Jacqueline R. Carrasco
• Enophthalmos is a descriptive term and condition referring to the posterior recession of the normal-sized globe within the orbit.
• Acquired or congenital.
• Congenital type is due to fetal/embryologic maldevelopment.
– Mechanical pull of orbital contents by fibrous contracture.
– Enlargement of orbit or lack of support by orbital floor may cause enophthalmos with hypoglobus.
• 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.
• Patient may report sinking in of eyeball, unilateral or bilateral, over time or may note a droopy lid.
• May have old photographs for comparison.
• 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
• 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.
– Contralateral exophthalmos.
– Horner syndrome.
– Phthisis bulbi.
• 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.
• Otolaryngologist for sinus pathology.
If the cause is orbital fracture or unknown, no nose-blowing or sneezing with mouth closed.
If chronic, may be difficult or impossible to correct fully.
• 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.
• 376.50 Enophthalmos, unspecified as to cause
• 376.51 Enophthalmos due to atrophy of orbital tissue
• 376.52 Enophthalmos due to trauma or surgery
• Enophthalmos with lid retraction may be a sign of silent sinus syndrome.