Initial Management of Orbital Trauma: Is an Ophthalmologic Evaluation Necessary?

Abstract

BACKGROUND: Orbital fractures may be associated with globe injuries, resulting in delayed ophthalmic complications and visual disturbance. The debate regarding the necessity of ophthalmologic evaluation in the initial management of orbital trauma continues. Therefore, there is a need to establish the rate of ocular injuries associated with orbital fractures. METHODS: A retrospective review of patients with orbital fractures who received ophthalmologic consultation and computed tomography scan analysis at a level 1 trauma center, from 2014 to 2020 was performed. The inclusion criteria were patients 18 years or older with confirmed computed tomography scan diagnosis of orbital fracture and ophthalmology consultation. Patient demographics, injuries, comorbidities, and surgical outcomes were collected. RESULTS: A total of 201 patients with 224 orbital fractures (11.4% bilateral) were included. The mean age at injury was 50.5 ± 25.2 years; 21.9% of patients had an associated neurologic injury at the time of ED evaluation. The most common mechanisms of injury were mechanical fall (41%), occupational injuries (26.9%), and motor vehicle accident (25%). The posterior segment of the eye was most affected (16.1%), followed by the anterior segment (13.4%) and ocular adnexa (13.4%). A significant ocular injury was present in 21.9% of orbital fractures. These included choroidal hemorrhage (6.1%), hyphema (5.4%), retinal hemorrhage (4.5%), retrobulbar hematoma (4%), globe rupture (3.6%), choroidal hemorrhage (1.4%), retinal detachment (1.3%), corneal laceration (0.9%), choroidal rupture (0.4%), macular hemorrhage (0.6%), and retinal tear (0.4%). The mechanism of injury was not associated with an increased risk for a serious ocular injury. The most common ophthalmologic findings on examination were diplopia (30.4%), reduced extraocular movement (9.8%), and periorbital laceration (8.9%). Of all patients, 53.1% presented with one orbital wall fracture, of which, the orbital floor was the most commonly involved (44.2%). Associated facial fractures were found in 68.8% of patients. computed tomography scans showed displaced fracture in 44.6% of orbits, comminution in 45.3% and herniation of orbital contents in 42.9%. On multiple variable analysis, motor vehicle accident (OR = 2.5 [1.4–4.7], P = 0.003) and injury to the posterior segment (OR = 2.6 [1.2–5.8], P = 0.045) were associated with the need of surgical treatment. However, injury to the anterior segment (OR = 3.4 [1.5–8.0], P = 0.028) and ocular adnexa (4.0 [1.6–10.1], P = 0.002) were associated with the need of medical treatment alone. CONCLUSIONS: Our retrospective series demonstrated a 22% incidence of ocular trauma in orbital fractures. There were no association between mechanism of injury and serious ocular trauma. This emphasizes that the management of orbital traumas requires a multidisciplinary approach, including the facial trauma team and ophthalmology.