Introduction
Background
Enophthalmos is posterior displacement of the eye. The anterior projection of the eye is most commonly measured relative to the outer edge of the orbit, the orbital rim, but it also may be assessed relative to the frontal and maxillary prominences, or the contralateral eye.
Pathophysiology
Primary enophthalmos indicates a congenital etiology. Some degree of facial asymmetry is common, but congenital relative enophthalmos or ocular retrusion may occur with in utero maldevelopment (eg, plagiocephaly, microphthalmos).
Secondary enophthalmos is due to an acquired change in the volumetric relationship between the rigid bone cavity, the orbit, and its contents (predominantly the orbital fat and the eye). Expansion of the orbital cavity without change in the volume of the orbital contents (ie, a blow out fracture) leads to enophthalmos. Alternatively, scarring contracture of the orbital fat and extraocular muscles may decrease soft tissue volume, making the orbital cavity less full and causing enophthalmos.
Frequency
United States
The occurrence is frequent.
International
Same as in the United States.
Mortality/Morbidity
Enophthalmos greater than 2 mm relative to the contralateral eye creates an observable cosmetic deformity. Depending upon the etiology, other significant morbidity may be associated.
Age
This condition occurs in all ages.
Clinical
History
Progressive sinking in of one or both eyes over any time frame (ranging from minutes to years).
Physical
Bilateral enophthalmos may be difficult to determine without radiographic studies or old photographs for comparison, but unilateral enophthalmos often is obvious 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 upon 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 - Important to establish progression or stability
- Ocular motility - Dysmotility might suggest mass (orbital tumor) or restrictive process (fracture).
- Skin and eyelids
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 (frequency of fracture sites - floor > medial wall > lateral wall > 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 gastrointestinal cancers may cause fat and globe retraction as well)
- Following surgery (as in resection of a mass lesion associated with local fat atrophy)
- Phthisis bulbi or prephthisis bulbi
- Orbital fat atrophy
- Pseudoenophthalmos
- Unilateral blepharoptosis
- Horner syndrome
- Contralateral exophthalmos
- Contralateral pseudoexophthalmos
- Contralateral high myopia
- Contralateral buphthalmos or megaloglobus
- Contralateral eyelid retraction
More on Enophthalmos |
 Overview: Enophthalmos |
| Differential Diagnoses & Workup: Enophthalmos |
| Treatment & Medication: Enophthalmos |
| Follow-up: Enophthalmos |
| References |
| Next Page » |
References
Cline RA, Rootman J. Enophthalmos: a clinical review. Ophthalmology. Mar 1984;91(3):229-37. [Medline].
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].
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].
Eubanks LE, McBurney EI, Galen W, et al. Linear scleroderma in children. Int J Dermatol. May 1996;35(5):330-6. [Medline].
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].
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].
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].
Soparkar CN, Patrinely JR, Davidson JK. Silent sinus syndrome-new perspectives?. Ophthalmology. Feb 2004;111(2):414-5; author reply 415-6. [Medline].
Further Reading
Keywords
sunken eye, eye retrusion, posterior eye displacement
