Clinical correlations of extraocular motility limitation pattern in orbital fracture cases: a retrospective cohort study in a level 1 trauma centre.

PURPOSE: Ocular pathology (OP) following orbital fracture can vary vastly in complexity and severity. Extra-ocular motility (EOM) limitations are frequently present in orbital trauma cases, with patterns of duction limitations being symmetrical or asymmetrical. The aim of this study was to identify if there was any association between increased OP following orbital fracture cases based on the pattern of EOM deficits. METHODS: This is a retrospective cohort study of patients with fractured orbits presenting with or without EOM limitations to a level 1 trauma center between August 2015 to January 2018. All pertinent elements of the ophthalmic examination were recorded. Outcome measures: Chi-square analyses assessed for association between symmetrical or asymmetrical EOM limitation and OP. Odds ratios were calculated with 95% confidence interval. RESULTS: 278 orbits with wall fractures were included in this study. A significant correlation between EOM limitation and increased OP following orbital trauma was found (p = 0.000081). Cases with symmetrical and asymmetrical EOM limitation were 7.9 (95%CI: 2.3-27.2) and 5.22 (95%CI: 1.9-13.9) times more likely to have OP than cases with no EOM limitation, respectively. With extraocular muscle entrapment excluded, cases with symmetrical limitations had a significantly higher incidence of OP than cases with asymmetrical limitations (p = 0.0161). CONCLUSIONS: OP is frequently observed in cases of orbital fracture. While any EOM limitations should prompt the clinicians to anticipate OP, intra-ocular injury may be more likely in cases of symmetrical EOM limitation. Future prospective studies are needed to further elucidate the relationship between EOM symmetricity and OP following orbital trauma.

Incidence of ocular surface squamous neoplasia in pterygium specimens.

OBJECTIVE: Pterygium and ocular surface squamous neoplasia (OSSN) have been recognized as likely related conditions and share similar risk factors such as ultraviolet radiation and chronic inflammation. The purpose of this study is to review the incidence of OSSN in pathology specimens sent as pterygium at a single tertiary centre between 2010 and 2022. METHODS: This is a retrospective chart review of patients operated on for pterygium between 2010 and 2022 at the University of Montreal Health Centre. Data collected include baseline demographics, results of pathology specimen, and clinical information for cases diagnosed as OSSN on pathology. RESULTS: A total of 1559 patients were operated on for a clinical diagnosis of pterygium between 2010 and 2022, of which 854 patients (55%) were male. A total of 1142 specimens had available pathology reports, and most of the specimens were consistent with pterygium on pathology (1105 of 1142; 97%). There was an unexpected finding of 3 cases of OSSN (3 of 1142; 0.3%). Other diagnosis besides pterygium were seen in 3% of specimens (34 of 1142), including nevus (n = 12), spheroidal degeneration (n = 3), pyogenic granuloma (n = 3), and lymphangiectasia (n = 2). The 3 cases of OSSN included an 81-year-old male of French-Canadian background, a 52-year-old male of South Asian background, and a 59-year-old female of French-Canadian background. The pathology was diagnosed as conjunctival intraepithelial neoplasia (CIN) grade 3, CIN grade 2, and CIN grade 2, respectively. CONCLUSION: The finding of OSSN in pterygium is rare in our population but can be clinically difficult to distinguish. It is important to send all pterygium specimens for pathology.

Incidence of ophthalmologic pathology and associated risk factors in orbital fractures at a level I trauma centre.

OBJECTIVE: To estimate the incidence of ophthalmologic pathology at presentation of patients with orbital fracture to a level I trauma centre and the most significant associated risk factors. METHODS: A total of 244 patients with 278 fractured orbits over a 2-year period at a level I trauma centre were reviewed. The primary outcome was the incidence of urgent ophthalmologic pathology, defined as requiring attention without delay. Patient demographics, history, findings on radiographic imaging, and physical examination findings at initial and follow-up examinations were recorded. Odds ratios with 95% confidence intervals were calculated. RESULTS: On initial examination and follow-up, 9.7% of orbits had ophthalmologic pathology. Only 3 patients (1.1%) had urgent pathology, including orbital compartment syndrome and globe rupture, whereas 22 patients (7.9%) had semiurgent pathology and 4 patients (1.4%) had nonurgent pathology. Subjective decreased vision (odds ratio [OR] = 3.5; p = 0.021), assault-related injuries (OR = 2.4; p = 0.036), work-related injuries (OR = 7.7; p = 0.004), afferent pupillary defect (OR = 19.2; p = 0.017), anisocoria (OR = 7.8; p = 0.001), and symmetrical extraocular movement limitation (OR = 5.2; p = 0.003) and fixed pupil (OR = 16.9; p < 0.001) had statistically significant odds ratios associated with pathology. Patient sex, eye involved, intoxication, anticoagulation, and antiplatelets, as well as previous ocular surgery, were not associated with pathology. CONCLUSIONS: Most orbital fractures do not present with ophthalmologic pathology. Subjective vision loss, history of assault or work trauma, and pupil abnormalities on examination were the greatest risk factors for pathology. Our results highlight the most important factors on patient presentation that should prompt first responders to seek urgent ophthalmologic consultation.

Significance of subconjunctival hemorrhage in predicting ocular pathology for patients with orbital fracture.

OBJECTIVE: Subconjunctival hemorrhage (SCH) is a common presentation in patients with orbital trauma and often warrants investigation of underlying ocular pathology. Our study aims to assess the significance of SCH severity, graded in a spatial 0-360° manner, as a predictor for ocular pathology in patients with orbital fracture. DESIGN: Retrospective chart review. PARTICIPANTS: Patients with fractured orbits (n = 265) presenting to a level 1 trauma centre between August 2015 and January 2018. METHODS: Key elements of ophthalmic assessment, including visual acuity, SCH (0-360°), anterior- and posterior-segment examination, Hertel exophthalmometry, and ocular pathology, were recorded. Simple logistic regression assessed for association between SCH severity and ocular pathology. Odds ratios (ORs) were calculated with 95% CI. RESULTS: Among the 265 fractured orbits, 158 (59.6%) presented with no SCH, and 107 (40.4%) had some degree of SCH. Ocular pathology was noted in 24 fractured orbits (9%). Most common pathologies included entrapment (22.2%), hyphema (16.7%), traumatic optic neuropathy (8.3%), and commotio retinae (8.3%). Simple logistic regression revealed a higher incidence of ocular pathology with increasing severity of SCH from 0-360° (OR = 1.004; 95% CI 1.001-1.007; p = 0.0085). In addition, χ2 analysis demonstrated a higher proportion of ocular pathology in 181-270° (25.0%; p = 0.0466) and 271-360° SCH subgroups (26.3%; p = 0.0031) compared with the 0° SCH subgroup (6.3%). CONCLUSIONS: Our findings suggest that there is some correlation between the extent of SCH and ocular pathology. However, patient care and investigations should continue to be directed by a full clinical assessment of patients with orbital trauma.

Primary care assessment of orbital trauma at a level 1 trauma centre.

OBJECTIVE: With increasing constraints on our publicly funded health care system, appropriate triage of trauma patients is becoming pivotal, making the primary care assessment (PCA) invaluable. Our study aims to compare the initial assessment of patients with orbital fractures with that conducted by the ophthalmology service. DESIGN: Retrospective chart review. PARTICIPANTS: 243 patients with 277 fractured orbits presenting to a level 1 trauma centre seen between August 2015 and January 2018. METHODS: Key elements of the PCA, including subjective vision loss, visual acuity, intraocular pressure, pupil examination, and extraocular movements, were documented and compared with the assessment by the ophthalmology service as the control. The primary outcome was inter-rater reliability as estimated by Cohen's kappa (κ) coefficient. Secondary outcomes included the sensitivity and specificity, as well as the rate of completion of examination components. RESULTS: PCA examination findings agreed with the ophthalmology service on most components of the examination with the highest agreement with relative afferent pupillary defects and detection of hyphemas (κ = 1). Primary care physicians less often performed most aspects of the assessment. Among performed components of the examination, the average sensitivity was 60.6%, and the average specificity was 84.2%. CONCLUSIONS: Our results show good inter-rater reliability of the PCA compared with the ophthalmology examination but low rate of completion of examination components, suggesting a potential overdependence on the ophthalmology assessment. Given the limited resources of the public health care system, our study may highlight the PCA as a potential focus to improve effective and safe patient management.

Unilateral upper eyelid eversion and kink associated with epidemic keratoconjunctivitis.

PURPOSE: Upper lid eversion in adults from non-cicatricial causes is rare. We report a case of upper eyelid eversion secondary to epidemic keratoconjunctivitis (EKC). OBSERVATIONS: A 37 year-old female presented with unilateral upper lid eversion. Known for left upper lid ptosis repair in childhood, the patient presented with seven-day history of severe bilateral conjunctivitis and eversion of her left upper lid three days prior. On exam, she had follicular conjunctivitis, punctate epithelial keratopathy with subepithelial infiltrates and membranes bilaterally, with an everted upper lid tarsus, and swollen and ulcerated palpebral conjunctiva. She received topical and oral prednisone to quickly reduce the inflammation, as well as moxifloxacin drops and lubrication. When the swelling subsided, the tarsus adopted a kinked and everted configuration, and was managed successfully with reversion, pressure patching, shielding and close follow-up. CONCLUSIONS AND IMPORTAMCE: This is the first reported case of upper lid eversion secondary to EKC, likely due to sudden marked inflammation and edema of the posterior lamella caused by the adenoviral infection. This case was successfully managed with conservative therapy.