Intimate Partner Violence: An Underappreciated Etiology of Orbital Floor Fractures Thomas J. Clark, B.S.*, Lynette M. Renner, Ph.D., M.S.W.†, Rachel K. Sobel, M.D.‡, Keith D. Carter, M.D., F.A.C.S.§, Jeffrey A. Nerad, M.D., F.A.C.S.║, Richard C. Allen, M.D., Ph.D., F.A.C.S.§, and Erin M. Shriver, M.D., F.A.C.S.§ *Carver College of Medicine, University of Iowa, Iowa City, Iowa; †School of Social Work, University of Minnesota, St. Paul, Minnesota; ‡Department of Ophthalmology, Boston University School of Medicine, Boston, Massachusetts; §Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, Iowa; and ║Department of Ophthalmology, Cincinnati Eye Institute, Cincinnati, Ohio, U.S.A.
Purpose: To evaluate the prevalence of intimate partner violence (IPV) in a large population of female orbital floor fracture patients and provide recommendations on effectively identifying and referring IPV survivors. Methods: Retrospective review of facial fracture patients examined at the University of Iowa Hospitals and Clinics between January 1995 and April 2013. International Classification of Diseases, Ninth Revision, codes and medical record review were used to determine the prevalence of IPV victimization and clinical outcomes. Results: A total of 1,354 women and 4,296 men sustained facial fractures. Of these, 405 women and 1,246 men sustained orbital floor fractures. Leading mechanisms of orbital floor fractures in women were motor vehicle collisions (29.9%) and falls (24.7%). Twenty percent had no etiology documented. Intimate partner violence–associated assault was the third leading documented cause of orbital floor fractures in women (7.6%) followed by non–IPV-associated assault (7.2%). Among women with orbital floor fractures due to assault, leading patterns of injury included the following: isolated orbital floor fractures (38.7%, 12/31 in IPV patients; 55.2%, 16/29 in nonIPV patients), zygomaticomaxillary complex fractures (35.5%, 11/31 in IPV patients; 17.2%, 5/29 in non-IPV patients), and orbital floor plus medial wall fractures (16.1%, 5/31 in IPV patients; 24.1%, 7/29 in non-IPV patients). Involvement of ancillary services was documented in 20.0% (7 law enforcement and 5 social service agencies, 12/60) of assault-related orbital floor fracture cases. Ascertainment of patient safety was documented in 1.7% (1/60) of these cases. Conclusions: Ophthalmologists treating orbital floor fracture patients should maintain a high index of suspicion for IPV and
Accepted for publication February 1, 2014. Supported by an unrestricted grant from Research to Prevent Blindness, Inc., New York, New York, to the University of Iowa Department of Ophthalmology and Visual Sciences. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://www.op-rs.com). Presented at ASOPRS 44th Annual Fall Scientific Symposium in New Orleans, LA, on November 15, 2013. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Erin M. Shriver, m.d., f.a.c.s., Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242. E-mail: [email protected]
screen accordingly. Following IPV disclosure, patient safety should be assessed and referral provided. (Ophthal Plast Reconstr Surg 2014;30:508–511)
phthalmologists who treat orbital fracture patients undoubtedly interact with survivors of intimate partner violence (IPV). The World Health Organization defines IPV as “acts of physical, sexual and/or emotional abuse by a current or former intimate partner, whether cohabiting or not.”1 Intimate partner violence affects diverse populations, including both men and women, regardless of socioeconomic status, sexual orientation, age, or ethnicity.1,2 More than 12 million Americans experience IPV annually, and more than one third of American women have experienced IPV at some point in their lifetime.2 Intimate partner violence takes a significant economic toll on the American healthcare system. In 2003, the financial cost of IPV against US women was estimated to be $8.3 billion.3 More importantly, the effects of IPV can be devastating because 42% of murdered women are killed by an intimate male partner.4 Despite the high prevalence and severity of IPV, 56% of IPV cases go undetected or unaddressed in the Emergency Department setting.5 Several studies, including a 2010 systematic review and meta-analysis, have identified the head, neck, and face (including the eyes) as the most common sites of IPV-associated injury with reported rates as high as 94%.6–8 One study of 218 female domestic violence survivors found that 68% had been hit in the face with 45% having been struck specifically in the eyes.9 With this pattern of injury, ophthalmologists will undoubtedly encounter IPV-related injuries. Given the low rate of IPV recognition in the Emergency Department, these patients are likely to present to the eye clinic undetected. Despite under appreciation, IPV remains a significant cause of orbital floor fractures. Although the awareness of IPV has grown over the past few decades, little has been discussed in the ophthalmic literature. One small study evaluating 17 adult females with orbital floor fractures examined by an academic oculoplastics service found that in 6 patients fractures were caused by sexual assault or domestic violence.10 A larger study at the same institution found domestic violence to be the mechanism of injury in 3 of 41 (7%) female patients with orbital fractures.11 Beck et al.12 reported that 14% (11/79) of women with orbital fractures presenting to an Eye Emergency Department sustained their injuries as a result of “definite” intentional Ophthal Plast Reconstr Surg, Vol. 30, No. 6, 2014
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violence by a husband, boyfriend, or son or “probable” intentional violence by a known individual. Specific statistics on IPV were not given. These earlier studies unanimously called for an increased index of suspicion for IPV among ophthalmologists and encouraged appropriate screening in female patients presenting with ocular injuries, including orbital fractures. This study aims to evaluate the prevalence rate of IPV in a large population of female orbital floor fracture patients evaluated by an oculoplastics service at an academic institution and to provide recommendations on how to effectively identify and refer survivors of IPV.
MATERIALS AND METHODS A retrospective chart review of all patients with facial fractures examined at the University of Iowa Hospitals and Clinics between January 1995 and April 2013 was performed to determine the incidence of IPV victimization and review the details of this population’s clinical course and recovery. International Classification of Diseases, Ninth Revision, codes were used to determine the total number of patients with facial fractures, both male and female, and the number and percentage of facial fracture patients with orbital floor fractures. The subset of female patients who sustained orbital floor fractures was isolated, and the leading causes of injury were elucidated. The group of female patients who sustained orbital fractures secondary to assault was selected for further analysis and divided into “IPV assault” and “non-IPV assault” subgroups, based on the World Health Organization definition of IPV.1 The charts of these patients were thoroughly reviewed to determine the fracture patterns sustained, laterality of the injury, patient’s age at the time of assault, relationship to the perpetrator (if known), presence or absence of surgical repair, time between injury and surgery as well as type of orbital floor implant placed (if applicable), and clinical outcomes. The rate of documented involvement of ancillary services (e.g., social work, law enforcement, psychiatry, etc.) in female patients with orbital floor fractures due to assault was determined. This study received institutional review board approval, adhered to the standards of the Declaration of Helsinki, and was Health Insurance Portability and Accountability Act compliant.
RESULTS A total of 5,650 patients with facial fractures were examined at the University of Iowa between January 1995 and April 2013. Twentyfour percent (n = 1,354) were women, and 76.0% (n = 4,296) were men. Thirty percent (n = 405) of female and 29.0% (n = 1,246) of male facial fracture patients sustained orbital floor fractures. Leading mechanisms of orbital floor fractures in women were motor vehicle collisions (29.9%, 121/405) and falls (24.7%, 100/405). A large number (20.5%, 83/405) of women with orbital floor fractures had no etiology documented. Intimate partner violence–associated assault was the third leading documented cause of orbital floor fractures in women (7.6%, 31/405) followed by non–IPV-associated assault (7.2%, 29/405). Multiple other etiologies combined to account for the remainder of cases (10.1%, 41/405). Among the female patients with orbital floor fractures due to IPV assault, 38.7% (12/31) had isolated orbital floor fractures, 35.5% (11/31) zygomaticomaxillary complex fractures, 16.1% (5/31) orbital floor plus medial wall fractures, 6.5% (2/31) zygomaticomaxillary complex plus medial wall fractures, and 3.2% (1/31) zygomaticomaxillary complex plus medial wall plus orbital roof fractures. Among the female patients with orbital floor fractures due to non-IPV assault, 55.2% (16/29) had isolated orbital floor fractures, 24.1% (7/29) orbital floor plus medial wall fractures, 17.2% (5/29) zygomaticomaxillary complex fractures, and 3.5% (1/29) zygomaticomaxillary complex plus medial wall fractures. Among the female patients with orbital floor fractures
Orbital Floor Fractures in Survivors of Intimate Partner Violence
due to assault (IPV and non-IPV), the injury was left-sided in 70.0% (42/60), right-sided in 28.3% (17/60), and bilateral in 1.7% (1/60). The mean age of women who sustained orbital floor fractures from IPV was 32.1 years (median: 29 years; range: 18–50 years) compared with 34.5 years (median: 37 years; range: 17–59 years) in the non-IPV assault group. A 2-sample t test with unequal variance revealed no statistically significant difference among the mean ages of women in the IPV versus non-IPV assault groups (p = 0.380). Perpetrators of IPV included boyfriend (32.3%, 10/31), husband (19.4%, 6/31), “domestic partner” (19.4%, 6/31), ex-boyfriend (16.1%, 5/31), ex-husband (6.4%, 2/31), and fiancé (6.4%, 2/31). Fifty-two percent (n = 16) of women with orbital floor fractures from the IPV assault group underwent surgical repair compared with 62.0% (n = 18) of women from the non-IPV assault group. Documented indications for surgery included persistent motility defects, diplopia affecting daily activities, significant enophthalmos, hypoglobus, large fracture size, and patient preference. The median time between injury and surgery was 13 days (range: 3–40 days) in the IPV assault group and 14 days (range: 1–192 days) in the non-IPV assault group. SUPRAMID orbital implants (S. Jackson, Inc., Alexandria, VA, U.S.A.) were placed over the floor defect in 10 (62.5%) IPV-related cases and 15 (83.3%) non–IPV-related cases. Porous polyethylene with titanium (MEDPOR TITAN and MEDPOR BARRIER Microplate Channel implants, Stryker Corporation, Kalamazoo, MI, U.S.A.) were placed over the floor defect in 4 (25.0%) IPV-related cases and 2 (11.1%) non–IPV-related cases. Three patients (2 IPV and 1 non-IPV) did not require placement of an orbital floor implant due to a minimally displaced floor fracture following zygomaticomaxillary complex fracture reduction. A total of 4 (1 IPV and 3 non-IPV patients) of the 34 patients who underwent surgery required subsequent procedures. One patient in the IPV group underwent implant removal due to formation of an implant-associated pseudocyst causing proptosis and hyperglobus. Of the 3 patients in the non-IPV group who required additional procedures, 1 underwent implant removal due to cyst formation causing hyperglobus, 1 had implant replacement due to persistent diplopia and enophthalmos, and 1 required fistula closure. Of the female patients with orbital floor fractures due to assault, involvement of ancillary services was documented in 20.0% (12/60) of cases. Referral to social service agencies was noted in 8.3% (5/60) of cases, and law enforcement involvement was documented in 11.7% (7/60) of cases. Ascertainment of patient safety at home was documented in 1.7% (1/60) of cases.
DISCUSSION High Prevalence Rate of IPV. In this study, IPV-associated assault was the third leading documented mechanism of injury in female orbital floor fracture patients, occurring in 7.6%. Non-IPV assault followed with a prevalence rate of 7.2%. This translates into 1 of every 7 orbital floor fractures in female patients resulting from assault and 1 of every 13 resulting from IPV-related assault. The association between IPV and orbital floor fractures is supported by a previous study that evaluated 326 adult female facial trauma patients and noted a higher than expected number of zygomaticomaxillary complex fractures, orbital blow-out fractures, and intracranial injuries in IPV survivors.13 In the prior study’s population, 5.5% (18/326) of patients sustained injuries from IPV-associated assault and 14% (45/326) were injured by non-IPV assault.13 Of note, 20.5% of the female orbital floor fracture patients in the current study population had no etiology documented. Based on the highly under-reported nature of IPV,14 it is probable that a substantial portion of these patients also sustained injury secondary to IPV that went unreported or undocumented. Given Iowa’s relatively low rate of IPV prevalence (seventh lowest in the United States),15 these percentages are undoubtedly an underestimate for many sectors of the United States.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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The statistics reported herein likely surpass the prevalence assumed by many in the ophthalmic community. A survey of Canadian orthopedic surgeons revealed a perceived IPV prevalence rate of