Ophthalmologists can play a role in helping stop cycle of domestic violence

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Reviewed by Danica Kindrachuk, MD, FRCSC

Ophthalmologists can affect outcomes of cases of domestic or intimate partner violence by asking questions of the person who presents with injuries, according to Danica Kindrachuk, MD, FRCSC, an ophthalmologist affiliated with Memorial University of Newfoundland in St. John’s, Canada. “The more people ask, the more likely it (domestic violence) will not get missed,” Kindrachuk said in an interview with Ophthalmology Times.

“It is a chance for us in ophthalmology to truly save a life,” said Kindrachuk, who spoke on the topic of domestic violence at the Canadian Ophthalmological Society Annual Meeting and Exhibition. Moreover, Kindrachuk pointed out that it is vital to raise awareness in the minds of both the patient and the health care provider.

“The onus is on the ophthalmologist to ask questions,” she said. “Appropriate referral is indicated and while ophthalmologists are not experts in the counselling necessary, we need to be able to [pick up on domestic violence] and ask the questions.”

Underlining the gravity of domestic violence, Kindrachuk noted that it is a greater threat to life than cancer, motor vehicle accidents, or war among females aged 15 to 44 years worldwide.1 Other alarming statistics are that 50% of all female homicides in North America are committed by an intimate partner, and 50% of these homicides are linked to emergency department visits within 2 years of death. In Canada, more than 25% of all police reported violent crimes are tied to intimate partner violence.1

The ophthalmologist would typically see cases that have presented to emergency departments or urgent care centers while on call, said Kindrachuk, but cases can present nonemergently in the office. A vital statistic is that of all injuries caused by domestic violence, 45% involve the eyes,2 according to Kindrachuk. The injuries to the eye can be varied and include lid lacerations, corneal abrasions, hyphema, orbital fractures, retinal detachment, commotio retinae, lens dislocation, and ruptured globe, Kindrachuk noted. A study out of the University of Iowa involving 190 women found that assault was the fourth-leading cause of ocular injury and women reported that the intimate partner was the perpetrator in 38% of cases, with the true percentage likely higher due to underreporting.3

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Cases that present in the office setting are most often traumatic cataracts, with Kindrachuk giving a recent example in her practice of a young female with very asymmetric cataract with severe phacodonesis. When asked, the patient admitted to being in an abusive relationship and accepted assistance.

Although domestic violence affects men and women, statistics consistently show women experience significantly higher rates of domestic violence and are more likely to experience severe injuries, Kindrachuk said. It is important that clinicians not have preconceived notions about domestic violence and appreciate that it can affect individuals of all ethnicities, cultures, and socioeconomic levels, Kindrachuk added.

The other “reality check” for clinicians is that they tend to underestimate the frequency of presentations of domestic violence, with one study revealing that orthopedic surgeons estimated only 1% of injuries in a cast clinic are due to intimate partner violence when the real proportion was 32%, almost one-third of the cases (and likely higher due to underreporting).4

Women may not voluntarily report they have been abused, but they are open to discuss it if prompted by physicians, Kindrachuk stressed, adding that one study involving 750 patients surveyed in a waiting room found that 92% of respondents stated they were comfortable discussing this issue with a health care provider, regardless of the provider’s gender.5

Certain clues suggest that injuries are a result of domestic violence, Kindrachuk explained. “When there is trauma to the head and neck region, intimate partner violence is 7.5 times more likely to be the underlying cause than when there is trauma to other anatomical locations,” Kindrachuk said.4 “Because ophthalmologists’ focus is on this region alone, we should have a higher index of suspicion than other doctors.”

Another clue is the side of the body where the injuries are located, she added. “If the injury is on the left side, you should be even more suspicious because most of the population is right-hand dominant,” Kindrachuk said.

Still another clue is the behavior of the partner if present with the victim at the visit, added Kindrachuk, who suggested that clinicians find creative ways to speak with the victim one-on-one. “You might say we are going to do another test in another room where we can only accommodate the patient,” Kindrachuk explained. “If the partner is very controlling about that request, that would be a red flag.”

In terms of guidelines on screening, the United States Preventive Services Task Force recommends universal screening and the World Health Organization recommends a case-based inquiry linked to presentations suggestive of domestic violence.

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Ophthalmologists may tell the injured patient that it is standard practice to screen for domestic violence because it is so common. Cases, if identified, should be referred to appropriate local resources like shelters and emergency housing. Another intervention that may prove effective is to simply ask patients whether they feel safe going home, Kindrachuk added.

Evidence demonstrates that health care providers screening for domestic violence is not futile. In one study of 528 patients in an urban emergency department, 84% agreed to speak to an advocate, and more than 50% of these patients participated in outpatient follow-up. At one year, 49% of those were no longer in danger from the abuser.6 Another study found that those who discuss intimate partner violence with a health care provider are 4.6 times more likely to access an intervention and 2.6 times more likely to exit the relationship.7

“When you intervene as an ophthalmologist, the interventions may not be effective 100% of the time, but they are effective,” Kindrachuk concluded, underlining that situations of domestic violence represent a chance for ophthalmologists to save lives.

Danica Kindrachuk, MD, FRCSC

P: 709-726-8253

Kindrachuk has no financial disclosures related to this content. This article is based on Kindrachuk’s presentation at the Canadian Ophthalmological Society Annual Meeting and Exhibition, held June 15 to 18 at the Québec City Convention Centre in Canada.

References:

1. Cohen AR, Clark TJE, Renner LM, Carter PC, Shriver EM. Intimate partner violence as a mechanism of traumatic ocular injury in women. Can J Ophthalmol. 2019;54(3):355-358. doi:10.1016/j.jcjo.2018.05.017

2. Berrios DC, Grady D. Domestic violence. Risk factors and outcomes. West J Med. 1991;155(2):133-135.

3. Cohen AR, Clark TJ, Renner LM, Shriver EM. Evidence-based practice: intimate partner violence screening in women with orbital and ocular trauma. Presented at: American Academy of Ophthalmology Annual Meeting; Chicago, IL.

4. Bajgai P, Katoch D, Dogra MR, Singh R. Idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome: clinical perspectives. Clin Ophthalmol. 2017;11:1805-1817. doi:10.2147/OPTH.S128506

5. Sprague S, Goslings JC, Petrisor BA, et al; P.O.S.I.T.I.V.E. Investigators. Patient opinions of screening for intimate partner violence in a fracture clinic setting: P.O.S.I.T.I.V.E.: a multicenter study. J Bone Joint Surg Am. 2013;95(13):e91. doi:10.2106/JBJS.L.01326

6. Boudreaux ED, Francis JL, Loyacano T. Family presence during invasive procedures and resuscitations in the emergency department: a critical review and suggestions for future research. Ann Emerg Med. 2002;40(2):193-205. doi:10.1067/mem.2002.124899

7. Gerber MR, Wittenberg E, Ganz ML, Williams CM, McCloskey LA. Intimate partner violence exposure and change in women’s physical symptoms over time. J Gen Intern Med. 2008;23(1):64-69. doi:10.1007/s11606-007-0463-2