Intimate Partner Violence–Related Oculofacial Injuries During the COVID-19 Pandemic | Emergency Medicine | JAMA Ophthalmology | JAMA Network
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Invited Commentary
May 27, 2021

Intimate Partner Violence–Related Oculofacial Injuries During the COVID-19 Pandemic

Author Affiliations
  • 1Division of Oculofacial Plastic and Reconstructive Surgery, The Medical Eye Center, Manchester, New Hampshire
  • 2Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor
  • 3Division of Oculoplastic Surgery, W.K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
JAMA Ophthalmol. Published online May 27, 2021. doi:10.1001/jamaophthalmol.2021.1543

Intimate partner violence (IPV) refers to any behavior in a past or present intimate relationship that causes physical, psychological, or sexual harm. Prior to the COVID-19 pandemic, survey data from the US Centers for Disease Control and Prevention shows that 1 in 4 women and 1 in 10 men experience IPV in the United States.1 Approximately 30.6% of women experience IPV-related physical abuse, with 21.4% of these women experiencing severe physical injuries.1

The IPV public health crisis has since been exacerbated by the COVID-19 pandemic. In March 2020, law enforcement agencies observed an increase in domestic violence calls to US police departments by 27% in some regions after stay-at-home orders were implemented.2 The medical community has also observed a rise in the incidence and severity of IPV-related physical injuries, including head trauma, facial fractures, and visceral organ damage.3 The stay-at-home orders intended to curb the spread of COVID-19 may have inadvertently isolated many individuals who experience IPV with their abusers and/or triggered the development of new instances of violence. Individuals who experience IPV who were ready to leave abusive relationships may have suddenly found it difficult to access support networks, including lodging with family/friends and alternative shelters in the setting of travel restrictions and limited operating capacities. As a result, many of these individuals were left in potentially dangerous situations with limited options and resources.

Now more than ever, during the COVID-19 pandemic, strategies to effectively screen for and prevent IPV are needed. Ophthalmologists and oculofacial plastic surgeons can play a particularly vital role in this effort. The midface is the most commonly involved anatomical site of injury in IPV-related physical abuse, and women with physical injuries in the head, neck, and face are 7.5 times more likely to have experienced IPV compared with women with injuries elsewhere.4-6 IPV-related ocular injuries can be vision threatening and include intraocular hemorrhages, traumatic cataract, retinal detachment, and globe rupture.6 In addition, IPV-related physical injury is responsible for 7.6% to 10.2% of orbital and zygomaticomaxillary complex (ZMC) fractures in women,4,6,7 although the true prevalence is likely underestimated because the cause or perpetrator for many assault cases remain unidentified.1,5 ZMC fractures require a more severe mechanism of injury than orbital fractures, with substantial force and/or repeated trauma. Disturbingly, ZMC fractures occur twice as frequently in IPV-related assault compared with non-IPV–related violence.4,6 Thus, detection and prevention of IPV in patients with oculofacial injury is of paramount importance and could be vision saving and lifesaving.

Dawoud et al7 compared screening and community/social work referral outcomes before and after implementation of an IPV education program for faculty and trainees and a standardized IPV screening protocol for patients presenting to a level 1 trauma center emergency department with globe ruptures and facial fractures (orbital and ZMC).7 Their initiative was associated with a dramatic increase in potentially critical interventions, including a 55% increase in social work referrals, 79% increase in homegoing safety assessments, and 50% increase in law enforcement involvement.7 Further research could investigate whether this increase in referral translates into improved health outcomes of individuals who experience IPV. It would also be important to understand the durability of these programs over time as well as their generalizability to other settings, such as ambulatory clinics or telemedicine visits.

During the COVID-19 pandemic, physicians should be extra vigilant in their screening efforts for IPV. The implementation of telemedicine during the COVID-19 pandemic may additionally complicate the screening and identification of IPV. Use of telemedicine requires access to the internet, electronic devices, and privacy, all of which may be restricted in an abusive relationship. During telemedicine visits, physicians should be aware of nonverbal clues that may indicate signs of abuse, including lack of eye contact, tone of voice, and suspicious bruises. Universal screening of IPV in women of childbearing age, which is recommended by the US Preventive Services Task Force, may be especially important during the pandemic when certain indicators of abuse can potentially go unrecognized. Standardized screening, referral protocols, and educational programs such as those described by Dawoud et al7 may prove particularly beneficial in these unprecedented times.

Currently, stay-at-home restrictions are being relaxed and millions of individuals in the US are receiving their COVID-19 vaccinations. However, the effects of the pandemic are expected to be long-lasting. In the setting of a high unemployment rate and many school systems continuing to practice virtual learning, a substantial number of individuals in the US are continuing to spend a significant portion of their time in the home. From a health care standpoint, telemedicine may likely be incorporated into medical practices for the foreseeable future. With a trend of rising IPV-related injuries during the COVID-19 pandemic, ophthalmologists and oculofacial plastic surgeons will continue to play an important role in the detection of IPV, and systems interventions such as implementation of standardized screening and referral protocols as well as health care professional education programs may lead to improved advocacy for individuals who experience IPV.

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Article Information

Corresponding Author: Shannon S. Joseph, MD, W.K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, 1000 Wall St, Ann Arbor, MI 48105 (sjshan@med.umich.edu).

Published Online: May 27, 2021. doi:10.1001/jamaophthalmol.2021.1543

Conflict of Interest Disclosures: Dr S. S. Joseph consults for Horizon Therapeutics. No other disclosures were reported.

References
1.
Smith  SG, Zhang  X, Basile  KC,  et al. National Intimate Partner and Sexual Violence Survey: 2015 brief data—updated release. Published November 2018. Accessed March 29, 2021. https://www.cdc.gov/violenceprevention/pdf/2015data-brief508.pdf
2.
Boserup  B, McKenney  M, Elkbuli  A.  Alarming trends in US domestic violence during the COVID-19 pandemic.   Am J Emerg Med. 2020;38(12):2753-2755. doi:10.1016/j.ajem.2020.04.077PubMedGoogle ScholarCrossref
3.
Gosangi  B, Park  H, Thomas  R,  et al.  Exacerbation of physical intimate partner violence during COVID-19 pandemic.   Radiology. 2021;298(1):E38-E45. doi:10.1148/radiol.2020202866PubMedGoogle ScholarCrossref
4.
Clark  TJ, Renner  LM, Sobel  RK,  et al.  Intimate partner violence: an underappreciated etiology of orbital floor fractures.   Ophthalmic Plast Reconstr Surg. 2014;30(6):508-511. doi:10.1097/IOP.0000000000000165PubMedGoogle ScholarCrossref
5.
Saddki  N, Suhaimi  AA, Daud  R.  Maxillofacial injuries associated with intimate partner violence in women.   BMC Public Health. 2010;10:268-273. doi:10.1186/1471-2458-10-268PubMedGoogle ScholarCrossref
6.
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.2018.05.017PubMedGoogle ScholarCrossref
7.
Dawoud  SA, Cohen  AR, Renner  LM, Clark  TJ, Zimmerman  MB, Shriver  EM.  Detection and referral of orbital and ocular injuries associated with intimate partner violence following an educational and screening initiative in an emergency department.   JAMA Ophthalmol. Published online May 27, 2021. doi:10.1001/jamaophthalmol.2021.1546Google Scholar
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