Risk Factors for Urgent Ophthalmologic Pathology in Orbital

Risk Factors for Urgent Ophthalmologic Pathology in Orbital Fractures at a Level I Trauma Center Georges Nassrallah 1, Judy Gaffar 1, Matthew Kondoff 1, Michael Ross 2, Jean Deschênes 1. 1 Mc. Gill University, contact email: georges. nassrallah@mail. mcgill. ca 2 University of British Columbia. Canadian Ophthalmology Society Meeting June 19, 2020

Financial Disclosure • I do not have any affiliation (financial or otherwise) with a for-profit or not-for-profit organization that may have a direct or indirect connection to the content of my presentation.

Background • Cases of orbital trauma causing orbital fractures have a relatively significant risk of ocular involvement • Previous studies offer a wide range in the rate of ocular injury • 2 -90% !!! • Large variation in mechanisms of injury • In the absence of visual symptoms, one study found no rate of ocular injury (n = 46) • Our group’s previous work found that 13. 7% of all orbital fracture cases had ocular abnormalities (n = 73)

Purpose • The purpose of this study is to estimate the most significant risk factors on presentation of a patient with orbital fracture to a Level 1 trauma center associated with ophthalmologic pathology • Retrospective case-control study

Methods • 244 patients with 278 fractured orbits over a 2 -year period at a Level I trauma center (Montreal General Hospital) • Ophthalmic pathology: • Urgent: To be seen immediately • Semi-Urgent: Can be deferred to the following day • Non-Urgent: Can be deferred several days later Urgent Orbital compartment syndrome Globe rupture Semi-urgent Hyphema Traumatic uveitis Traumatic cataract Lens dislocation Traumatic mydriasis Corneal abrasion Corneal foreign body Conjunctival laceration Vitreous hemorrhage Retinal tear Retinal detachment Muscle entrapment Traumatic optic neuropathy Lid laceration Non-urgent Commotio retinae Orbital emphysema

Methods • Inclusion criteria • Cases with at least one orbital wall fractured and referred by the trauma team • Exclusion criteria • No exam by the ophthalmology service within 1 day of presentation • No CT evidence of orbital fracture

Methods • The following was recorded: • • Patient demographics History Physical exam findings at initial presentation and follow-up Radiographic findings • Odds ratios with 95% confidence intervals were calculated

Demographics Male (%) Female (%) Total orbits Total after exclusion 206 (74. 1%) 72 (25. 9%) Total 293 278 Total patients 176 (72. 1%) 68 (27. 9%) 244 Average (years) 46. 2 58. 5 49. 6 Median age (years) 43 61 46 OD 85 (41. 3%) 30 (41. 7%) 115 (41. 4%) OS 121 (58. 7%) 42 (58. 3%) 163 (58. 6%)

Results • 27 (9. 7%) orbits of 278 had pathology • 3 (1. 1%) urgent • 22 (7. 9%) semi-urgent • 4 (1. 4%) non-urgent Pathology Urgent Orbital compartment syndrome Globe rupture Cases 1 2 Semi-urgent Hyphema Traumatic uveitis Traumatic cataract Lens dislocation Traumatic mydriasis Corneal abrasion Corneal foreign body Conjunctival laceration Vitreous hemorrhage Retinal tear Retinal detachment Muscle entrapment Traumatic optic neuropathy Lid laceration 6 1 1 2 2 1 1 0 0 8 3 2 Non-urgent Commotio retinae Orbital emphysema 3 1

Results Mechanism (by patient) Assault Fall from own height Fall from > own height Fall down stairs Motor vehicle accident Cycling injury Car vs pedestrian Work related Bike vs car Sport injury Unclear Other Total Male (%) 56 (31. 8%) 34 (19. 3%) 19 (10. 8%) 9 (5. 1%) 12 (6. 8%) 11 (6. 3%) 8 (4. 5%) 9 (5. 1%) 8 (4. 5%) 4 (2. 3%) 2 (1. 1%) 4 (2. 3%) 176 Female (%) 21 (30. 9%) 26 (38. 2%) 6 (8. 8%) 7 (10. 3%) 2 (2. 9%) 0 (0. 0%) 1 (1. 5%) 0 (0. 0%) 68

Results Patients recorded 278 278 267 206 (74. 10%) 72 (25. 90%) 115 (41. 37%) 163 (58. 63%) 87 (32. 58%) Cases with pathology 21 6 9 18 11 Anticoagulation use 272 11 (4. 04%) Antiplatelet use Anticoagularion or Antiplatelet 271 History Male gender Female gender Right eye Left eye Intoxication Cases Odds ratio 95% Confidence interval p value 1. 249 0. 801 0. 684 1. 462 1. 484 0. 483 - 3. 228 0. 310 - 2. 070 0. 296 - 1. 582 0. 632 - 3. 381 0. 657 - 3. 350 0. 647 1. 353 1. 625 0. 375 0. 342 2 2. 098 0. 429 - 10. 253 0. 360 31 (11. 44%) 4 1. 398 0. 449 - 4. 347 0. 563 272 41 (15. 07%) 6 1. 714 0. 646 - 4. 546 0. 279 Intubation or sedation 278 51 (18. 35%) 3 0. 529 0. 153 - 1. 828 1. 686 Previous cataract surgery 264 28 (10. 61%) 2 0. 649 0. 145 - 2. 900 1. 428 Any previous ocular surgery 264 37 (14. 02%) 3 0. 746 0. 213 - 2. 615 1. 353 Subjective vision loss 212 21 (9. 91%) 6 3. 238 1. 133 - 9. 251 0. 028 *

Results Patients Cases recorded Assault 278 83 (29. 86%) Fall from own height 278 64 (23. 02%) Fall from > own height 278 33 (11. 87%) Fall down stairs 278 18 (6. 47%) Motor vehicle accident 278 18 (6. 47%) Mechanism of injury Cases with Odds ratio pathology 13 2. 401 4 0. 554 2 0. 568 1 0. 529 95% Confidence interval 1. 075 - 5. 364 0. 184 - 1. 664 0. 128 - 2. 516 0. 068 - 4. 142 p value 0. 033 1. 708 1. 544 1. 455 Cycling injury 278 16 (5. 76%) 0 0. 000 - - Car vs pedestrian 278 12 (4. 32%) 0 0. 000 - - Work related 278 12 (4. 32%) 5 7. 922 2. 321 - 27. 044 0. 001 Bike vs car 278 11 (3. 96%) 0 0. 000 - - Sport injury 278 5 (1. 80%) 1 2. 375 0. 256 - 22. 050 0. 447 Unclear 278 2 (0. 72%) 0 0. 000 - - * *

Results Patients recorded Cases 268 3 (1. 12%) 2 Fixed pupil 273 12 (4. 40%) Corectopia Anisocoria 275 Any EOM limitation Symmetrical EOM limitation Asymmetrical EOM limitation Physical exam Relative afferent pupillary defect Presence of subconjunctival hemorrhage 360° of subconjunctival hemorrhage vs less Need for speculum exam Cases with Odds ratio pathology 95% Confidence interval p value 19. 200 1. 681 - 219. 312 0. 017 * 7 16. 870 4. 907 - 58. 003 7. 313 E-06 * 2 (0. 73%) 12 (4. 36%) 1 5 9. 500 7. 825 0. 577 - 156. 406 2. 292 - 26. 713 0. 115 0. 001 * 240 57 (23. 75%) 13 3. 567 1. 564 - 8. 135 0. 003 * 240 17 (7. 08%) 6 5. 247 1. 761 - 15. 629 0. 003 * 240 42 (17. 50%) 8 2. 217 0. 898 - 5. 473 0. 084 275 116 (42. 18%) 15 1. 819 0. 817 - 4. 050 0. 143 106 18 (16. 98%) 4 0. 807 0. 241 - 2. 704 1. 271 268 7 (2. 61%) 2 3. 776 0. 696 - 20. 482 0. 124

Results Patients recorded 278 278 69 (24. 82%) 195 (70. 14%) 127 (45. 68%) Cases with pathology 5 23 8 17 Proptosis 246 67 (27. 24%) EOM entrapment Suspicion of globe rupture 274 CT finding Odds ratio 95% Confidence interval p value 0. 664 2. 641 0. 467 2. 179 0. 241 - 1. 826 0. 884 - 7. 892 0. 197 - 1. 106 0. 960 - 4. 947 1. 572 0. 082 1. 916 0. 063 7 0. 928 0. 373 - 2. 305 1. 129 28 (10. 22%) 9 6. 000 2. 374 - 15. 161 0. 00015 * 276 4 (1. 45%) 3 31. 000 3. 103 - 309. 717 0. 003 * Extraconal hematoma 278 89 (32. 01%) 7 0. 721 0. 293 - 1. 775 1. 523 Intraconal hematoma Either extra- or intraconal hematoma 278 7 (2. 52%) 4 14. 377 3. 031 - 68. 194 0. 00079 278 93 (33. 45%) 9 0. 994 0. 428 - 2. 307 1. 011 276 27 (9. 78%) 8 5. 097 1. 972 - 13. 171 0. 00077 Roof fracture Floor fracture Lateral wall fracture Medial wall fracture Ophthalmology consult recommendation Cases * *

Results • Mean time to presentation was significantly longer in cases with pathology (28. 67 hours vs 15. 14 hours, p = 0. 031) • Mean age, log. MAR visual acuity, IOP, relative and absolute IOP difference between eyes, Hertel measurement, relative and absolute difference in Hertel measurement, and the degree of subconjunctival hemorrhage were NOT significantly associated with pathology • INR, PTT and platelet levels were also not associated with pathology

Discussion • Subjective vision loss was the only element on history that was associated with ophthalmologic pathology • Assault and work-related injuries were important risk factors • The pupil exam was the most important element on physical exam • Suspicion of pathology on CT scan is significant

Conclusion • The rate of urgent ophthalmic pathology in cases of orbital fracture is low (1. 1%) • Given the severity of pathology, appropriate triage is essential • Subjective vision loss is more significant than objective visual acuity • Pupil exam and can be readily assessed by primary care • In times of limited resources (ex: a pandemic), our ability to triage consults becomes invaluable!

Selected References • Ross M, El-Haddad C, Deschênes J. Ocular Injury in Orbital Fractures at a Level I Trauma Center. Can J Ophthalmol. 2017; 52(5): 499 -502. • Mellema PA, Dewan MA, Lee MS, Smith SD, Harrison AR. Incidence of Ocular Injury in Visually Asymptomatic Orbital Fractures. Ophthalmic Plast Reconstr Surg. 2009; 25(4): 306 -8. • Cook T. Ocular and Periocular Injuries From Orbital Fractures. J Am Coll Surg. 2002; 195(6): 831 -4.

Contact Information • Email: georges. nassrallah@mail. mcgill. ca • All questions or comments are welcome!