Enophthalmos

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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Nov 9, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on Enophthalmos
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