Enophthalmos Clinical Presentation

  • Author: Charles NS Soparkar, MD, PhD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 16, 2010
 

History

Progressive sinking in of one or both eyes over any time frame (ranging from minutes to years) may be noted in the history of patients with enophthalmos.

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Physical

Bilateral enophthalmos may be difficult to determine without radiographic studies or old photographs for comparison, but unilateral enophthalmos is often obvious when comparing one eye with the other. Specific changes include the following:

  • Narrowed vertical eyelid fissure (vertical fissure may be widened or normal if associated with downward displacement of the eye, also known as hypoglobus or globe ptosis)
  • Superior sulcus deformity (deepened upper eyelid crease)
  • Lost fullness of fat bulge in upper and lower eyelids
  • Can be associated with hypoglobus (downward displaced eye), usually without significant associated diplopia (double vision)
  • Other physical findings, depending on etiology
    • Skin and eyelids
      • Thinned skin, muscle, fat, or even bone in a linear array may suggest Parry-Romberg syndrome or linear scleroderma.
      • Thickened indurated skin may suggest metastatic scirrhous carcinoma.
      • Blue boggy skin might indicate associated vascular malformation with varix.
    • Fifth nerve function
      • Decreased function of second division may suggest nerve entrapment in fracture.
      • Decreased function of either of the first 2 divisions may suggest tumor infiltration or cavernous sinus involvement.
    • Exophthalmometry measurement: This is important to establish progression or stability.
    • Ocular motility: Dysmotility might suggest a mass (orbital tumor) or restrictive process (fracture).
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Causes

Causes of secondary enophthalmos include the following:

  • Postnatal, inadequate, orbital cavity development
    • Bone growth arrest (eg, ionizing radiation for retinoblastoma)
    • Inadequate local tissue stimulation of orbital bone growth
      • Intraorbital (eg, phthisis bulbi, anophthalmos, fat atrophy in childhood)
      • Extraorbital (eg, maxillary bone growth problems)
  • Orbital cavity expansion
    • Outward fracture of orbital bones: In order of frequency, fracture sites are as follows: floor, medial wall, lateral wall, and roof.
    • Surgical expansion of the orbit (as in thyroid orbitopathy)
    • Silent sinus syndrome (ie, spontaneous, asymptomatic collapse of the maxillary sinus and orbital floor associated with negative sinus pressures)
    • Orbital varix with presumed slow bone erosion when the varix fills during recumbent position
  • Volumetric loss of orbital contents
    • Orbital fat atrophy
      • Following concussive trauma
      • Following severe inflammation or infection
      • Following external beam irradiation
      • Associated with wasting disorders (eg, Parry-Romberg hemifacial atrophy, linear scleroderma)
    • Contraction of orbital fat - Scirrhous carcinomas (most commonly metastatic breast, but pulmonary, prostate, and GI cancers may cause fat and globe retraction as well)[1]
    • Following surgery (as in resection of a mass lesion associated with local fat atrophy)
    • Phthisis bulbi or prephthisis bulbi
  • Pseudoenophthalmos
    • Unilateral blepharoptosis
    • Horner syndrome
    • Contralateral exophthalmos
    • Contralateral pseudoexophthalmos
    • Contralateral high myopia
    • Contralateral buphthalmos or megaloglobus
    • Contralateral eyelid retraction
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Contributor Information and Disclosures
Author

Charles NS Soparkar, MD, PhD  Clinical Assistant Professor, Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine; Deputy Chief, Department of Ophthalmology, Methodist Hospital of Houston

Disclosure: Nothing to disclose.

Specialty Editor Board

Jorge G Camara, MD  Professor of Ophthalmology, Department of Surgery and Director of Fellowship Training Program in Ophthalmic Plastic and Reconstructive Surgery for Countries Served by the Aloha Medical Mission, University of Hawaii John A Burns School of Medicine

Jorge G Camara, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Mark T Duffy, MD, PhD  Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic

Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience

Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

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  2. Soparkar CN, Patrinely JR, Cuaycong MJ, et al. The silent sinus syndrome. A cause of spontaneous enophthalmos. Ophthalmology. Apr 1994;101(4):772-8. [Medline].

  3. Soparkar CN, Patrinely JR, Davidson JK. Silent sinus syndrome-new perspectives?. Ophthalmology. Feb 2004;111(2):414-5; author reply 415-6. [Medline].

  4. Arikan OK, Onaran Z, Muluk NB, Yilmazbas P, Yazici I. Enophthalmos due to atelectasis of the maxillary sinus: silent sinus syndrome. J Craniofac Surg. Nov 2009;20(6):2156-9. [Medline].

  5. Cole P, Kaufman Y, Hollier L. Principles of facial trauma: orbital fracture management. J Craniofac Surg. Jan 2009;20(1):101-4. [Medline].

  6. Cline RA, Rootman J. Enophthalmos: a clinical review. Ophthalmology. Mar 1984;91(3):229-37. [Medline].

  7. Cory RC, Clayman DA, Faillace WJ, et al. Clinical and radiologic findings in progressive facial hemiatrophy (Parry-Romberg syndrome). AJNR Am J Neuroradiol. Apr 1997;18(4):751-7. [Medline].

  8. Davidson JK, Soparkar CN, Williams JB, et al. Negative sinus pressure and normal predisease imaging in silent sinus syndrome. Arch Ophthalmol. Dec 1999;117(12):1653-4. [Medline].

  9. Eubanks LE, McBurney EI, Galen W, et al. Linear scleroderma in children. Int J Dermatol. May 1996;35(5):330-6. [Medline].

  10. Manson PN, Clifford CM, Su CT, et al. Mechanisms of global support and posttraumatic enophthalmos: I. The anatomy of the ligament sling and its relation to intramuscular cone orbital fat. Plast Reconstr Surg. Feb 1986;77(2):193-202. [Medline].

  11. Numa WA, Desai U, Gold DR. Silent sinus syndrome: a case presentation and comprehensive review of all 84 reported cases. Ann Otol Rhinol Laryngol. Sep 2005;114(9):688-94. [Medline].

 
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Conventional frontal tomograph of a blow-out fracture.
 
 
 
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