Need to eval every orbital wall fracture?

[4ophtho]

At my program ENT and OMFS manage the orbital wall fractures repairs. We just rule out an open globe/clear it for surgery and check for other signs of ocular trauma.

Does every orbital wall fracture need a DFE? If the VA is normal and symmetric, the IOP normal, and pen light exam unremarkable (ie what the ER doc can manage to do) does the patient with an orbital wall fracture and no visual complaints need an ophthalmology consult and DFE?

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[OphthoQuestions]

At my program ENT and OMFS manage the orbital wall fractures repairs. We just rule out an open globe/clear it for surgery and check for other signs of ocular trauma.

Does every orbital wall fracture need a DFE? If the VA is normal and symmetric, the IOP normal, and pen light exam unremarkable (ie what the ER doc can manage to do) does the patient with an orbital wall fracture and no visual complaints need an ophthalmology consult and DFE?

I think it is sound medicine to get an Ophthalmology consult for orbital wall fractures (though I know it is a pain in the *** for the resident on-call). One way to think about it is this: if the trauma was severe enough to break orbital bones, it makes sense to make sure the eye is doing well also. I think a lot of this also has to do with legal ramifications. Let's say an ENT doc does an orbital wall repair and then 2 weeks later, the patient complains of decreased vision. Was it the initial trauma that caused the visual problems or the surgery?

 

[bucknut101]

Yes it is necessary. It's honestly what is best for the patient. And yes it does stink having to come in to evaluate these patients when your on call as orbital fractures are very common injuries at trauma center and can lead to busy busy call nights.
If the patient truly has no visual complaints and a normal ocular exam you could just have them follow up in clinic the next day rather than going to the ER or hospital in the middle of the night.
Even though a patient apparently has no complaints and a normal exam doesn't always mean everything is ok. You will learn to not always trust an ER doc's or a ENT/OMFS eye exam. I've seen hyphemas, traumatic iridodialysis, and other various injuries on patients that supposedly had no ocular injuries.
A DFE is always necessary soon after an oribtal fracture because blunt trauma can rarely cause retinal tears/detachments that if caught early can save a patients vision.

 

[Visionary]

Agree with above. The majority of times, in a visually asymptomatic patient, the globe will be fine. I did pick up an occult rupture on a call once. Asymptomatic patient. Some subconjunctival hemorrhage nasally. DFE revealed a small pre-retinal hemorrhage near the medial rectus insertion of the left eye. We explored and confirmed the rupture. It was right where the hemorrhage had been seen (a common location for globe ruptures, BTW). Better to be safe than sorry.

 

[MstaKing10]

A better question is if all orbital fractures need to have an eye exam immediately, or if they can wait until the following morning? This would be tough in a university setting with poorly compliant university style patients, but in general, I don't think you are doing the patient any disservice by delaying a full ophtho exam the following morning as opposed to in the middle of the night. This may be a delay of only a few hours as a lot of these calls tend to come in the witching hours of 1-3AM or so. Even a globe perforation may be better managed with the OR "A" crew the following morning. Also, letting the inebriated patients sober up a bit may allow for an overall better more accurate exam. One exception may be a retrobulbar hemorrhage with increased IOP that may need emergent lateral canthotomy. Most of these would be picked up on standard orbital CT though thus mandating an emmergent ophtho consult. Thoughts?

 

[Visionary]

A better question is if all orbital fractures need to have an eye exam immediately, or if they can wait until the following morning? This would be tough in a university setting with poorly compliant university style patients, but in general, I don't think you are doing the patient any disservice by delaying a full ophtho exam the following morning as opposed to in the middle of the night. This may be a delay of only a few hours as a lot of these calls tend to come in the witching hours of 1-3AM or so. Even a globe perforation may be better managed with the OR "A" crew the following morning. Also, letting the inebriated patients sober up a bit may allow for an overall better more accurate exam. One exception may be a retrobulbar hemorrhage with increased IOP that may need emergent lateral canthotomy. Most of these would be picked up on standard orbital CT though thus mandating an emmergent ophtho consult. Thoughts?

Agree. The best option is to have your practice in a city that has a university. Where I am, all globe trauma goes to the university. Haven't seen an open globe since fellowship.

 

[MR1]

True, having a university so the residents can "learn" is great. Honestly though there is nothing wrong with waiting until the next day to see these folks if they are asymptomatic (good vision). When on call as a resident and I would get called for these, I always asked if they were being admitted for something because if they were I'd just come see them at 7 or whatever before my day started. Much better to just get up one hour early as apposed to losing at least 2 in the middle of the night getting to the hospital, doing the exam, etc, running slow because you are tired, etc.

 

[Slide]

I hope some study or paper comes out on how these consults late in the night can wait until the morning or so. It sucks to come in at 2am to evaluate 4-5 patients with blowout fractures, only to find good VA, a relatively ok DFE (maybe commotio), and in the end have an uneventful outcome.

 

[Visionary]

I hope some study or paper comes out on how these consults late in the night can wait until the morning or so. It sucks to come in at 2am to evaluate 4-5 patients with blowout fractures, only to find good VA, a relatively ok DFE (maybe commotio), and in the end have an uneventful outcome.

Oh, to be a resident again...

 

[Pinkertinkle]

I would like to know if they need a full depressed scleral exam.

 

[Visionary]

I would like to know if they need a full depressed scleral exam.

Never performed scleral depression on an orbital fracture where I was looking for globe trauma. Probably not a good idea, honestly.

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[MstaKing10]

I would like to know if they need a full depressed scleral exam.

Eventually, but probably not on day one. This would be painful and difficult on a patient with swollen lids, poor cooperation, chemotic tissue etc. Certainly should be done at some point in their follow up though, perhaps as soon as 1-2 weeks after the initial trauma.

 

[Pinkertinkle]

Eventually, but probably not on day one. This would be painful and difficult on a patient with swollen lids, poor cooperation, chemotic tissue etc. Certainly should be done at some point in their follow up though, perhaps as soon as 1-2 weeks after the initial trauma.

hmm any residencies where this is standard policy? I believe generally its not?

 

[MR1]

Yes should be done in certain trauma cases. Not standard but if you are following a trauma patient and there are any symptoms or posterior segment findings then they need a depressed exam 1-2 wks out. I have found plenty a retinal dialysis this way

Like I said though. Normal vision. No symptoms. No retinal findings on regular DFE. Then depressed exam not needed.

 

[MstaKing10]

Yes should be done in certain trauma cases. Not standard but if you are following a trauma patient and there are any symptoms or posterior segment findings then they need a depressed exam 1-2 wks out. I have found plenty a retinal dialysis this way

Like I said though. Normal vision. No symptoms. No retinal findings on regular DFE. Then depressed exam not needed.

A depressed exam is a pretty benign procedure, can be done weeks out when pt is comfortable and in no pain. Most well trained comprehensive ophthalmologists can do it. So why not do it at some point in the course of their follow up? I too have found plenty of retinal dialysis, asymptomatic holes or tears. Young patients with well formed vitreous will usually not detach and are less likely to report flashes/floaters etc., thus, symptoms may not be a reliable indicator of pathology. Just a thought.