Primary Assessment of the Patient With Orbital Fractures Should Include Pupillary Response and Visual Acuity Changes to Detect Occult Major Ocular Injuries

Abstract

Sight-threatening injuries associated with orbital fractures are of major concern to maxillofacial surgeons whom are often the first asked to assess these patients. Eliciting signs and symptoms that are predictive of these injuries would allow expedited ophthalmic consultation and appropriate management. We hypothesized that abnormal pupillary response is predictive of major ocular injuries. A retrospective cohort study of patients with facial fractures was instituted with review of all associated ophthalmic injuries. The primary predictor variables were the presence or absence of post-traumatic ocular symptoms and signs (visual acuity change, diplopia, flashes and floaters, pain on globe movement, abnormal pupillary response, restriction of eye movement, and visual field defects). Secondary predictors were pattern of fracture and mechanism of fracture. The primary outcome variable was the presence or absence of major ocular injury assessed during formal ophthalmology consultation. Descriptive statistics were calculated as categorical values. Correlation between the presence or absence of predictors and outcome (major ocular injury) was calculated using χ2 analysis, with the significance value set at P≤.01. The study included 75 patients (25% of whom were female patients) with a mean age of 41±22years. We recorded 165 minor ocular injuries and 43 major ocular injuries. The mechanisms of injury included assault (48%, n=36), motor vehicle accident (21%, n=16), fall (17%, n=13), sport (11%, n=8), and occupational (3%, n=2). The fracture pattern included zygomaticomaxillary (36%, n=27), isolated orbital floor (25%, n=19), complex (20%, n=15), and isolated orbital nonfloor (19%, n=14). Of the primary outcome predictors, only abnormal pupillary response (odds ratio, 36; P<.001) and subjective visual acuity changes (odds ratio, 10; P<.001) were predictive of major ocular injury. The mechanism of injury and pattern of fracture were not predictive of major ocular injury. During primary assessment of the patient with orbital fractures, abnormal pupillary response and subjective visual acuity changes are key predictors of occult major ocular injury.