Algorithm may predict ocular injuries in patients with orbital fractures
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Researchers created an algorithm for non-ophthalmologists to assist in triage decisions and help predict ocular injuries in patients who have experienced an orbital fracture.
“This is relevant because access to a specialized ophthalmic exam is limited in many settings, and it can be costly for patients to travel to a location where they have access to such an exam. It would therefore be useful to create a tool that we could share with the non-ophthalmologist so that they can know when to involve ophthalmology in the setting of orbital fracture,” study co-author Elizabeth J. Rossin, MD, PhD, told Healio/OSN.
The researchers identified specific clinical and radiographic features associated with increased risk for significant ocular injuries following orbital fractures. The retrospective case series included 500 eyes of 430 consecutive patients between 2012 and 2017. The rate of substantial ocular injury was 20.4%, with 14.4% requiring immediate ophthalmic attention.
Researchers identified five factors that helped to predict ocular injury and can be easily assessed at bedside without the use of specialized ophthalmic instrument or skill. The variables were blunt trauma with a foreign object, inability to count fingers, roof fracture, diplopia on primary gaze, and conjunctival hemorrhage or chemosis.
The researchers created a bedside tool for non-ophthalmologists to identify those who should receive an ophthalmic examination. The tool was simulated on 97 eyes of 88 new consults, extracting only the five variables from their medical records. The tool was found to have 95.4% sensitivity and 40% specificity with a 31.8% positive predictive value and a 96.8% negative predictive value.
The results are comparable to other widely used screening tools in medicine, Rossin said.
“Even with low sensitivity, we are able to safely identify roughly 30% of patients who did not need an urgent ophthalmic evaluation. We hope that the non-ophthalmologist will be able to use this tool to help make triage decisions,” she said.
Perspective
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This is a well-designed study that not only validates the findings of previous reports on the prevalence of severe ocular injuries associated with orbital fractures but most importantly identifies five variables (presence of subconjunctival hemorrhage, orbital roof fracture and double vision, history of injury with a foreign body, and inability to count fingers at 1 to 2 feet) associated with the urgent patient’s visit that would help the non-ophthalmologist distinguish patients with orbital fracture with high risk for sight-threatening injuries from those with low risk for severe ocular injuries.
The algorithm proposed by the authors does not require specialized training or equipment, which make it suitable for non-ophthalmology physicians, who are the first ones to evaluate patients with facial trauma. In addition, this relatively simple algorithm has a high sensitivity and high negative predictive value, which translate into recognition of most patients with orbital fractures and significant ocular injuries and could help the emergency physician with the decision for immediate ophthalmology consultation or referral for outpatient ophthalmic follow-up.
Although the authors validated their model with test cases, this was also done retrospectively. Therefore, it may be necessary to test this algorithm prospectively in the emergency setting by non-ophthalmologists to confirm its accuracy and before implementing it broadly as a triage tool.
The timing and urgency of an ophthalmology consultation for patients presenting to the emergency room with facial fractures is ultimately a decision made by the evaluating physician based on individual case presentations, but in my opinion, the proposed algorithm has the potential to be used as a guideline to facilitate the identification of patients who would require immediate specialized care. This would be particularly helpful in rural areas and in centers where ophthalmology services are not available. Additional benefits of this screening tool would include better use of time (patient and physician) and resources (specialty care, emergency transfers, additional emergency visits, etc), potentially reducing health care costs.
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Rossin EJ, et al. JAMA Ophthalmol. 2021;doi:10.1001/jamaophthalmol.2020.5108.
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