Is Ophthalmology Consult Needed for Acute Orbital Fractures?

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BACKGROUND

Failure to recognize concomitant ocular injury in orbital fracture patients is a feared consequence of evaluation in the acute setting. These injuries and their accompanying functional sequelae range in severity, and reconstructive surgeons need to be sensitive to the possibility of major ocular injuries that could potentially have serious outcomes. Indications for specialty-trained ophthalmology evaluation in patients with orbital fractures remain controversial, with some advocating for an immediate and comprehensive evaluation of every patient with an orbital fracture. In many institutions, however, this may be difficult to achieve. Additionally, a reflexive emergent ophthalmologic consultation on every orbital fracture yields many normal examinations and therefore potentially places a great burden on the healthcare system. Current literature was reviewed to guide management of these injuries.

BEST PRACTICE

All patients who present with acute orbital fractures should have an initial ophthalmologic examination by the emergency department physicians. Thereafter, the exam by the reconstructive surgeons should, at a minimum, document extraocular muscle (EOM), pupillary response, visual acuity, and gross evidence of ocular injury (corneal damage, hyphema, proptosis, etc.). Additional research is needed to establish standardized screening criteria; in the absence of such criteria, the presence of the factors listed below (especially two or more) should increase suspicion for severe ocular injury and therefore necessitate an ophthalmology consult. In the absence of these features, an ophthalmology consult may be deferred; however, the risk of morbidity should be strongly considered by the treatment teams. Additionally, should any factors be preventing an appropriately thorough initial evaluation, such as patient sedation or decreased level of consciousness, ophthalmology should be consulted.

• Decreased visual acuity
• Decreased color perception
• Decreased EOM or pain with EOM
• Diplopia
• Photopsias
• Scotomata
• Floaters
• Anisocoria
• Foreign body
• Penetrating wound or concern for open globe
• Hyphema
• Afferent pupillary defect
• Retrobulbar hematoma