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Enophthalmos: Causes, Symptoms & Treatment
Enophthalmos is a condition in which the eyeball is displaced backward into the orbit. It can result from trauma, tissue changes, or underlying diseases affecting the eye socket.
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Enophthalmos is a condition in which the eyeball is displaced backward into the orbit. It can result from trauma, tissue changes, or underlying diseases affecting the eye socket.
What is Enophthalmos?
Enophthalmos is a medical condition in which the eyeball is recessed or sunken deeper than normal within the orbit (eye socket). This is the opposite of exophthalmos, where the eye protrudes forward. Enophthalmos can affect one or both eyes and is often noticeable as a sunken or hollowed appearance of the affected eye. It may be accompanied by other visual symptoms depending on the underlying cause.
Causes
Enophthalmos can result from a variety of conditions:
- Orbital floor fracture (blow-out fracture): A break in the bony floor of the orbit, often caused by blunt facial trauma, allows orbital contents to herniate downward, leading to sunken positioning of the eyeball.
- Orbital fat atrophy: Loss of the fatty tissue that normally supports the eyeball within the orbit, which may occur with aging, radiation therapy, or systemic disease.
- Metastatic tumors: Certain cancers, particularly breast cancer metastases, can cause fibrotic (scarring) changes in the orbit that pull the eyeball inward.
- Horner syndrome: A disruption of sympathetic nerve pathways that can produce a pseudo-enophthalmos alongside drooping of the eyelid (ptosis) and a constricted pupil (miosis).
- Chronic inflammation or scarring: Fibrotic changes following orbital infections or prior surgeries.
- Congenital causes: In rare cases, enophthalmos may be present from birth.
Symptoms
Common signs and symptoms of enophthalmos include:
- A visibly sunken or recessed eyeball
- Deepening of the upper eyelid fold (superior sulcus deformity)
- Diplopia (double vision), particularly if eye muscle movement is restricted
- Restricted visual field
- Facial asymmetry
- Occasional pain or pressure in the orbit
Diagnosis
Enophthalmos is diagnosed through clinical examination and imaging studies:
- Exophthalmometry (Hertel exophthalmometer): A simple instrument used to measure the exact forward projection of each eyeball relative to the lateral orbital rim, allowing comparison between both eyes.
- Computed tomography (CT) of the orbit: The gold standard for visualizing bony structures, fractures, and soft tissue changes within the orbit.
- Magnetic resonance imaging (MRI): Used as a complement to CT for evaluating soft tissue, tumors, or inflammatory conditions.
- Ophthalmological examination: Assessment of eye motility, visual acuity, and visual field.
Treatment
Treatment depends on the underlying cause and the degree of functional impairment:
- Surgical repair: Orbital floor fractures are commonly treated with surgical reconstruction of the orbital floor using implants or autologous bone grafts to restore normal anatomy and eliminate double vision.
- Orbital volume augmentation: In cases of fat atrophy or scarring, implants or fat transfer can be used to restore orbital volume and correct the sunken appearance.
- Treatment of the underlying condition: When enophthalmos is caused by Horner syndrome or malignancy, addressing the primary condition is the main priority.
- Observation: Mild enophthalmos without functional symptoms may not require active treatment.
References
- Kaufman, P.L., Alm, A. (eds.): Adler's Physiology of the Eye. 11th edition. Saunders Elsevier, 2011.
- Burnstine, M.A.: Clinical Recommendations for Repair of Isolated Orbital Floor Fractures. Ophthalmology, 109(7):1207-1210, 2002. PubMed PMID: 12093644.
- Rootman, J. (ed.): Diseases of the Orbit. 2nd edition. Lippincott Williams & Wilkins, 2003.
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