A Global Call to Action

I have only felt truly unprepared once in clinic. My patient was a mother of two and she had an orbital floor fracture. I had been performing orbital surgery for a while, so I wasn’t nervous about the procedure. It was the patient who made me uncomfortable. Why? Because her injury was a result of intimate partner violence (IPV). The World Health Organization (WHO) defines IPV as “acts of physical, sexual and/or emotional abuse by a current or former intimate partner” (1). It transcends the boundaries of ethnicity, culture and socio-economic class, and occurs in all relationship types. It is the most common violence against women (2), and a leading cause of death and disability worldwide – so why aren’t we, as ophthalmologists, talking about it? To put it simply, we don’t know what to say. I didn’t know what to say. We aren’t taught how to speak to IPV patients in medical school, or what signs we’re supposed to look out for. And, at that time, there wasn’t much data on ocular signs or symptoms of IPV-related injuries. In fact, there is little information on IPV prevalence or impact as a mechanism of ocular and orbital trauma – strange when you consider that 45 percent of IPV-related injuries occur around the eyes (3).

Are you surprised by that statistic? Because I was. It hadn’t even occurred to me how many of my patients might have been victims of IPV until I began treating this one patient. As she met some criteria for surgery but not all, I was left debating whether to operate. This woman has been through so much trauma, why would I put her through more? My fellow, Rachel Sobel, disagreed. She had treated two other IPV patients and they said surgery actually helped with the healing process. The procedure confirmed they had been victims of a major assault, and made them feel as if they were physically being put back together. Perhaps unsurprisingly, my patient decided to have the surgery. I held her hand as she went under anesthetic, in tears, telling me how she put her children at risk. But when she came out of surgery, she was a new woman. She said she felt incredible. My fears of causing another trauma didn’t play out at all. Not only did she feel better, she healed incredibly well too. The whole episode made me realize ophthalmologists are not doing enough to understand IPV – so I decided to educate myself.

Identifying IPV

I started by looking at orbital floor fractures – the kind my patient had – with a medical student, Thomas ‘TJ’ Clark, and what we found formed the basis of the paper, “Intimate Partner Violence: An Underappreciated Etiology of Orbital Floor Fractures” (4). We found the leading causes of orbital floor fractures in female patients were motor vehicle accidents (29.9 percent) and falls (24.7 percent). IPV was the third leading cause (7.6 percent), followed by non–IPV-associated assault (7.2 percent). To put that in context, 1 in every 13 orbital fractures in female patients resulted from IPV-related assault. Shockingly, 20 percent of cases had no documented cause. Among the women with orbital floor fractures due to assault, leading patterns of injury included isolated orbital floor fractures (38.7 percent, 12/31), zygomaticomaxillary complex fractures (35.5 percent, 11/31), and orbital floor plus medial wall fractures (16.1 percent, 5/31).

Female patients who have experienced IPV typically present with several injury sites, including soft tissue trauma (61 percent), and trauma to the head or neck (88–94 percent) (5). Almost immediately, I started seeing patients with these injuries in clinic. But I had been seeing them all along – I just never noticed before. More importantly, I never asked. As it turns out, I was not alone. When asked about IPV in their patient population, 87 percent of surveyed Canadian orthopedic surgeons reported prevalence at one percent or less. The actual figure was closer to 32 percent (6). This disconnect between patients and clinicians is not uncommon. I used to justify my own reluctance to talk about the cause of my patient’s injuries in two ways. The first was thinking the patient would talk to me if they wanted to. This is not the case: a recent study found that the majority of female patients expect a healthcare provider to initiate the conversation, with only one in four IPV patients spontaneously offering testimony (7). My patients weren’t keeping quiet because they had nothing to say, they were just waiting for me to speak first.

The second way I justified my silence was by assuming it was the emergency department’s job to detect IPV. I was wrong about that too. Most IPV patients are only identified after repeatedly accessing the healthcare system, and 56 percent go undetected or unaddressed in the emergency department setting (8). With ERs failing to identify IPV, it falls on us as ophthalmologists to detect it in the clinic. But how? To find out, I enlisted the help of Lynette Renner at the University of Minnesota. Lynette is Director of the Minnesota Center Against Violence and Abuse, and has dedicated her life to IPV. Together, we created two screening tools for physicians to use (see IPV Screening). But first, you need to identify who might need this screening.

Injury patterns

Unlike child abuse, there is no agreed upon injury pattern or history for IPV. This is something we are working to address but, until then, there are some signs to look out for. The first concerns the type and severity of the injury sustained. In a study Ali Cohen, a medical student, and I conducted of 190 patients with traumatic ocular injuries, five had IPV-related ocular trauma (9). All five had also sustained scleral lacerations or ruptured globes, with four requiring enucleation due to permanent vision loss. Such an injury pattern – multiple severe ocular or orbital injuries – can be an indication of IPV.

The second is location. The majority of intentional violence injuries are located in the maxillofacial region, with nasal fractures accounting for the highest percentage of maxillofacial fractures (33 percent), followed by trauma to the bony orbit (20.2 percent) and the zygoma (16.7 percent). More specifically, 81 percent of IPV facial fractures occur on the left side. This statistic could reflect the fact that 90 percent of the population is right handed (10) and the majority of IPV injuries are the result of blunt trauma from a closed fist.

It is worth noting that although both men and women can be victims of (or subject to) IPV, women are significantly more at risk. Studies estimate that IPV prevalence ranges from 10 to 69 percent internationally – with some regions reporting rates as high as 71 percent (11). The average IPV patient is a woman between the ages of 20 and 40 (12). She is 7.5 times more likely to present at the emergency department with head, neck or facial trauma than a female patient with other injury patterns. If you believe your patient has been the victim of IPV for any or all of these reasons, they are worth screening.

Screening and referral

First of all, it is important to remember we are not experts in IPV – and we are not expected to be. But we are expected to help our patients, and we can do that by being aware of IPV screening protocols. If a patient presents with a traumatic orbital or ocular injury of questionable cause, ask the questions outlined in this article. If you live in a US state with mandatory reporting, you must tell your patient you are legally required to disclose information to the police before conducting the screening. It is best to have the conversation unaccompanied in a quiet setting. I normally say there is an exam I need to do down the hall, and take them somewhere private. There, I introduce the purpose of the screening: “Because IPV is so common, there are some standard questions I ask my patients”, asking “Have you been physically, sexually or emotional abused by an intimate partner?” At this point, most people say, “Thank you, but my injury has nothing to do with my partner.” In this case – a negative screening – I take them back to the room and continue my clinic as usual. If the patient responds with a “Yes.” I ask “Are your current injuries a result of this kind of abuse?” If the screening is positive, I tell the patient: “I am glad you shared this with me and I am so sorry this happened to you,” “It is not your fault”, and “You are not alone.” I offer to contact a social worker right away or refer the patient to the appropriate community-based service, who will then brief them on their options and decide on the best course of action.

It is impossible to underplay the importance of early identification. IPV injuries escalate. It is estimated 50 percent of women who have been killed by their intimate partner presented at an emergency department prior to that. The nature of our profession means we have a unique opportunity to intervene before it is too late and save these patients lives. I have had residents tell me they think their patients have sustained IPV, and they missed the opportunity to help them. This isn’t true. If you have treated a patient for an injury you believe was the result of IPV, simply screen them at their next appointment. If they don’t come to their follow up, call and ask them to come in to follow up on their ophthalmic condition. You can speak with them about the circumstances of their injury when they are in the clinic. It may seem uncomfortable or intrusive at first, but it gets easier with time.

Patients don’t care whether is it the physician, nurse or technician who initiates the conversation, or whether the screener is male or female, so it is important every member of the healthcare team – technicians, nurses and residents – is trained to screen for IPV. With comprehensive training, healthcare providers will gain confidence in their ability to question patients and refer them on to ancillary services, including crisis centers, social services and domestic violence hotlines.

Though these services will take care of the patients emotional and psychological needs, it is our job to assess patient safety. In a landmark study, researchers found of all patients presenting with confirmed or probable IPV injuries at a Level 1 trauma center, 63 percent were discharged without any assessment of their safety at home (13). Our own research yielded similar results. Only 1.7 percent of the women with assault-related fractures in our study population had documentation relating to patient safety in their medical charts. This statistic needs to change. The potentially lethal nature of IPV makes it essential for clinicians to assess patient safety – so ask.

Ophthalmologists for social change

Since our paper was published, I have given talks both here in the US and internationally, and written a short course for the American Academy of Opthalmology (AAO) on IPV screening and referrals. At last year’s AAO annual meeting, I was moved by Ekta Rishi’s poster describing severe ophthalmic complications from acid attacks.  With the support of Women in Ophthalmology, the   Women Ophthalmologists Society (WOS) in India - founded by Mohita Sharma - is now currently researching IPV, as it relates directly to the ocular injuries sustained from acid attacks. It is believed there are around 1,500 acid attacks worldwide each year, and in 80 percent of cases, the victim is female (14). In time, we hope other institutions will publish their data and help improve the understanding of IPV victimization, and treatment, internationally. In the US, the rate of IPV stands at 30 percent – or more than 12 million Americans every year (15). These women aren’t just our patients – they are also our colleagues, our family and our friends. By finding a way to detect and discuss IPV, we are opening the door for detection, intervention and psychological recovery.

As ophthalmologists, we have the ability to permanently, and positively, alter our patient’s lives. But why stop there? We are also in a unique position as clinicians to affect large-scale social change. In Iowa, for example, hospital residents helped stop firework legislation for several years and are currently advocating to make helmets mandatory for drivers under 18 when riding a moped or motorcycle. Why not make IPV our next challenge? We, as a team, have a key role to play in identifying victims, providing support, and making appropriate referrals – but we can’t do it by staying silent. We need to start asking questions. Pediatricians implemented a protocol to protect children showing signs of abuse 50 years ago, and improved safety for children everywhere. The same could happen for victims of IPV.

I previously mentioned that 20 percent of the orbital floor fractures we found had no documented cause. Given the highly under-reported nature of IPV, it is likely that many of these patients also sustained injury secondary to IPV that went undocumented. This is something we’re working on in Iowa. Our emergency department now has a box on the patient’s chart to say whether or not they have had a discussion about IPV. It’s a confidential way for healthcare teams to document what has – or hadn’t – been said, so clinicians know how to proceed at follow-up appointments. By playing a part in coordinated care efforts, healthcare practitioners can improve outcomes for millions of women worldwide – and we may become better clinicians in the process.