Abstract
Purpose :
The initial assessment of polytrauma patients is a critical component in determining the necessary urgent therapies and appropriate subspecialty referral. At our center, the ophthalmology service is consulted for all orbital fractures as a matter of protocol. However, with increasing constraints on our publicly funded healthcare system, appropriate triage of these patients is becoming pivotal, and to do so safely, an appropriate primary care assessment is invaluable. Our study aims to compare the initial assessment by primary care physicians with that conducted by the ophthalmology service.
Methods :
277 fractured orbits belonging to 243 patients presenting to a level 1 trauma center were included in this retrospective chart review. Key elements of the primary care assessment including subjective vision loss, visual acuity, intraocular pressure, pupil exam and extraocular movements were documented and compared with the assessment by the ophthalmology service as the control. The primary outcomes were the sensitivity and specificity of the elements of the primary care assessment using ophthalmology assessment as the gold standard. Secondary outcomes included the rates of completion of exam components.
Results :
When compared with ophthalmology assessments, primary care physicians asked less often about reduced vision (34.4% vs 86.3%, p < 0.0001), and measured visual acuity (3.6% vs 76.9% p < 0.0001) and intraocular pressure (0.4% vs 92.4%, p < 0.0001) far less often. They less often assessed for afferent pupillary defect (13.7% vs 96.8%, p < 0.0001) but were more likely to assess other pupillary abnormalities, though still less often than the ophthalmology service (82.0% vs 99.35, p < 0.0001). They were also less likely to check for oculomotor deficits (31.4% vs 86.3%, p < 0.0001). Across all components of the primary care assessment, there was a high specificity associated with findings (87.5%-100%). However, the sensitivity of these assessment components was low (0%-41.7%).
Conclusions :
Our results suggest a potential overdependence on the ophthalmologic assessment by primary care staff in complex cases of polytrauma. Given the limited resources of the public healthcare system and increasing wait times for both emergency and ambulatory care, our study may highlight the primary care assessment as a potential focus to improve effective and safe patient management and referral.
This is a 2020 ARVO Annual Meeting abstract.