Plastic Surgery Research Council

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The Orbital Index: A Novel Comprehensive Quantitative Tool for Prediction of Delayed Enophthalmos in Orbital Floor Fracture Management
Brandon De Ruiter, BS, Frank Lalezar, MD, Evan Mostafa, BS, Daniel Baghdasarian, BS, Avinoam Levin, BA, Edward H. Davidson, MD.
Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY, USA.

PURPOSE: 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 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 rounding (fascioligamentus 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. 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 201 fractures meeting the inclusion criteria; 35% scored 0 (operative rate 3%), 12% scored 1 (8%), 10% scored 2 (10%), 11% scored 3 (18%), 9% scored 4 (50%), 12% scored 5 (63%%), and 11% scored 6 (77%). 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). 94% of scoring across all components, aggregate Index scores, and operative decisions were within 1 point of reference. 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)
CONCLUSION: The Orbital Index is a reproducible tool to stratify risk for enophthalmos in orbital floor fracture management.


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