of an orbital fracture are rare. Many orbital fractures do not lead to enophthalmos, diplopia, or impaired ocular motility [4,5]. Immediate Surgical repair is, however, indicated when the oculocardiac reflex is present, a syndrome often defined by symptoms of bradycardia, nausea and vomiting, syncope, and potential asystole [6]. Commonly caused by entrapment of extraocular muscles, surgical release of the entrapped tissue is required to relieve the stimu- lus. This phenomenon is more common in the pediatric population due to “trap-door” or greenstick fractures of the orbital bones and is most

https://doi.org/10.1016/j.ajem.2022.04.025 0735-6757/Published by Elsevier Inc.

often seen with entrapment of the inferior rectus muscle [7]. These types of fractures are also classically referred to as “white-eyed blowout

Table 1

Summary of patient and fracture demographics.

fractures” because the child’s eye may appear grossly normal on physi- cal examination until restriction is noted on upgaze [8].

Total

(n = 379)

With intervention (n = 71)

Without intervention (n = 308)

Two other indications for intervention may not necessitate immedi-

ate surgery but still call for early surgical intervention within 48 h. The first is muscle entrapment, for which early intervention has been Sex, n (%)	(17-96)
shown to reduce postoperative diplopia [9]. It is necessary for restriction Male	288 (76)	57 (80)	231 (75)
to be differentiated from frank entrapment, for which forced duction Female	91 (24)	14 (20)	77 (25)
Fracture etiology, n (%)

Mean age (range) 45.8

42.0 (17-88) 47.0 (17-96)

moving the globe to evaluate for entrapment. Significant enophthalmos is the second relative indication for Urgent surgery, as early intervention has been shown to reduce long-term enophthalmos [10]. The ophthal- mology literature does not quantify the incidence of these specific surgical indications.

testing can be useful. Forced duction testing is performed by grasping	Assault/Violence	145 (38)	36 (51)	109 (35)
the anesthetized bulbar (ocular) conjunctiva with forceps and manually	MVC/MCC	87 (23)	12 (17)	75 (24)

The ophthalmology department is frequently consulted to assist in the evaluation and management of orbital fractures. Commonly, these patients do not demonstrate indications for immediate surgery and, as a result, it may not be necessary for ophthalmology to see them emergently. Here, we present data of orbital fracture patients and out- comes at a Level I trauma center and propose a protocol for triaging orbital fractures for appropriate ophthalmology consultation in the ED.

1. Methods

This study was conducted according to a protocol approved by the Brooke Army Military Medical Center Institutional Review Board. The protocols and methods used also complied with the standards set forth by the Declaration of Helsinki.

A retrospective chart review was performed for all patients present- ing to the Brooke Army Medical Center (BAMC) ED with clinical or radiologic evidence of an orbital wall fracture between December 2014 and November 2016. All patients with orbital fractures that received an ophthalmology consultation during the described time pe- riod were included in the study. Of note, it is currently standard practice at our Level I trauma center that all patients with an orbital fracture re- ceive an ophthalmology consult. The diagnosis of an orbital wall fracture was confirmed with radiologic imaging in the ED, typically with com- puted tomography (CT) scans, but occasionally via plain film x-rays.

Demographic information, as well as mechanism and location of the orbital wall fracture were obtained. Emergent ophthalmic conditions in- cluding open globe, extraocular muscle entrapment, roof fracture, and retrobulbar hemorrhage were also recorded. Surgical and non-surgical interventions were documented, and follow-up was tracked over time. Exact confidence intervals for a single incidence rate were calculated

Fall from standing	80 (21)	7 (10)	73 (24)
Other (e.g., blunt	38 (10)	5 (7)	33 (11)
object)
Fall from height Fracture location, n (%)	29 (8)	11 (15)	18 (6)
Inferior	140 (37)	26 (37)	114 (37)
Multiple	136 (36)	22 (31)	114 (37)
Medial	55 (14)	12 (17)	43 (14)
Superior	29 (8)	6 (8)	23 (7)
Lateral	19 (5)	5 (7)	14 (5)

MVC = motor vehicle collision; MCC = motorcycle collision.

management), 24 lacerations (22 with bedside closure and 2 with repair in the operating room [OR] for canalicular involvement), 14 cor- neal abrasions (treated with antimicrobial drops and/or lubrication), and 1 retinal tear (treated with retinopexy).

Statistically significant correlations with ophthalmic intervention were demonstrated for globe rupture (p = 0.0003), entrapment (p < 0.0001), roof fracture (p = 0.046), retrobulbar hemorrhage (p < 0.0001), subjective visual acuity decrease (p < 0.0001), and diplo- pia (p < 0.0001). Other important Physical exam findings that showed statistically significant correlations with ophthalmic intervention in- cluded presence of a relative Afferent pupillary defect (rAPD; p = 0.0016), pupillary abnormality (e.g., anisocoria; p = 0.0017), motility defect (i.e., restricted gaze in one or more directions, often due to a “stunned” cranial nerve or extraocular muscle; p < 0.0001), oculocardiac reflex (p < 0.0001), corneal abrasion (p < 0.0001), lacera- tion (p < 0.0001), and hyphema (p = 0.0003). Table 2 summarizes the rate of ophthalmic intervention corresponding to each of these subjec- tive, radiographic, and physical exam findings.

Table 2

Rates of ophthalmic intervention corresponding to subjective, radiographic, and physical exam features.

using Wilson’s approximation. Correlation data was calculated using

chi-square contingency tables and the Pearson correlation coefficient. A p-value less than 0.05 was considered significant. Statistical analysis was performed using JMP software (SAS Institute, North Carolina, USA).

Subjective exam finding

Decreased visual acuity	37.0	0.21	<0.0001
Diplopia	44.4	0.25	<0.0001

% requiring

ophthalmic intervention

Pearson

correlation coefficient

p-value

1. Results

A total of 379 patients with orbital wall fractures were identified. The mean patient age was 45.8 years (range 17-96 yrs). Of note, BAMC does not typically accept pediatric patients in the ED, but three patients were 17 years old. There were 288 male patients (76.0%) and 91 female patients (24.0%). The most common etiologies for orbital wall fractures were assault/violence (38%), motor vehicle collision/mo- torcycle collision (MVC/MCC; 23%), and fall from standing (FFS; 21%). The most common locations of orbital wall fractures were the inferior wall (37%), multiple walls (36%), and the medial wall (14%). Underlying characteristics of these patients and their orbital wall fractures are summarized in Table 1. Additional ophthalmic complications found in these patients included 4 hyphemas (managed with topical predniso- lone and atropine without any need for intraocular pressure [IOP]

Radiographic finding

Open globe 80.0 0.41 0.0003

Retrobulbar hemorrhage 57.9 0.37 <0.0001 EOM entrapment

Suspected 43.3 0.23 0.0002

Confirmed 100.0 1.00 <0.0001

Roof fracture	28.6	0.11	0.046
Physical exam finding
rAPD	54.6	0.28	0.0016
Pupillary abnormality	47.1	0.24	0.0017
Motility defect	46.4	0.30	<0.0001
Oculocardiac reflex	83.3	0.45	<0.0001
Eyelid laceration	67.4	0.48	<0.0001
Corneal abrasion	70.8	0.44	<0.0001
Hyphema	80.0	0.42	0.0003

EOM = extraocular muscle; rAPD = relative afferent pupillary defect.

Table 3

Summary of emergent clinical features.

n (133) % of total % of emergent

clinical features

Emergent clinical feature

Table 4

Summary of immediate surgical and non-surgical interventions.

n^d % of total patients

Surgical intervention

% of emergent clinical features

Open globe	5	1.3	3.8
Entrapment concern	39	10.3	29.3
Confirmed entrapmenta	10	2.6	7.5
Orbital roof fracture	49	13.0	36.8
Retrobulbar hemorrhage	40	10.6	30.1

^a Subset of the 39 patients with concern for entrapment.

Globe exploration	4	1.1	3.0
Entrapment repair/ORIF	13	3.4	9.8
Bedside laceration repair	22	5.8	16.5
Canalicular repair	2	0.5	1.5
Bedside C&C	11	2.9	8.3
Non-surgical intervention Antimicrobiala	14	3.7	10.5
IOP management	11	2.9	8.3
Lubricationb	6	1.5	4.5
Hyphema managementc	4	1.1	3.0
Retinopexy	1	0.3	0.8

Emergent features associated with orbital wall fractures were exhib- ited in 133 patients of the 379 (35.1% [95% CI: 30.5% - 40.0%]), 71 of whom (53.4% of those with emergent features [95% CI: 44.9% - 61.6%]; 18.7% of total patients [95% CI: 15.1% - 23.0%]) underwent immediate intervention. These features included 5 globe ruptures (3.8% of emergent features, 1.3% of total), 39 concerns for entrapment (29.8% of emergent features, 10.3% of total), 49 orbital roof fractures (37.4% of emergent features, 13.0% of total), and 40 cases of retrobulbar hemor- rhage (30.1% of emergent features, 10.6% of total). Of those with suspected entrapment, only 10 patients were found to have a true en- trapment (25.6% of suspected) as confirmed by forced ductions and CT scans. These features are summarized in Table 3. Additionally, 14 pa- tients (3.7% of total) reported a subjective decrease in visual acuity and 10 patients (2.6% of total) endorsed diplopia.

Of the 71 patients who received immediate intervention, 52 under- went surgical intervention and 19 received non-surgical intervention. Four of the five patients with globe ruptures underwent emergent globe exploration and one was managed with sinus precautions, topical moxifloxacin, and topical prednisolone until a delayed exploration was performed. All 10 patients with entrapment underwent emergent surgi- cal repair in the OR by otolaryngology (ENT), oral and maxillofacial sur- gery (OMFS), or ophthalmology. Of these 10 patients, all demonstrated restricted pre-operative motility and five exhibited the oculocardiac re- flex. Additionally, three other patients who demonstrated decreased motility underwent emergent surgical repair but were found to not be entrapped. Eleven patients with retrobulbar hemorrhage (27.5% of total retrobulbar hemorrhages) underwent bedside lateral canthotomy with cantholysis. Other surgical interventions included eyelid and cana- licular laceration repair. Immediate non-surgical interventions included antimicrobials, IOP monitoring, lubrication, hyphema management (i.e., topical prednisolone QID and topical atropine 1% BID), and retinopexy. Table 4 summarizes the interventions performed in these 71 patients.

1. Discussion

Orbital wall fractures represent a significant portion of trauma in the United States, and ophthalmology consultation is typically viewed as an obligation in most EDs. However, emergent evaluation by an ophthalmologist is generally not necessary, as rates of immedi- ate intervention are extremely low [11]. Most orbital wall fractures are non-emergent cases. The management of facial trauma, includ- ing orbital wall fractures, often utilizes a Multidisciplinary team consisting of emergency medicine, OMFS, ENT, plastic surgery, and ophthalmology. Here, we restate the low urgency of many orbital fractures and suggest that emergent ophthalmology consultation for all orbital fractures be reconsidered and triaged according to the patient’s specific features.

Indications for delayed repair are more common than those necessitating immediate intervention, as most orbital fractures can be managed initially via observation and then followed by surgical intervention within 2 weeks. Often, this delay is necessary for periorbital edema to decrease, allowing for a more extensive and

ORIF = open reduction and internal fixation; C&C = lateral canthotomy & cantholysis; IOP

= intraocular pressure.

^a Bacitracin ointment, topical moxifloxacin QID, and/or topical erythromycin QID.

^b Lacri-lube.

^c Topical prednisolone QID and atropine 1% BID.

^d Total number exceeds 71 due to multifactorial management.

complete examination. Additionally, patients may be uncooperative upon initial presentation and the ED may not have equipment avail- able for a thorough ophthalmic assessment. Following proper exam- ination, indications for delayed repair are enophthalmos greater than 2 mm, ocular motility dysfunction, persistent diplopia in primary gaze, CT findings of ocular muscle impingement with greater than 50% of floor involvement, progressive V2 hypoesthesia, and abnormal forced duction testing [9]. The literature supports delaying intervention within this 2-week interval [12].

In our study, we examined all orbital fractures and confirmed a low rate of emergent intervention, with only 18.7% of patients requiring im- mediate surgical or non-surgical intervention, which is consistent with the rates of other studies [12,13]. Our study confirms that orbital fractures can be associated with serious complications that require im- mediate ophthalmic intervention. Such complications include globe rupture, extraocular muscle entrapment, roof fractures, and retrobulbar hemorrhage. We also found that, while patients with a subjective de- crease in visual acuity or diplopia do not necessarily warrant immediate intervention, they still necessitate emergent evaluation to rule out more Serious conditions.

To account for the low rate of required emergent interventions and to facilitate proper triaging of facial trauma and orbital fractures in the ED, we propose the South Texas Orbital Fracture Protocol (STOP; Fig. 1). This algorithm utilizes the subjective exam, physical exam, and radiographic findings to determine if the ophthalmology department needs to be consulted emergently or if conservative management can be delivered in the ED with subsequent outpatient ophthalmology follow-up (typically within the next 24-48 h). Subjective findings warranting ophthalmic consultation include pediatric patients (due to the risk for entrapment), Decreased vision, and diplopia. The latter two findings are supported in the literature, as patients with no visual symptoms likely do not require evaluation [14]. Radiographic findings deserving ophthalmic consultation include findings of open globe, retrobulbar hematoma, extraocular muscle (EOM) entrapment, and roof fracture. Of these, open globe and EOM entrapment will likely re- quire immediate surgical exploration and/or repair in the OR, while retrobulbar hematoma may lead to bedside canthotomy and cantholysis or IOP monitoring. Finally, the physical exam findings necessitating ophthalmic consultation are eyelid lacerations, pupillary defects, motil- ity defects, oculocardiac reflex (OCR), corneal abrasions, and hyphema. Of these, the presence of the OCR demands immediate surgical action. The other physical exam findings would necessitate an ophthalmic eval- uation but would likely result in less urgent intervention at the bedside.

Fig. 1. South Texas Orbital Fracture Protocol (STOP).

These subjective, radiographic, and physical exam features in the STOP are supported by our data as those most likely to require early ophthal- mic intervention.

Retrospective application of the STOP to our database of 379 orbital fractures proves its utility in ED evaluation of such injuries. Out of the 379 patients with orbital fractures, 193 patients would have been ex- cluded if STOP was applied, allowing for the inclusion of 186 patients who would have, therefore, required ophthalmology consultation. This corresponds to a 51% decrease in ED consultations. Additionally, the rate of ophthalmic intervention also improves from 18.7% originally to 37.6% in those 186 patients. Fig. 2 summarizes the effects our STOP would have had on this patient population. Of note, one patient that was excluded via application of the STOP was found to have an asymp- tomatic, likely chronic retinal tear. This patient underwent retinopexy and was the only missed intervention when applying the algorithm.

The results of our retrospective application of the STOP have impor- tant implications for both emergency and ophthalmology departments,

Fig. 2. Retrospective application of South Texas Orbital Fracture Protocol (STOP).

as well as the overall medical system. Unnecessary consultation adds additional burden to the healthcare system and healthcare providers, which contributes to excess time spent in the ED, decreased sleep time, cumulative sleep debt, and increased burnout [15-17]. With a high incidence of orbital fracture consults but minimal need for ophthal- mic intervention in these instances, these issues may be exacerbated by automatic consultation in the setting of orbital fractures. However, proper triage via our STOP can help reduce healthcare burden and in- crease intervention rates without compromising patient care standards. All other orbital fractures that do not meet the subjective exam, physical exam, or radiographic findings included in the STOP can, instead, be managed conservatively by the ED with outpatient subspe- cialist evaluation. Conservative management includes ice to reduce periorbital edema [18], pain control, and sinus precautions (i.e., nasal saline spray, refrainment from nose-blowing, and minimization of Val- salva maneuvers). Consideration can also be given to the utilization of Prophylactic antibiotics in these patients. For low-risk patients (those without upper respiratory symptoms and not using steroids), antibiotics can be withheld. Should antibiotics be prescribed, a five-to- seven-day course of cephalexin is recommended, although other narrow-spectrum agents can be used as well [19]. Additionally, an out- patient ophthalmology consultation should be scheduled for 1-2 days after discharge (ideally the next clinic day or Monday if the patient pre- sented on a Friday or Saturday). Proper application of this algorithm will reduce unnecessary ophthalmology consultation, thus reducing burden on the healthcare system with subsequent improvement in healthcare efficiency and reduced costs [20]. Additionally, it may lessen the number of unnecessary inter-facility transfers, which can be a problem at larger institutions. Finally, it is suspected that implementation of this algorithm would help to reduce ophthalmology resident sleep depriva-

tion and burnout.

The primary limitation of our study is its retrospective nature. A prospective study of patients with orbital fractures would be beneficial in further identifying patient factors that may require less urgent evaluation. Other limitations are that this study took place at a single institution and that our institution does not typi- cally see pediatric patients. Finally, given the lack of long-term outcome data and the differences among the practices of various civilian and military institutions, the results of this study should be critically considered within the context of the specific institu- tion and patient.

In conclusion, orbital fractures are a common complication of facial trauma, often triggering ophthalmology consultation in the ED. While some cases can be associated with severe ophthalmic complications, the majority do not require emergent ophthalmology consultation. Sta- tistically significant correlations were found between the following sub- jective, radiographic, and physical exam features and the need for ophthalmic intervention: globe rupture, EOM entrapment, retrobulbar hemorrhage, subjective visual acuity decrease, diplopia, rAPD, pupillary abnormality, motility defect, oculocardiac reflex, corneal abrasion, eye- lid laceration, and hyphema. These results argue for a reconsideration of urgent ophthalmology consultation and triage based on the patient’s unique features, as aided by our South Texas Orbital Fracture Protocol (STOP). Retrospective application of the STOP to this database resulted in a 51% decrease in ophthalmology consultations and an increased rate of immediate ophthalmic intervention, from 18.7% to 37.6%. There- fore, ED adoption of our STOP may lead to decreased rates of unneces- sary ophthalmology consultation with subsequent improvements in healthcare efficiency, reduced costs, and a lesser burden on ophthalmol- ogy residents. Future prospective studies are necessary to validate this protocol before it can be formally recommended.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Credit authorship contribution statement

Joseph Jeffrey: Conceptualization, Formal analysis, Writing - original draft, Writing - review & editing. Frederick Nelson: Conceptu- alization, Data curation, Investigation, Supervision, Writing - review & editing. Joshua Hohlbein: Writing - review & editing. Aditya Mehta: Conceptualization, Data curation, Formal analysis, Investigation, Meth- odology, Writing - review & editing. Brett Davies: Conceptualization, Supervision, Writing - review & editing.

Declaration of Competing Interest

There were no relevant financial conflicts of interest regarding this work. There was no funding received for this study.

Acknowledgements

We would like to thank Dr. James Aden at Brooke Army Medical Center for his assistance with the statistics performed in this study.

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