Preoperative Examination for Orbital Floor Repair: Provider Qualifications
An ophthalmologist must perform the preoperative examination for orbital floor repair, not an optometrist, as this complex evaluation requires the specialized training and clinical judgment of an experienced ophthalmologist to assess for vision-threatening injuries, muscle entrapment, and surgical planning considerations.
Why an Ophthalmologist Is Required
Scope of Practice and Training Requirements
The American Academy of Ophthalmology explicitly states that diagnosis and management of strabismus and orbital trauma require the training and clinical judgment of an experienced ophthalmologist 1.
The preoperative assessment for orbital floor fractures demands evaluation of potentially sight-threatening conditions that fall outside the scope of optometric practice, including assessment for globe injury, optic neuropathy, retinal damage, and complex extraocular muscle dysfunction 1.
Specialized ophthalmologic examination is critical particularly when signs and symptoms of severity are present, as 24% of orbital fractures have serious ocular injury and 5.5% result in complete vision loss 2, 3.
Critical Components Requiring Ophthalmologic Expertise
The preoperative examination must include:
Vision testing, refraction, pupillary examination for afferent defects, intraocular pressure measurement, confrontational visual field testing, and slit-lamp examination to rule out globe injury 1, 3.
Dilated or undilated fundus examination with attention to fundus torsion, testing of facial sensation, and exophthalmometry 1.
Detailed sensorimotor examination including versions, ductions, saccades, pursuit, vergence, and near reflex, with alignment testing in multiple gaze positions 1.
Forced duction and forced generation testing to distinguish restriction from paresis of extraocular muscles 1, 3.
Specialized testing such as double Maddox rod, Lancaster red-green, Hess screen, or synoptophore if there is concern for disrupted central fusion 1.
Surgical Planning Responsibilities
The operating ophthalmologist should ideally perform the preoperative assessment to formulate a surgical plan and establish a relationship with the patient before surgery 1.
The ophthalmologist must determine surgical timing, which varies from immediate repair (within 24-48 hours) for entrapped muscle with oculocardiac reflex to early repair (within 1-2 weeks) for symptomatic diplopia with positive forced ductions 4, 3.
Preoperative forced duction assessment and attention to ocular torsion are essential for surgical planning to minimize risk of undesired postoperative results 1.
Role of Allied Health Professionals
Working under the supervision of an ophthalmologist, orthoptists can assist with examination, diagnosis, and nonsurgical management, but cannot independently perform the preoperative assessment 1.
Certain aspects of data collection may be conducted by trained team members under the ophthalmologist's supervision and review, but the ophthalmologist remains responsible for the examination and review of all data 1.
Common Pitfalls to Avoid
Delaying ophthalmology evaluation can lead to missed opportunities for early intervention, as diplopia develops in up to 86% of orbital fracture patients as edema resolves 5, 3.
Assuming a normal initial exam by a non-ophthalmologist means no problems exist is dangerous, as persistent diplopia occurs in 37% of patients even after surgical repair 5, 3.
Non-ophthalmologist surgeons may detect only limited findings such as changes in visual acuity, pupillary response, and extraocular muscle dysfunction, missing more subtle or serious ocular injuries that require specialized examination 6.