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Stratifying Risk of Delayed Enophthalmos in Orbital Floor Fractures using the Orbital Index
Brandon J. De Ruiter, BS1, Frank Lalezar, MD1, Daniel Baghdasarian, BS1, Evan Mostafa, BS1, Avinoam Levin, BA1, Edward H. Davidson, MD2.
1Montefiore Medical Center/Albert Einstein College of Medicine, Division of Plastic Surgery, New York, NY, USA, 2Case Western Reserve University, Department of Plastic Surgery, Cleveland, OH, USA.

BACKGROUND
Early identification of surgical indication is critical to optimizing outcomes in orbital floor fracture management. Absolute indications for surgical repair of orbital floor fractures are acute muscle entrapment and globe malposition. However, identifying those at risk for delayed enophthalmos and requiring subsequent surgery remains a challenge. This study aims to validate a clinical prediction tool using computed tomography (CT) data to stratify risk for delayed enophthalmos and establish a threshold for surgical intervention.
METHODS
The Orbital Index stratifies fractures by size, location, and inferior rectus muscle rounding (a surrogate for fascioligamentous sling disruption); scale of 0-6. A twenty year (1998-2018) single-center retrospective analysis of orbital floor fractures was performed, scores were assigned and verified by two investigators and correlated with treatment course. Unoperated patients identified on review were then invited for follow-up evaluation and enophthalmos was measured with Hertel Exophthalmometry. Inter-observer reproducibility across scoring components was assessed comparing scores between craniofacial specialists, plastic surgery trainees and medical students. Providers were surveyed pre-and post-intervention to determine whether use of this tool improved understanding and communication.
RESULTS
The Orbital Index demonstrated high fidelity, inter-observer reproducibility, and identified a score of ≥4 as a surgical threshold. Retrospective chart review identified 202 fractures meeting the inclusion criteria; 34% scored 0 (operative rate 3%), 12% scored 1 (8%), 10% scored 2 (14%), 10% scored 3 (20%), 10% scored 4 (45%), 12% scored 5 (63%), and 11% scored 6 (78%). A statistically significant difference in decision for operative intervention was found between scores of 3 vs 4 (p=0.04), but not scores 0 vs 1 (p=0.27), 1 vs 2 (p=0.82), 2 vs 3 (p=0.43), 4 vs 5 (p=0.43), or 5 vs 6 (p=0.29). Mean weighted Cohenís Kappa was 0.73 corroborating scoring reproducibility. 13 patients returned for follow-up evaluation. All 9 patients with an Index <4 had <2mm enophthalmos. Three of the four patients with an Index score ≥4 had ≥2mm enophthalmos. Participants demonstrated increased ability to correctly identify surgical need with use of the Orbital Index (p=0.01). Pre-and post-intervention surveys demonstrated increased subject self-reported understanding (p=0.001) and communication. (p=0.0003)
CONCLUSIONS
The Orbital Index is a reproducible tool to stratify risk for enophthalmos in orbital floor fracture management.


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