Jacqueline R. Carrasco

BASICS

DESCRIPTION

• Enophthalmos is a descriptive term and condition referring to the posterior recession of the normal-sized globe within the orbit.

• Acquired or congenital.

PATHOPHYSIOLOGY

• Congenital type is due to fetal/embryologic maldevelopment.

• Acquired.

– Mechanical pull of orbital contents by fibrous contracture.

– Enlargement of orbit or lack of support by orbital floor may cause enophthalmos with hypoglobus.

ETIOLOGY

• 3 categories: Structural abnormality, fat atrophy, and traction.

• Orbital floor fracture.

• Postsurgical (s/p decompression or mass resection).

• Scirrhous breast carcinoma metastatic to the orbit.

• Orbital fat atrophy (such as that secondary to radiation or wasting syndromes, among others).

• Silent sinus syndrome.

• Orbital venous malformation (due to bone erosion or fat atrophy).

• Duane retraction syndrome.

• Reported cases due to inflammatory conditions and after CSF shunting procedure.

COMMONLY ASSOCIATED CONDITIONS

See Etiology section.

DIAGNOSIS

HISTORY

• Patient may report sinking in of eyeball, unilateral or bilateral, over time or may note a droopy lid.

• May have old photographs for comparison.

PHYSICAL EXAM

• Superior sulcus deepened.

• Narrowed palpebral fissure.

• Hertel exophthalmometry to establish baseline or chart progression, may not be helpful in diagnosis if bilateral.

• Skin changes—thinned if wasting syndrome, thickened in scirrhous carcinoma.

• Motility or sensation may be affected if the etiology is fracture.

• Check vision and for afferent papillary defect to evaluate concomitant optic neuropathy.

DIAGNOSTIC TESTS & INTERPRETATION

Diagnostic Procedures/Other

• CT scan of orbits with coronal and axial cuts.

• If concern for inflammatory cause or malignancy, MRI with and without gadolinium and fat suppression.

• May need orbitotomy for tissue biopsy.

DIFFERENTIAL DIAGNOSIS

• Pseudo-enophthalmos.

– Contralateral exophthalmos.

– Horner syndrome.

– Phthisis bulbi.

– Microphthalmos.

TREATMENT

ADDITIONAL TREATMENT

General Measures

• Depending on etiology.

– Fracture repair.

– Oncologic evaluation for treatment of metastatic carcinoma.

– Orbital soft tissue replacement with filler material, such as porous implant, hyaluronic acid, polyacrylamide gel injection.

– Sinus aeration with functional endoscopic sinus surgery if suspect silent sinus syndrome.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

• Ophthalmologist.

• Otolaryngologist for sinus pathology.

PATIENT EDUCATION

If the cause is orbital fracture or unknown, no nose-blowing or sneezing with mouth closed.

COMPLICATIONS

If chronic, may be difficult or impossible to correct fully.

ADDITIONAL READING

• Athanasiov PA, Prabhakaran VC, Selva D. Non-traumatic enophthalmos: A review. Acta Ophthalmol 2008;86(4):356–364.

• Bernardini FP, Rose GE, Cruz AA, Priolo E. Gross enophthalmos after cerebrospinal fluid shunting for childhood hydrocephalus: The “silent brain syndrome.” Ophthal Plast Reconstr Surg 2009;25(6):434–436.

• Hamedani M, Pournaras JA, Goldblum D. Diagnosis and management of enophthalmos. Surv Ophthalmol 2007;52(5):457–473.

CODES

ICD9

• 376.50 Enophthalmos, unspecified as to cause

• 376.51 Enophthalmos due to atrophy of orbital tissue

• 376.52 Enophthalmos due to trauma or surgery

CLINICAL PEARLS

• Enophthalmos with lid retraction may be a sign of silent sinus syndrome.

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