What is Enophthalmos?

Enophthalmos is a medical term used to describe a condition where the eyeball is displaced or moved back within the eye socket. This shouldn’t be confused with other similar conditions including hyperglobus, hypoglobus, esoglobus, and exoglobus. Its opposite condition is called proptosis or exophthalmos, where the eyeball is moved forward.

In practical terms, if you have enophthalmos, it might look like your eye is sunken or deeper in its socket. You might also observe a bigger depression or groove at the top part of your eye (the superior sulcus), possibly along with your upper eyelid retracting or drooping (an issue known as ptosis), or sometimes both. Because of the shifting of tissues around the eye and eyelid, some people also experience lagophthalmos, which is when you can’t fully close your eyes. Dryness of your eye may be the first symptom you notice. Some might even notice that their eyes don’t seem to be situated in the same position.

However, it’s important to remember that the normal position of the eyeball can vary depending on factors like age, ethnicity, and gender. For instance, people of African descent tend to have shallower eye sockets than White people, which can give the appearance of more prominent or “proud” eyes.

What Causes Enophthalmos?

Enophthalmos is a condition where the eyeball sinks into the eye socket. It can be present at birth (congenital) or develop later (acquired), and can be linked to systemic syndromes and diseases that affect the eye socket.

Enophthalmos can be caused by several factors including enlargement of the eye socket, shrinkage in the contents of the eye socket or reduction of the contents within the eye socket.

**Enlargement of the eye socket**

The eye socket can become enlarged due to a defect or displacement of its walls. Some examples include:

– Orbital fractures usually caused by trauma such as sports injuries, car accidents or fights. If the fracture leads to the contents of the eye socket (like the fat, muscle) to be pushed out into the surrounding areas, this can cause enophthalmos.

– Silent sinus syndrome is when fluid gathers within the sinus cavity, creating negative pressure which pulls down the floor of the eye socket. This may lead to enophthalmos without any pain or history of sinus problems.

– The eye socket can also become enlarged as we age, causing enophthalmos.

**Reduction of eye socket contents**

As we age, the fat in and around our eyes can reduce, causing posterior displacement of the eyeball. This can also be linked to syndromes affecting the ocular surface in elderly. Some drugs used to treat glaucoma can also lead to fat loss and enophthalmos.

Orbit surgery that removes normal or abnormal soft tissue can result in orbital volume loss which can result in enophthalmos.

Trauma, even in the absence of fractures, can lead to fat loss in the eye socket and enophthalmos.

**Shrinkage of eye socket contents**

Certain diseases like cancer can spread into the eye socket. For example, metastatic breast carcinoma can replace the fat in the eye socket and promote the deposition of collagen, resulting in shrinkage of the soft tissue and enophthalmos.

Congenital fibrosis syndrome is a disorder present from birth where the muscles that control eye movement are underdeveloped. This can lead to the appearance of enophthalmos.

Enophthalmos, Phthisis Bulbs. The image shows phthisis bulbs in the right eye
after intraocular infection, which resulted in a smaller globe, giving the
impression of enophthalmos.
Enophthalmos, Phthisis Bulbs. The image shows phthisis bulbs in the right eye
after intraocular infection, which resulted in a smaller globe, giving the
impression of enophthalmos.

Risk Factors and Frequency for Enophthalmos

Enophthalmos, a condition often seen in medical records, tends to affect males more than females. This is because the most frequent cause is linked to injuries. A study that looked back at 629 patients with eye socket fractures noted that for every female patient, there were nearly 6 male patients. The average age of these patients was 37.2 years.

  • Enophthalmos more often affects males due to its common cause: trauma.
  • In a study of 629 patients with eye socket fractures, there were about 6 males for every female.
  • The patients in the study were on average 37.2 years old.

Signs and Symptoms of Enophthalmos

Enophthalmos is a condition where the eye appears to sink into the eye socket. The symptoms you might notice can depend on the underlying cause, but commonly include:

  • Facial asymmetry
  • Double vision
  • Dry eye
  • Cosmetic complaints
  • Droopy upper eyelid (ptosis)
  • Difficulty focusing
  • Deep superior sulcus

When enophthalmos affects only one eye, differences between the two eyes may be obvious visually. The recessed eye may appear ‘deep-set’, and there may be related issues such as a droopy eyelid or reduced eyelid opening. A technique called the chin-up view is often used to detect relative enophthalmos by visually comparing the two eyes.

Enophthalmos is diagnosed by measuring the anteroposterior, or front-to-back, position of the eye. The eye socket is made up of seven bones that form a protective shell for the eye, which normally protrudes slightly beyond the edge of the eye socket. If the eye is 2mm or more behind its normal position, this is defined as enophthalmos. The goal is to measure whether the position of one eye is different from the other or from a ‘normal’ position.

A device called an exophthalmometer is commonly used to measure the position of the eye in relation to the border of the eye socket. There are several types of these devices, each with its advantages and disadvantages:

  • Hertel exophthalmometer: easy to use, but its accuracy can be affected if the lateral orbital rim (the outer edge of the eye socket) is compromised.
  • Naugle exophthalmometer: similar to the Hertel, but uses a 4-point fixation system and black markers to improve accuracy.
  • Leudde prism exophthalmometer: includes a prism to eliminate parallax problem which can distort measurements if the observer’s viewpoint changes.
  • Mourits exophthalmometer: combines features from the Hertel and Leudde devices.

Testing for Enophthalmos

When it comes to examining diseases or injuries of the eye socket, or “orbit”, computed tomography (CT) scans and magnetic resonance imaging (MRI) are often used. CT scans are very useful when we need to look closely at the bones, meanwhile MRI is useful for scrutinizing soft tissues or non-bony parts of the eye socket.

A CT scan gives doctors a clear look at the structures inside the eye socket. This helps them accurately measure ‘enophthalmos’, a condition where the eye sits further back into the eye socket than normal. If there’s a fracture, for instance, parts of the nasal septum or the stylus process in the skull could be used as reference points to measure the enophthalmos. CT scans also play a crucial role in looking at how much volume has changed within the socket, by comparing it to the unaffected eye.

Research has shown that CT scans can accurately measure the volume of the eye socket, and the amount of structure displacements in fractures, in order to calculate the degree of enophthalmos. Reconstructed images of the eye socket, particularly from the front or side views, can help in assessing any injuries to the orbital floor, which is the bottom part of the eye socket, and important for surgery planning.

However, an important point is that CT scans do expose the patient to some radiation. Once the diagnosis is confirmed and if there’s no need to examine specific soft tissue changes (for instance, cancer), a clinical device called an exophthalmometer can be used for tracking the condition. It offers a radiation-free way for long-term follow-up of patients, thereby reducing the need for repeated CT scans.

Treatment Options for Enophthalmos

Enophthalmos, which is when the eye appears to have sunk into the skull, is treated after a detailed clinical review of the patient, inclusive of a full medical history and eye examination. This may include looking at old photos to note any changes in the eyes over time. The process would also involve checking the patient’s visual fields (range of vision), eye movements, and any changes in their visual sharpness or clarity.

In cases where this condition is caused by trauma or injury, it could be easier to diagnose. This is because patients often show symptoms like bulging eyes (proptosis), double vision (diplopia), and then eventually, enophthalmos, over a few weeks after the injury has occurred.

Sometimes, patients with injuries that have led to this condition may choose to avoid eye surgery. This could be the case if the fracture is small, or if symptoms like diplopia that are typically caused by post-traumatic enophthalmos aren’t significant. In cases where an oculocardiac reflex presents—characterized by continual vomiting, a slower heart rate (bradycardia), and fainting—especially in young children, immediate surgery is often the preferred course of action. This reflex happens when soft tissue, usually the inferior rectus muscle located in the eye, gets stuck. If surgery is not done immediately, the recommendation is to do it about two weeks after the injury, a time period that usually allows any swelling to subside and a proper evaluation of enophthalmos or diplopia to be made. This timing can also lower the risk of a serious complication called orbital compartment syndrome, which can lead to vision loss if not treated in time.

The desire to correct the look of the sunken eye, particularly if it’s noticeable, could be another reason to consider surgery. The extent to which enophthalmos is visible can vary depending on factors like race, age, and the general anatomy of the patient’s face and eye socket. If surgery is considered, CT scans can help guide the procedure using an ‘enophthalmos estimate line.’ This is a line drawn from the furthest part of the fracture to where it was before the injury occurred; it helps estimate how severe the enophthalmos might get over time. The main goal of any surgical intervention is to get the eye moving as normally as possible and to resolve any double vision.

Surgical techniques can include the use of metal plates to fix the fracture or the placement of implants in the floor of the eye socket to support its contents. In rare cases, injections of fat to support the eyeball may be used. These methods can also benefit people dealing with a condition called Silent Sinus Syndrome. For them, additional procedures that involve clearing out the bony passageway connected to the sinus (uncinectomy) and creating a larger opening into the maxillary sinus (maxillary antrostomy) might be performed. These procedures aim to help drain any fluid build-up and relieve pressure in the sinus system. Also, by letting air into the sinus, they may reduce the appearance of enophthalmos by up to 2 mm.

Enophthalmos, which refers to a sunken-eye appearance, can sometimes be confused with conditions like pseudoenophthalmos where the eye’s position doesn’t actually change. The difference can be important to understand when diagnosing a patient. Outside of true enophthalmos, a number of other conditions could potentially lead to a similar appearance:

  • An exophthalmos, which is a bulging eye, or a proptosis condition on side might make the normal side seem enophthalmic (sunken).
  • Facial asymmetry, like asymmetry following trauma or congenital conditions like hemifacial microsomia, can give off an illusion of pseudoenophthalmos.
  • Phthisis bulbi: This condition can cause the globe of the eye to shrink following a trauma, surgery or infection, which can create the semblance of a sunken globe and related ptosis, despite the absence of a true axial posterior displacement of the globe.
  • Microphthalmos: This congenital condition is characterized by a small eye, where the overall volume of the eye globe is reduced without any other ocular abnormalities. This could be seen in patients with hemifacial microsomia.
  • Anisometropia: In this condition, one eye may look larger if it is more myopic, giving an appearance of being bulged and making the other eye seem enophthalmic in comparison. Likewise, if one eye is more hypermetropic, it might seem smaller and give the impression of enophthalmos.
  • Horner syndrome: In this condition, a lesion on the eye’s sympathetic pathway can lead to ptosis, miosis, anhidrosis and an appearance of enophthalmos.
  • Congenital or acquired ptosis: This condition can cause the upper eyelid to sag, giving the appearance of enophthalmos.
  • Post-enucleation socket syndrome: This condition arises when the loss of an eye decreases the orbital volume.

Each of these conditions may lead to what appears to be a sunken eye, but wouldn’t be labeled as enophthalmos. It’s crucial for physicians to differentiate between these possibilities for accurate diagnosis.

What to expect with Enophthalmos

The future health outcome for patients with enophthalmos, a condition where the eye appears sunken into the skull, can vary widely depending on what caused the condition. Surgical treatment is usually offered to younger patients suffering from silent sinus syndrome (a rare disease that causes facial pain and sinus issues) or orbital (eye socket) fractures. In these cases, recovery results are generally very good.

After surgery to repair trauma to the orbital area, patients often find that both the appearance and functionality of their eye area improve. However, some may still experience a sunken appearance and limited eye movement, depending on the severity of the bone and tissue damage.

If a patient has enophthalmos because of cancer spreading to the orbital area, addressing the sunken eye isn’t usually a priority. This is because the type of cancer, and whether it has spread to other parts of the body, will primarily dictate the patient’s health outlook.

For those patients needing orbital exenteration (a procedure where all of the eye’s contents are removed) due to the spread of cancer, a case study of 39 patients found that roughly 41.2% of them survived for at least 5 years after the procedure.

Possible Complications When Diagnosed with Enophthalmos

Surgery to treat enophthalmos (a condition where the eye appears sunken) can unfortunately have several potential complications. These include:

  • Facial asymmetry (uneven facial features)
  • Residual diplopia (continued double vision) or limitation of eye movement
  • Vision loss
  • Entropion or ectropion (conditions where the eyelid turns inwards or outwards)
  • Iatrogenic worsening of enophthalmos (the enophthalmos or sunken eye appearance worsening because of the surgery itself)

Preventing Enophthalmos

If a person develops a condition called enophthalmos, where the eyeball is abnormally positioned deeper than normal in the eye socket, it is important that they understand how this could affect their everyday activities like driving or working. This largely depends on the impact enophthalmos has on their vision and whether they experience double vision. If the person also has fractures around the eye socket (orbital fractures), they would be advised not to blow their nose. This is because blowing the nose might force air into the areas around the eye (a condition known as orbital emphysema), which could potentially worsen the condition.

Frequently asked questions

Enophthalmos is a condition where the eyeball is displaced or moved back within the eye socket.

Enophthalmos more often affects males due to its common cause: trauma.

The signs and symptoms of Enophthalmos include: - Facial asymmetry - Double vision - Dry eye - Cosmetic complaints - Droopy upper eyelid (ptosis) - Difficulty focusing - Deep superior sulcus When Enophthalmos affects only one eye, visual differences between the two eyes may be noticeable. The recessed eye may appear "deep-set" and there may be additional issues such as a droopy eyelid or reduced eyelid opening. The chin-up view technique is often used to visually compare the two eyes and detect relative Enophthalmos. Enophthalmos is diagnosed by measuring the front-to-back position of the eye, known as the anteroposterior position. The eye socket is composed of seven bones that form a protective shell for the eye. Normally, the eye protrudes slightly beyond the edge of the eye socket. If the eye is 2mm or more behind its normal position, it is considered Enophthalmos. The goal of diagnosis is to determine whether the position of one eye is different from the other or from a "normal" position. To measure the position of the eye in relation to the border of the eye socket, an exophthalmometer is commonly used. There are several types of exophthalmometers, each with its own advantages and disadvantages. These include the Hertel exophthalmometer, Naugle exophthalmometer, Leudde prism exophthalmometer, and Mourits exophthalmometer. The choice of exophthalmometer depends on factors such as ease of use and accuracy, taking into account any potential compromises or issues that may arise.

Enophthalmos can be caused by several factors including enlargement of the eye socket, shrinkage in the contents of the eye socket, or reduction of the contents within the eye socket.

The doctor needs to rule out the following conditions when diagnosing Enophthalmos: 1. Pseudoenophthalmos 2. Exophthalmos or proptosis 3. Facial asymmetry 4. Phthisis bulbi 5. Microphthalmos 6. Anisometropia 7. Horner syndrome 8. Congenital or acquired ptosis 9. Post-enucleation socket syndrome

The types of tests that are needed for Enophthalmos include: 1. Computed Tomography (CT) scans: CT scans are used to examine the bones and structures inside the eye socket. They can accurately measure the degree of enophthalmos, assess any injuries to the orbital floor, and help in surgery planning. 2. Magnetic Resonance Imaging (MRI): MRI scans are useful for scrutinizing soft tissues or non-bony parts of the eye socket. They can provide a clear look at the structures inside the eye socket and help in assessing any soft tissue changes, such as cancer. 3. Exophthalmometer: Once the diagnosis is confirmed and if there's no need to examine specific soft tissue changes, an exophthalmometer can be used for long-term follow-up of patients. It offers a radiation-free way to track the condition. In addition to these tests, a detailed clinical review of the patient, inclusive of a full medical history and eye examination, is also necessary to properly diagnose enophthalmos.

Enophthalmos is treated through a detailed clinical review of the patient, including a full medical history and eye examination. This may involve looking at old photos to note any changes in the eyes over time. The process also includes checking the patient's visual fields, eye movements, and any changes in their visual sharpness or clarity. In cases where enophthalmos is caused by trauma or injury, it may be easier to diagnose due to symptoms like bulging eyes, double vision, and eventually enophthalmos. The treatment approach can vary depending on the severity of the condition and the patient's symptoms. Surgery may be considered to correct the appearance of the sunken eye and to restore normal eye movement and resolve double vision. Surgical techniques can include the use of metal plates, implants, or injections of fat to support the eye. In some cases, additional procedures may be performed to address related conditions and relieve pressure in the sinus system.

The potential side effects when treating Enophthalmos include: - Facial asymmetry (uneven facial features) - Residual diplopia (continued double vision) or limitation of eye movement - Vision loss - Entropion or ectropion (conditions where the eyelid turns inwards or outwards) - Iatrogenic worsening of enophthalmos (the enophthalmos or sunken eye appearance worsening because of the surgery itself)

The prognosis for enophthalmos can vary depending on the cause of the condition. In cases where enophthalmos is caused by silent sinus syndrome or orbital fractures, surgical treatment is usually offered and recovery results are generally very good. However, if enophthalmos is caused by cancer spreading to the orbital area, addressing the sunken eye is not usually a priority and the patient's health outlook will primarily depend on the type and spread of the cancer.

An ophthalmologist or an oculoplastic surgeon.

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