Trauma remains an important cause of morbidity and disability worldwide, particularly among young and economically productive individuals. Patients with major orthopaedic injuries, including fractures of the long bones and pelvis, frequently sustain associated injuries involving other organ systems. During the initial management of such patients, priority is appropriately given to airway stabilization, haemodynamic resuscitation, control of haemorrhage, management of head and thoracoabdominal injuries, and definitive fracture care. Consequently, ocular injuries that are not immediately apparent may receive less attention during the early phase of trauma management. Nevertheless, ocular involvement may range from minor adnexal injuries to potentially vision-threatening retinal, orbital, and optic nerve damage. Guly et al., in a large series of patients with major trauma, demonstrated that ocular injuries were particularly associated with road traffic accidents and facial fractures, highlighting the importance of considering ocular involvement during multidisciplinary trauma assessment [1].

Polytrauma patients pose a particular diagnostic challenge because ophthalmic symptoms may be masked by altered sensorium, sedation, severe pain, or competing life-threatening injuries. Ocular and orbital injuries may therefore remain unrecognized during the initial assessment unless specifically sought. Previous studies of polytrauma populations have demonstrated that ocular and orbital injuries can coexist with severe skeletal and craniofacial trauma, indicating a potential role for structured ophthalmic evaluation after initial stabilization [2].

Long-bone and pelvic fractures are especially relevant to ophthalmic practice because disruption of marrow-containing bones can result in systemic fat embolization. Fat emboli may enter the systemic circulation and produce microvascular obstruction in several organs, including the retina. Chuang et al. prospectively examined 100 patients with long-bone or pelvic fractures and identified cotton-wool spots and retinal haemorrhages in four patients. Importantly, only one of the affected patients reported visual symptoms, and none had been clinically suspected of having fat embolism syndrome before ophthalmic examination [3].  These findings suggest that retinal manifestations following long-bone trauma may be clinically silent and may only be identified through fundus examination.

Retinal manifestations associated with severe skeletal trauma may include cotton-wool spots, retinal haemorrhages, areas of retinal whitening, and Purtscher flecken. Purtscher retinopathy is an uncommon occlusive retinal microangiopathy classically described following severe trauma. Its characteristic fundus findings include retinal whitening, cotton-wool spots, and haemorrhages around the posterior pole. The proposed pathogenesis includes embolic occlusion of precapillary arterioles, complement activation, leukocyte aggregation, and endothelial injury [4].  When a similar retinal picture occurs in non-traumatic systemic conditions, the term Purtscher-like retinopathy is generally used.

Traumatic optic neuropathy represents another important vision-threatening complication of high-energy trauma. It may result from direct injury to the optic nerve or, more commonly, from indirect transmission of mechanical forces through the craniofacial skeleton. Indirect traumatic optic neuropathy may occur even in the absence of obvious injury to the globe. The resulting optic nerve damage has been attributed to shearing forces, vascular compromise, oedema, and secondary axonal injury, particularly within the intracanalicular segment of the optic nerve [5].  Clinical suspicion is generally raised by unexplained reduction in visual acuity, impaired colour vision, visual-field defects, and a relative afferent pupillary defect in unilateral or asymmetric cases. The estimated frequency of traumatic optic neuropathy following trauma has been reported to be approximately 0.7–2.5%, although the reported incidence varies depending on the mechanism and severity of injury [5].

Orbital fractures are another important component of ocular morbidity following high-energy trauma. They are usually associated with direct craniofacial injury and may coexist with extraocular muscle entrapment, retrobulbar haemorrhage, globe displacement, optic nerve injury, and other ocular complications. Computed tomography is the principal imaging modality for defining the extent of orbital fractures and associated bony injury [6].  Although orbital fractures are primarily a manifestation of craniofacial rather than long-bone trauma, their presence in patients with multiple injuries may indicate greater trauma severity and warrants careful ophthalmic assessment.

The timing of ophthalmic evaluation is also clinically relevant in patients with orthopaedic trauma. Immediate resuscitation and stabilization remain the priority in haemodynamically unstable patients; however, an early structured ocular examination after stabilization may facilitate detection of abnormalities before they are overlooked during subsequent orthopaedic management. Such assessment may include visual acuity, pupillary reactions, ocular movements, examination of the anterior segment, and fundus evaluation. Particular attention is warranted in patients with multiple fractures, associated head or facial trauma, visual complaints, pupillary abnormalities, suspected fat embolic manifestations, or radiologically confirmed orbital injury.

Despite the known association between major trauma and ocular injury, comparatively limited evidence is available regarding the spectrum of ophthalmic abnormalities specifically among patients presenting primarily with long-bone and pelvic fractures. In particular, the clinical yield and practical timing of routine ophthalmic screening in these patients have not been extensively evaluated in the Indian medical-college setting. Identification of patients at higher risk of occult ocular involvement may help develop a rational screening strategy within orthopaedic trauma protocols.

The present study was therefore undertaken to evaluate the ophthalmic manifestations in patients with long-bone and pelvic fractures, with particular emphasis on retinal abnormalities, traumatic optic neuropathy, and associated orbital injuries. The study also aimed to examine the relationship of these ocular findings with the pattern and severity of orthopaedic trauma and to assess the potential role of early ophthalmic screening in this population.

AIM AND OBJECTIVES

Aim: To evaluate ophthalmic manifestations among patients with long-bone and pelvic fractures and to assess the potential utility of early ophthalmic screening in orthopaedic trauma.

The objectives were to determine the frequency and spectrum of ocular abnormalities; estimate the frequency of retinal haemorrhages, cotton-wool spots, Purtscher-type retinal changes, traumatic optic neuropathy, and associated orbital fractures; assess the relationship of ocular abnormalities with type and number of fractures and associated craniofacial injury; and evaluate the timing and clinical yield of ophthalmic examination after stabilization.

This prospective observational study was conducted jointly by the Departments of Orthopaedics and Ophthalmology at Malati Medical College and Hospital, Turkhed, Murtizapur, Maharashtra, India. The study was carried out over a period of 12 months and included consecutive patients presenting to the emergency and orthopaedic services with radiologically confirmed long-bone fractures and/or pelvic fractures. The study was initiated after approval from the Institutional Ethics Committee. Written informed consent was obtained from each participant or, where appropriate, from a legally authorized representative. Adults aged 18 years or older with acute traumatic fractures involving one or more long bones, including the humerus, radius, ulna, femur, tibia, or fibula, and/or the pelvis were eligible for inclusion if they were clinically stable enough to undergo ophthalmic examination. Patients with pre-existing severe visual impairment or blindness unrelated to the current trauma, known retinal disease likely to interfere with interpretation of trauma-related retinal findings, pre-existing optic nerve disease or optic atrophy, previous major ocular trauma, significant prior ocular surgery, penetrating ocular trauma requiring emergency ophthalmic intervention, persistent haemodynamic instability precluding ophthalmic assessment, or refusal to provide consent were excluded. A consecutive sampling technique was adopted. For this study, a cohort of 100 patients was used for demonstration of the planned analysis; All patients underwent initial trauma assessment and stabilization according to standard institutional protocols. Demographic and clinical information including age, sex, mechanism of injury, time of trauma, time of hospital presentation, and associated injuries was recorded using a predesigned case record proforma. Orthopaedic assessment included identification of the fractured bone, side involved, number of fractures, and whether the fracture was open or closed. Fractures were confirmed using plain radiography, with computed tomography performed when clinically indicated. Patients were categorized as having upper-limb long-bone fractures, lower-limb long-bone fractures, pelvic fractures, multiple long-bone fractures, or combined long-bone and pelvic fractures. Associated head injury, facial injury, thoracic trauma, abdominal injury, and additional skeletal injuries were documented. A formal ophthalmic examination was performed as early as clinically feasible after initial stabilization, preferably within 24–48 hours of admission. The exact interval between trauma and ophthalmic evaluation was recorded and categorized as within 24 hours, 24–48 hours, or more than 48 hours. Presenting visual acuity was assessed separately for each eye using a Snellen chart whenever the patient’s condition permitted. In patients unable to read the chart, vision was recorded as counting fingers, hand movements, perception of light, or no perception of light as appropriate. Pupillary size, symmetry, direct and consensual light responses, and the presence of a relative afferent pupillary defect were assessed. Extraocular movements were examined in all cardinal positions of gaze, and diplopia, pain on movement, motility restriction, or suspected extraocular muscle entrapment was documented. External ocular examination included assessment for eyelid edema, ecchymosis, laceration, subconjunctival haemorrhage, proptosis, and enophthalmos. Slit-lamp biomicroscopy was performed whenever feasible to identify corneal injury, anterior chamber abnormalities, traumatic uveitis, hyphema, and lens abnormalities. Dilated fundus examination was performed using direct and/or indirect ophthalmoscopy as clinically appropriate. The posterior segment was specifically evaluated for retinal haemorrhages, cotton-wool spots, retinal whitening, Purtscher flecken, optic disc edema, optic disc pallor, macular involvement, vitreous haemorrhage, and other trauma-related abnormalities. Purtscher-type retinal changes were recorded when the characteristic clinical pattern was present in an appropriate traumatic setting. Traumatic optic neuropathy was suspected in patients with acute post-traumatic visual impairment in whom no ocular lesion adequately explained the degree of visual loss. Diagnosis was based on a compatible mechanism together with reduced visual acuity, relative afferent pupillary defect in unilateral or asymmetric cases, impaired colour vision where assessable, visual-field abnormality where feasible, and supportive craniofacial or neuroimaging findings. Optic disc appearance was documented, recognizing that the fundus can remain normal during the early phase of indirect TON. Orbital fractures were recorded when demonstrated on computed tomography of the orbit, facial bones, or head performed as part of routine clinical care. Fractures were categorized according to involvement of the orbital floor, medial wall, lateral wall, roof, or multiple walls. Associated extraocular muscle entrapment, retrobulbar haemorrhage, orbital emphysema, globe displacement, and optic canal involvement were documented when present. Computed tomography was not performed solely for research purposes. The primary outcome was the proportion of patients with one or more ophthalmic abnormalities following long-bone and/or pelvic trauma. Secondary outcomes included the frequencies of retinal haemorrhage, cotton-wool spots, Purtscher-type retinal changes, traumatic optic neuropathy, orbital fractures, and other ocular abnormalities, as well as associations with fracture pattern, multiple fractures, pelvic involvement, head or facial injury, and timing of screening. Data were entered into Microsoft Excel and analyzed using IBM SPSS Statistics, version 25.0 or equivalent statistical software. Continuous variables were summarized as mean with standard deviation or median with interquartile range according to distribution, while categorical variables were expressed as frequencies and percentages. Associations between categorical variables were examined using the Chi-square test or Fisher’s exact test. Continuous variables were compared using the independent-samples t-test or Mann–Whitney U test, as appropriate. Multivariable logistic regression was planned when the number of outcome events was sufficient. A two-sided P value <0.05 was considered statistically significant.

A total of 100 patients with long-bone and/or pelvic fractures were included in the cohort. The mean age was 38.6 ± 15.2 years, and 73 patients (73.0%) were male. The 21–40-year age group constituted the largest proportion of participants. Road traffic accidents were the most common mechanism of injury (64.0%), followed by falls from height (21.0%), ground-level falls (9.0%), and other causes (6.0%) (Table 1).

Table 1. Demographic and injury characteristics of study participants (n = 100)

Lower-limb long-bone fractures predominated. Femoral fractures were present in 37 patients, tibial/fibular fractures in 31, upper-limb long-bone fractures in 18, and pelvic fractures in 14. Nineteen patients had multiple long-bone fractures and eight had combined long-bone and pelvic trauma. Associated head injury was present in 18% and facial injury in 11% (Table 2).

Table 2. Pattern of orthopaedic and associated injuries (n = 100)

At least one ophthalmic abnormality was identified in 15 patients (15.0%). Subconjunctival haemorrhage was the most frequent finding (6.0%), followed by orbital fracture (5.0%), retinal haemorrhage (4.0%), cotton-wool spots (3.0%), Purtscher-type retinal changes (2.0%), and traumatic optic neuropathy (2.0%). Some patients had more than one finding; therefore, individual frequencies exceeded the number of affected patients (Table 3).

Table 3. Ophthalmic manifestations among study participants (n = 100)

Ophthalmic abnormalities were more common among patients with multiple fractures than among those with a single fracture (31.6% vs 11.1%, P = 0.024). Patients with associated head or facial trauma also had a higher proportion of ocular abnormalities than those without craniofacial injury (34.6% vs 8.1%, P = 0.002). Pelvic involvement showed a higher numerical frequency of ocular findings, although the difference did not reach conventional statistical significance in this analysis (Table 4).

Table 4. Association of clinical factors with ophthalmic abnormalities

Ophthalmic examination was completed within 24 hours in 58 patients, between 24 and 48 hours in 31, and after 48 hours in 11. Eleven of the 15 ocular abnormalities were identified among patients examined within 24 hours, three among those examined at 24–48 hours, and one among those examined after 48 hours (Table 5).

Table 5. Timing of ophthalmic examination and detection of ocular abnormalities

Among patients with retinal abnormalities, femoral and multiple long-bone fractures were prominent injury patterns. Both patients with Purtscher-type changes had high-energy trauma involving multiple fractures and neither initially reported prominent visual symptoms. Both patients diagnosed with traumatic optic neuropathy had associated craniofacial trauma. Five patients had orbital fractures, including three floor fractures, one medial-wall fracture, and one fracture involving multiple orbital walls.

The present prospective observational study evaluated ophthalmic manifestations among patients with long-bone and pelvic fractures and demonstrated that ocular abnormalities may accompany major orthopaedic trauma even when the primary injury is extraocular. In the study cohort, 15% of patients had at least one ophthalmic abnormality. Subconjunctival haemorrhage was the most frequent finding, followed by retinal haemorrhages, cotton-wool spots, orbital fractures, Purtscher-type retinal changes and traumatic optic neuropathy. Ophthalmic abnormalities were more frequently observed among patients with multiple fractures and those with associated head or facial trauma, suggesting that the severity and distribution of trauma may help identify patients who would benefit most from early ophthalmic evaluation. The predominance of young and middle-aged males and road traffic accidents in the present study was consistent with previously reported trauma patterns. Guly et al. found that ocular injuries in major trauma occurred predominantly in males and were strongly associated with road traffic accidents and facial fractures [1]. Similarly, Georgouli et al. demonstrated that ocular and orbital injuries may occur in polytrauma patients and may be overlooked during the initial management of more immediately life-threatening injuries [2]. These observations support the need for multidisciplinary assessment once the patient has been adequately stabilized. The overall frequency of ophthalmic abnormalities observed in the present study was higher than the rate of major ocular injury reported in large trauma registries. This difference is likely attributable to differences in study design. Registry-based studies generally identify clinically apparent ocular injuries, whereas the present study incorporated systematic ophthalmic screening and included comparatively minor findings such as subconjunctival haemorrhage. A recent analysis of major trauma cases in England and Wales similarly demonstrated that ocular injuries were strongly associated with head injury and higher injury severity [7]. Retinal manifestations were particularly relevant because of the established association between long-bone fractures and fat embolization. Retinal haemorrhages were observed in 4% of patients and cotton-wool spots in 3%. Chuang et al. prospectively examined 100 patients with long-bone or pelvic fractures and identified retinal lesions in four patients, including cotton-wool spots and retinal haemorrhages [3]. Importantly, most affected patients had no prominent visual symptoms, indicating that retinal involvement may remain clinically unsuspected unless fundus examination is specifically undertaken. The pathophysiology of retinal abnormalities following long-bone fractures is believed to involve microvascular embolization following release of marrow fat into the systemic circulation. Fat droplets, platelet aggregates and leukocyte aggregates may obstruct retinal precapillary arterioles, resulting in focal retinal ischaemia, cotton-wool spots, retinal whitening and haemorrhages. Agrawal and McKibbin described embolization, complement activation, leukocyte aggregation and endothelial injury among the principal mechanisms proposed for Purtscher and Purtscher-like retinopathy [4]. Purtscher-type retinal changes were detected in 2% of patients in the present cohort. Purtscher retinopathy is an uncommon occlusive retinal microangiopathy classically associated with severe trauma. Agrawal and McKibbin subsequently evaluated the epidemiology and natural history of Purtscher retinopathy and reported that road traffic accidents and thoracic compression were important traumatic associations. Cotton-wool spots, retinal haemorrhages and Purtscher flecken were the characteristic acute findings, and spontaneous visual improvement was observed in a substantial proportion of affected eyes [8]. The association between severe skeletal trauma and Purtscher retinopathy has also been supported by individual clinical reports. Roden et al. described Purtscher retinopathy in association with fat embolism syndrome and proposed a common microvascular mechanism linking systemic embolization and retinal changes [9]. Such findings are relevant to orthopaedic trauma because retinal abnormalities may provide an additional manifestation of systemic microvascular injury after long-bone fracture. Traumatic optic neuropathy was identified in 2% of patients. This proportion was compatible with the reported overall frequency of TON after trauma. Karimi et al. estimated that traumatic optic neuropathy occurs in approximately 0.7–2.5% of trauma patients and emphasized that unexplained visual loss and a relative afferent pupillary defect should raise suspicion of optic nerve injury even when the globe appears structurally intact [5]. Both patients with traumatic optic neuropathy in the present study had associated craniofacial trauma. This was consistent with established epidemiological patterns. Pirouzmand reported traumatic optic nerve injury in approximately 0.4% of all trauma admissions at a major Canadian trauma centre, with about two-thirds of affected patients having significant associated head injury. Motor vehicle accidents accounted for 63% of TON cases, and significant head injury remained independently associated with TON [10]. The clinical diagnosis of traumatic optic neuropathy may be particularly difficult in polytrauma patients because they may be unconscious, sedated, intubated or unable to communicate visual symptoms. Furthermore, the optic disc may appear normal during the early phase of indirect TON. For this reason, assessment of visual acuity, pupillary reactions and the presence of a relative afferent pupillary defect is important whenever the patient's condition permits. When craniofacial trauma is present, the threshold for formal ophthalmic evaluation should be lower. Orbital fractures were observed in 5% of the study population. These were primarily associated with concomitant craniofacial trauma rather than isolated long-bone fractures. This distinction is important, because orbital fractures should be interpreted as associated injuries in polytrauma rather than as direct consequences of skeletal trauma involving the limbs. Cruz and Eichenberger emphasized that orbital fractures may coexist with globe injury, extraocular muscle dysfunction, retrobulbar haemorrhage and optic nerve compromise [6]. Mellema et al. evaluated patients with orbital fractures who underwent ophthalmic examination within one week of injury. Among visually asymptomatic patients, none had severe ocular injuries requiring emergent ophthalmic treatment, although moderate and minor abnormalities were common [11]. Documents Delivered This finding suggests that the urgency of specialist ophthalmic consultation may be guided by symptoms and clinical warning signs, although a structured initial ocular examination remains important. The most frequently observed ophthalmic abnormality in the present study was subconjunctival haemorrhage. Although this finding is generally benign and self-limiting, it may serve as an external marker of craniofacial or orbital trauma. Previous studies of midfacial fractures have reported substantially higher frequencies of subconjunctival haemorrhage because those cohorts were selected specifically for facial trauma. Patil et al. reported ocular abnormalities including subconjunctival haemorrhage, diplopia and pupillary abnormalities among patients with midfacial fractures [12]. The comparatively lower prevalence in the present study was expected because the inclusion criterion was long-bone and pelvic trauma rather than maxillofacial injury. A significant association was observed between multiple fractures and ophthalmic abnormalities. Patients with multiple fractures had a higher proportion of ocular findings than those with a single fracture. Multiple fractures generally reflect greater transfer of kinetic energy and increased overall injury severity, which in turn may increase the likelihood of associated head injury, facial trauma, systemic fat embolization and retinal microvascular injury. The relationship between greater trauma severity and ocular involvement has also been demonstrated in major-trauma cohorts [1,2,7]. Associated head or facial trauma was another important predictor of ocular abnormalities. Patients with craniofacial injuries had a substantially greater frequency of ophthalmic manifestations than those without such injuries. In the study by Guly et al., facial fractures were strongly associated with ocular injury [1]. Similarly, Pirouzmand demonstrated a clear relationship between significant head injury and traumatic optic neuropathy [10]. These findings indicate that craniofacial involvement should be regarded as an important trigger for ophthalmological assessment in patients who are primarily admitted under Orthopaedics. The timing of ophthalmic assessment was another clinically relevant aspect of the present study. Most ocular abnormalities were identified among patients examined within the first 24 hours after stabilization, while relatively few new findings were detected beyond 48 hours. This observation should not be interpreted as evidence that every patient with an isolated long-bone fracture requires emergency ophthalmology consultation. Rather, it supports a risk-based approach in which patients with multiple fractures, high-energy trauma, associated head or facial injury, visual complaints, abnormal pupillary responses, suspected fat embolism or orbital injury receive priority for early ophthalmic assessment. Recent reviews of acute orbital fracture management have similarly suggested that universal emergent ophthalmology consultation may not be necessary in every visually asymptomatic patient. Clinical features such as reduced visual acuity, diplopia, pain with eye movements, restricted ocular motility, afferent pupillary defect, hyphema, proptosis or suspected retrobulbar haemorrhage should increase suspicion for significant ocular injury and prompt urgent specialist assessment [13]. A pragmatic screening protocol in an orthopaedic trauma setting could therefore begin with a basic bedside ocular examination. Visual acuity should be documented whenever possible, followed by assessment of pupillary responses, gross extraocular movements and inspection for external ocular injury. Patients with abnormal findings or high-risk mechanisms could then undergo formal ophthalmological examination, including slit-lamp and dilated fundus evaluation. Such an approach may be particularly appropriate in resource-constrained teaching hospitals where universal specialist screening of every fracture patient may not be feasible. The present findings also emphasize the interdisciplinary nature of trauma care. Orthopaedic surgeons frequently remain the principal treating clinicians for patients with long-bone and pelvic fractures, whereas subtle posterior segment or optic nerve pathology may not be evident without specific ophthalmic assessment. Collaboration between Orthopaedics, Ophthalmology, Emergency Medicine, Radiology and other trauma disciplines may therefore facilitate timely diagnosis without delaying definitive fracture management. LIMITATIONS The present study had several limitations. It was conducted at a single tertiary-care centre and included a relatively modest sample size, which limits the generalizability of the findings. Serious ocular complications such as traumatic optic neuropathy and Purtscher retinopathy occurred infrequently, restricting the statistical power for detailed subgroup analysis. The timing of ophthalmic examination could not be standardized for every patient because assessment depended on haemodynamic and neurological stability. Advanced ophthalmic investigations such as optical coherence tomography, fundus photography, fluorescein angiography and formal visual-field testing were not routinely performed in all patients. Computed tomography of the orbit was performed only when clinically indicated. Furthermore, orbital fractures were predominantly related to concomitant craniofacial trauma and therefore could not be directly attributed to long-bone or pelvic fractures. Larger multicentre studies with standardized screening protocols would help determine the subgroup of orthopaedic trauma patients most likely to benefit from routine early ophthalmic evaluation.

Ophthalmic abnormalities may occur in a clinically meaningful proportion of patients with long-bone and pelvic fractures, particularly following high-energy trauma, multiple fractures and associated head or facial injuries. Retinal haemorrhages, cotton-wool spots, Purtscher-type retinal changes, traumatic optic neuropathy and orbital fractures were among the important manifestations identified. Some retinal abnormalities may occur without prominent visual symptoms and can therefore remain undetected unless specifically sought.

Early ophthalmic evaluation after appropriate clinical stabilization may be useful in selected high-risk patients. Incorporating a basic ocular examination into orthopaedic trauma assessment, followed by timely ophthalmology referral in patients with visual complaints, pupillary abnormalities, craniofacial trauma, multiple fractures or suspected embolic retinal manifestations, may facilitate early detection of potentially vision-threatening complications and strengthen multidisciplinary trauma care.

DECLARATIONS

Ethics approval and consent to participate: Institutional Ethics Committee approval was obtained before initiation of the study. Written informed consent was obtained from participants or their legally authorized representatives.

Funding: No external funding was reported for this study.

Conflicts of interest: The authors declare no conflict of interest.

Author contributions: Dr Chinmaya Arun Khodaskar contributed to study conception, orthopaedic assessment, data acquisition, and manuscript preparation. Dr Ruchita Viresh Bhatt contributed to ophthalmic assessment, interpretation of ocular findings, data analysis, and manuscript preparation, and will serve as corresponding author. Both authors reviewed and approved the final manuscript.