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Globe Retraction Clinical Presentation

  • Author: Michael T Yen, MD; Chief Editor: Andrew G Lee, MD  more...
Updated: Mar 15, 2016


Obtain a complete history, including age at onset of signs and symptoms, duration of symptoms, progression or improvement of symptoms, rapidity of progression, and review of systems for other medical conditions, as follows:

  • Acute versus chronic
  • Mechanism of injury - Fist, ball, motor vehicle accident, metallic foreign body
  • Past ocular and medical history - Previous ocular or orbital trauma, previous eye surgery, other ocular conditions (eg, amblyopia, glaucoma, retinal detachment), family history of cancer, known primary tumor, previous surgeries (eg, biopsies or urogenital tract procedures), history of radiotherapy to orbit

Ophthalmic symptoms

Ophthalmic symptoms may include the following:

  • Diplopia - Strabismus, globe displacement, restriction of extraocular movements, traumatic optic nerve or ocular motor nerve palsy, floor fracture, convergence retraction nystagmus
  • Narrowing of palpebral fissure - Ptosis (ie, mechanical, neurogenic, myogenic), narrowing during adduction, pseudoptosis (globe retraction/enophthalmos), Duane syndrome
  • Pain - Hemorrhage and edema, perineural invasion, or orbital tumor
  • Decreased vision - Optic nerve compression, traumatic optic neuropathy, concurrent ocular injury, amblyopia
  • Anomalous head position - Stereopsis, binocularity


Complete ophthalmologic examination (defer if obvious globe rupture)

A complete ophthalmologic examination includes the following:

  • Vision and pupils - Amblyopia, ocular trauma, traumatic optic neuropathy, relative afferent pupillary defect, anisocoria
  • Extraocular motility and alignment - Traumatic ocular motor cranial nerve palsy, entrapment of extraocular muscles, pain with extraocular movements, severity of strabismus, lack of abduction (Duane type I), lack of adduction (Duane type II), lack of both adduction and abduction (Duane type III), presence of upshoots or downshoots in adduction, multiple motility deficits (posterior traction and tethering of globe in scirrhous breast carcinoma)
  • External examination - Infraorbital anesthesia, enophthalmos of globe (Hertel exophthalmopathy), globe ptosis, narrowing of palpebral fissure with adduction, blepharoptosis or pseudoptosis, deep superior sulcus, preauricular or submandibular adenopathy, restrictive enophthalmos (eg, scirrhous breast carcinoma), pseudoenophthalmos due to contralateral exophthalmos
  • Intraocular pressure -Angle-recession glaucoma, secondary glaucoma from orbital mass
  • Anterior segment - Evidence of previous trauma (eg, corneal scar, angle recession, corectopia, phacodonesis, iridodonesis, lens rupture, lens subluxation)
  • Posterior segment - Retinal detachment, chorioretinal scarring, hemorrhage, optic nerve pallor, optic nerve avulsion


Duane retraction syndrome is a congenital condition that is believed to be due to aberrant innervation of extraocular muscles.

Abnormal synergistic innervation between medial and lateral rectus muscles causes co-contraction of 2 muscles resulting in globe retraction during attempted adduction.

Abnormal synergistic innervation between medial and vertical rectus muscles may explain upshooting and downshooting eye movements.

Blunt trauma is the most common cause of orbital blowout fractures.

Iatrogenic causes such as orbital decompression or sinus surgery may cause enophthalmos.

Risk factors for breast cancer include the following:

  • Increasing age
  • Family history - Especially first- and second-degree relatives with premenopausal cancer (including paternal relatives)
  • Early menstruation/late menopause
  • Nulliparity
  • Premalignant breast lesions or previous carcinoma in 1 breast (especially premenopausal)
  • History of previous radiation therapy to chest

Physical Examination

Physical examination should assess for the following:

  • Evidence of trauma elsewhere
  • Other cranial neuropathies
  • Evidence of prior breast carcinoma or metastatic disease


Complications may result from the following:

  • Delayed diagnosis
  • Inadequate imaging
  • Surgical complications
Contributor Information and Disclosures

Michael T Yen, MD Professor of Ophthalmology, Division of Ophthalmic Plastic, Lacrimal, and Orbital Surgery, Cullen Eye Institute, Medical Director, Alkek Eye Center, Co-Director, BCM Aesthetics, Program Director, ASOPRS Fellowship, Baylor College of Medicine

Michael T Yen, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J James Rowsey, MD Former Director of Corneal Services, St Luke's Cataract and Laser Institute

J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Sigma Xi, Southern Medical Association, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Chief Editor

Andrew G Lee, MD Chair, Department of Ophthalmology, Houston Methodist Hospital; Clinical Professor, Associate Program Director, Department of Ophthalmology and Visual Sciences, The University of Texas Medical Branch; Clinical Professor, Department of Surgery, Division of Head and Neck Surgery, University of Texas MD Anderson Cancer Center; Professor of Ophthalmology, Neurology, and Neurological Surgery, Weill Medical College of Cornell University; Clinical Associate Professor, University of Buffalo, State University of New York School of Medicine

Andrew G Lee, MD is a member of the following medical societies: American Academy of Ophthalmology, Association of University Professors of Ophthalmology, American Geriatrics Society, Houston Neurological Society, Houston Ophthalmological Society, International Council of Ophthalmology, North American Neuro-Ophthalmology Society, Pan-American Association of Ophthalmology, Texas Ophthalmological Association

Disclosure: Received ownership interest from Credential Protection for other.

Additional Contributors

Gerhard W Cibis, MD Clinical Professor, Director of Pediatric Ophthalmology Service, Department of Ophthalmology, University of Kansas School of Medicine

Gerhard W Cibis, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Ophthalmological Society

Disclosure: Nothing to disclose.

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Patient presented with persistent diplopia after an interpersonal altercation. Forced ductions revealed tight inferior and medial rectus muscles on right side. CT scan revealed orbital floor and medial wall fractures in right orbit.
Patient with metastatic breast carcinoma to the intraconal space of the right orbit resulting in mild globe retraction and enophthalmos.
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