Primary Assessment of the Patient With Orbital Fractures Should Include Pupillary Response and Visual Acuity Changes to Detect Occult Major Ocular Injuries.

PURPOSE: Sight-threatening injuries associated with orbital fractures are of major concern to maxillofacial surgeons whom are often the first asked to assess these patients. Eliciting signs and symptoms that are predictive of these injuries would allow expedited ophthalmic consultation and appropriate management. We hypothesized that abnormal pupillary response is predictive of major ocular injuries. PATIENTS AND METHODS: A retrospective cohort study of patients with facial fractures was instituted with review of all associated ophthalmic injuries. The primary predictor variables were the presence or absence of post-traumatic ocular symptoms and signs (visual acuity change, diplopia, flashes and floaters, pain on globe movement, abnormal pupillary response, restriction of eye movement, and visual field defects). Secondary predictors were pattern of fracture and mechanism of fracture. The primary outcome variable was the presence or absence of major ocular injury assessed during formal ophthalmology consultation. Descriptive statistics were calculated as categorical values. Correlation between the presence or absence of predictors and outcome (major ocular injury) was calculated using χ2 analysis, with the significance value set at P ≤ .01. RESULTS: The study included 75 patients (25% of whom were female patients) with a mean age of 41 ± 22 years. We recorded 165 minor ocular injuries and 43 major ocular injuries. The mechanisms of injury included assault (48%, n = 36), motor vehicle accident (21%, n = 16), fall (17%, n = 13), sport (11%, n = 8), and occupational (3%, n = 2). The fracture pattern included zygomaticomaxillary (36%, n = 27), isolated orbital floor (25%, n = 19), complex (20%, n = 15), and isolated orbital nonfloor (19%, n = 14). Of the primary outcome predictors, only abnormal pupillary response (odds ratio, 36; P < .001) and subjective visual acuity changes (odds ratio, 10; P < .001) were predictive of major ocular injury. The mechanism of injury and pattern of fracture were not predictive of major ocular injury. CONCLUSIONS: During primary assessment of the patient with orbital fractures, abnormal pupillary response and subjective visual acuity changes are key predictors of occult major ocular injury.

Medical image. Calcified facial haematoma.

Doctors have been promoting alcohol as a health tonic for a very long time. The last 30 years has seen the accumulation of a considerable medical literature investigating the potential role of alcohol use as a protection against coronary heart disease. When viewed through the lens of two major early reviews in the mid-1980s, Sir Richard Doll's contributions of the mid-1990s, two large meta-analyses of 10 years ago and two most recent overviews, the health-giving properties of alcohol use become increasingly debatable. The influence of the alcohol industry is raised as a factor in the exaggeration of alcohol use as a health intervention, in similar fashion to activities of pharmaceutical companies. The status of alcohol as a potentially dangerous recreational drug is emphasised as a warning against talking up alcohol as a cardio-protection manoeuvre by anyone.

White-eyed blowout fracture: another look.

Orbital floor fractures have the potential to cause significant morbidity both in the short and long terms and commonly present to the ED for initial assessment. Although treatment of the majority of these injuries involves clinic review and possible later surgery, there is a specific subset that present to emergency clinically suggestive of a head injury. This subset, 'white-eyed blowout', usually occurring under 18 years of age, with a history of trauma and little sign of soft tissue injury, describes a trap door orbital floor fracture with herniation and acute entrapment of orbital muscle and is regarded as a maxillofacial emergency. The injury presents with marked nausea, vomiting, headache and irritability suggestive of a head injury that commonly distracts from the true aetiology. It requires prompt diagnosis and treatment to avoid permanent morbidity. We present three cases and discuss their management.