Urgency to evaluate facial / ocular trauma with orbital wall fractures

[JWSIV]

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Polling the site to see if there is a consensus for evaluation of orbital fractures with retrobulbar hemorrhage:
1) With NO clinical evidence of orbital compartment syndrome and
2) NO visual complaints (other than mild blurry vision or documented VA >20/40):

 

[MstaKing10]

Who is performing the exam to confirm presence or absence of compartment syndrome and to check vision? This may influence my vote.

 

[solitude]

which fractures? How large of a RBH, and how is this ascertained (presumably CT)? Is the CT thin cut with orbits? What evaluation is being performed by the person deciding on, presumably, an ophtho consult? How is the non-ophthalmologist checking VA? Are they checking pupils? What questions are they asking about vision? How many times are they checking the patient to see if the RBH is enlarging and visual problems are developing? Are they checking IOP? Motility? CVF? Who is the ophtho being consulted?

the devil is in the details. Usually there is not a "consensus" on almost anything when you start picking it apart.

 

[MstaKing10]

This has been debated forever. No ophtho resident wants to be consulted in the middle of the night to see these patients but I don’t trust an ER doc to do it. Also the follow up can be tricky. May not be an outpatient for a while if injuries are bad enough. If they sit around with some problem for days or weeks that’s a problem. In some cases these patients are non compliant and may choose not to come back. Either way it’s a missed opportunity. Interested to hear other opinions.

 

[eyeeye_captain]

If we stick to the original scenario, I don’t think I’ve ever seen a serious eye problem under those circumstances having covered at least a half dozen extremely busy level 1 centers. Reasonable to be seen outpatient or soon as an inpatient assuming there actually is good follow-up available.

This is a solid example of why the “every fracture must be seen by ophtho” policy when relatively few fractures are operative is garbage. Radiology will call anything a retrobulbar hemorrhage for CYA purposes and the trauma/face team is just checking a box with the consult.

For those who feel like it has to be seen ASAP, how many actual compartment syndromes have you seen? The two cantholyses I’ve ever done had the entire EM department come over to observe because none of them had ever seen one. I’ll agree that the evaluation is better if one of us sees it, but a tense eye isn’t a subtle finding and that wasn’t the question.

 

[JWSIV]

I'm surprised that anyone is suggesting that an immediate consultation is necessary.
First, diagnosing orbital compartment syndrome (Im just going to call it OCS) is the ER's responsibility, NOT the on call ophthalmologist. If OCS is suspected, it is negligent to wait for the diagnosis to be confirmed by the on call eye doctor. Those patients should be recognized and treated before even making it to the CT scan (ideally).
Secondly, look at the case scenario - NO CLINICAL SIGNS OF OCS. Size of the RBH, which fractures, motility, CVF? None of that is even relevant to diagnosing OCS anyway. Who is performing the exam? The ED physician. He/She is the one liable for performing a thorough screening exam.
Any other potentially vision threatening condition can be diagnosed by close outpatient follow up. Arguably outpatient follow up is superior for a better exam in a controlled setting with the tools that are available in the office as opposed to the emergency room.

 

[TheLesPaul]

Compartment syndrome is not subtle. The ER (physicians, not NPs) are good at checking pupils and motility. Their sense of IOP is also binary -- HIGH or normal-ish. So with a sluggish pupil, restricted movements, and a HIGH pressure then yes I will come in to check it immediately. If the pupil is 4 > 2, full EOM, and IOP <30 then f/u in clinic. I will also peek at the scan to make sure nothing crazy if on the fence.

 

[Slide]

I'm surprised that anyone is suggesting that an immediate consultation is necessary.
First, diagnosing orbital compartment syndrome (Im just going to call it OCS) is the ER's responsibility, NOT the on call ophthalmologist. If OCS is suspected, it is negligent to wait for the diagnosis to be confirmed by the on call eye doctor. Those patients should be recognized and treated before even making it to the CT scan (ideally).
Secondly, look at the case scenario - NO CLINICAL SIGNS OF OCS. Size of the RBH, which fractures, motility, CVF? None of that is even relevant to diagnosing OCS anyway. Who is performing the exam? The ED physician. He/She is the one liable for performing a thorough screening exam.
Any other potentially vision threatening condition can be diagnosed by close outpatient follow up. Arguably outpatient follow up is superior for a better exam in a controlled setting with the tools that are available in the office as opposed to the emergency room.

Pretty much. Unfortunately the response for many ED physicians is that once the eye is involved, they wash their hands of it until ophthalmology is consulted. The last ER doc who checked an IOP for us checked it through the eyelid.

 

[MstaKing10]

Just wondering for those that take hospital call outside of academic centers or residency programs (ie in private practice), how are these cases handled? Does the ER evaluate and send to your clinic as outpatient or is there a request for immediate evaluation?

 

[TheLesPaul]

Just wondering for those that take hospital call outside of academic centers or residency programs (ie in private practice), how are these cases handled? Does the ER evaluate and send to your clinic as outpatient or is there a request for immediate evaluation?

They do what you ask them to, and the liability is yours

 

[MstaKing10]

They do what you ask them to, and the liability is yours

That’s what I figured. Guess it’s a judgement call and trust in ER doctor to examine properly. I’m certain they chart “Ophthalmology consulted” and move on. You’re the one on the hook after that.

 

[idkididk]

If you're asking this to get out of ED consults for fractures, it's not going to work

 

[Slide]

That’s what I figured. Guess it’s a judgement call and trust in ER doctor to examine properly. I’m certain they chart “Ophthalmology consulted” and move on. You’re the one on the hook after that.

or "refer to tertiary/academic center to provide care not possible here" lol

 

[eyeeye_captain]

If you're asking this to get out of ED consults for fractures, it's not going to work

It’s surprisingly easy. Don’t take hospital call.

 

[TeddyBoomBoom]

Pretty much. Unfortunately the response for many ED physicians is that once the eye is involved, they wash their hands of it until ophthalmology is consulted. The last ER doc who checked an IOP for us checked it through the eyelid.

bruh… as an ER doc… that’s sucks. Was it an actual attending?

I’ve said before that I am 100% aware that optho does not trust our exams. I work at multiple sites - NONE of whom has a working slit lamp. I get that you guys don’t really care about our bedside US’s re: retinal/vitreal detachment.

I try to get ahead of the actual emergencies. For an actual AACG (I’ve legit only seen probably 3) I at least get the first round of meds on board while i’m calling you. I’ve done a grand total of two lat canths in my life, and neither of those needed imaging prior to doing so.

I *do* tend to want guidance on things like eye herpes, multiple orbital fxs but no entrapment (ophtho vs omfs), and aacg follow up if get it under control in the ED, since none of my sites even have ophto follow up.

I just try to get the best exam I can, and present the case to the optho with my honest opinion. If the optho consult understands that im not trying to “sell” the case one way or the other, things go better.

🤷

 

[RetinaDude]

I no longer take ER call but do respond to calls from the ER if one of my current patients presents to them. I always try to be understanding and patient with the doc because I know ophthalmology is a “weird” part of the medical world and most people either don’t like dealing with it or don’t feel super comfortable. In addition, many places lack adequate equipment to feel confident about an ophthalmic evaluation.

 

[TheLesPaul]

I don't give any pushback about getting patients in to my office. ER usually is happy if I can see the patient same-day or same-week at the latest. No need to argue about it