Ophthalmology Consult Protocol for Orbital Fractures Utilizing Evidence-Based Data

Abstract

Previous retrospective studies demonstrate that emergent evaluation by an ophthalmologist for orbital fractures is not required in visually asymptomatic patients, although a consult is often seen as a necessity in many hospital institutions.1,2 These studies do not specifically focus only on patients who require surgical intervention.1,2 To determine when an ophthalmology consult is indicated for a surgical patient, the maxillofacial and ophthalmology departments at UF Health Jacksonville collaborated for an evidence-based approach utilizing retrospective and prospective data. The retrospective arm looked at patients, ages 18 and older, from 2012-2017, who had an isolated, surgically repaired orbital fracture without pre-operative ophthalmology consultation, and a follow-up in the OMS clinic at least 1 week after surgery. The parameters of extra-ocular movements, visual acuity, and diplopia were determined by the physical exam in both the pre-op and postop setting to determine if the lack of an ophthalmology consult adversely affected the outcome. A total of 84 patients met criteria, and 82 out of 84 had no diplopia postop; the other 2 patients had binocular diplopia postop consistent with diplopia that was also present pre-op. All patients had extraocular movements intact postop, and 100% had visual acuity intact postop. Based on our retrospective results, a prospective arm was created where patients 18 years and older, from August 2019-February 2020, with a surgically repairable orbital fracture were included. Patients with intra-ocular disturbances or a history thereof in the adjacent globe received an ophthalmology consult pre-op according to our designed protocol, while those who did not require a consult following to our protocol did not receive a consult. Of the 26 patients that underwent surgical repair under the prospective arm, 19 did not require an ophthalmology consult, while 7 did receive an ophthalmology consult pre-operatively. Eighteen of the 19 patients without a consult did not have a postop visual complication – normal visual acuity, intact extra-ocular movements, and no diplopia. One of the 19 had postop diplopia consistent with diplopia he presented with pre-operatively. Combining the results of both arms, 103 patients without a pre-op ophthalmology consult were used in the study. Three of the 103 patients had postop diplopia consistent with pre-op diplopia. Over 97% success rate was achieved, as 100 out of the 103 patients had no visual complications following our 3 variables. These results lead the authors to conclude that visually asymptomatic patients with surgically operable orbital fractures do not routinely require an ophthalmology consult using evidence-based data.