Enophthalmos: An Overview

Introduction:

The term ‘en’ means ‘in’, and ‘ophthalmos’ refers to ‘eye’. The opposite of this condition is exophthalmos, also known as bulging eyes. Enophthalmos can either be present at birth (congenital) or develop later in life (acquired). It can also occur in one eye (unilateral) or both eyes (bilateral). Enophthalmos can occur following car, truck, or motorcycle accidents or after physical fights that can cause orbital fractures. Orbital fractures are fractures in the bones surrounding the eyes and are common in men.

What Are the Reasons for Enophthalmos?

The following are the reasons for enophthalmos:

• Change in the Size of the Orbit (Eye Socket) Of the Eye: The term ‘orbit’ refers to the bony cage around the eye and includes the cavity's contents. If the orbit or the socket enlarges in size, the contents of the orbit, including the eyeball, can shift in position. A change in the size of the orbit occurs due to the following reasons:

1. Bone fractures that occur around the eyes can most often cause damage to the orbital floor. An orbital blowout fracture is a very serious condition.

2. In chronic maxillary sinus atelectasis or Silent sinus syndrome (SSS), the orbital floor can become weak and curve outwards due to maxillary sinus disease. The maxillary sinus disease involves the sinus cavities that are situated on either side of the cheeks.

3. Changes in the bone due to aging.

4. Enophthalmos can also occur due to missing or deformed parts of facial bones due to conditions like neurofibromatosis (a group of genetic disorders that can form tumors on the nerve tissue).

• Change in the Contents of the Eye Sockets: These include:

1. Long-term consequences of radiation therapy to the head.

2. Trauma and surgery to the orbit, even if the bones are not broken.

3. Diseases that can cause alterations in fat distribution throughout the body, including the face, can result in enophthalmos. Examples of such conditions include Human Immunodeficiency Virus (HIV) and Parry-Romberg Syndrome (a condition in which the tissue on one side of the face progressively wastes away).

4. Scleroderma is an autoimmune condition in which the tissues become thick, especially in the skin. The digestive tract, kidneys, and other body parts may also be affected.

5. The reduction in fat tissue and age-related muscle weakening can also cause enophthalmos. Two conditions associated with age-related changes include senile sunken eye syndrome and giant fornix syndrome. Giant fornix syndrome can occur with recurring pink eye (conjunctivitis). Both of these conditions can affect the surface of the eye.

6. Few medications used in the treatment of glaucoma (a group of eye conditions that can result in blindness) can also cause enophthalmos.

• Change in the Size of the Eye: These changes are as follows:

1. Severe eye damage due to trauma even if the bones are not fractured.

2. Congenital fibrosis syndrome (a condition in which fibrosis or scarring occurs in both eyes). Since the condition affects both eyes, the changes cannot be appreciated by merely looking at the person.

3. The sites of metastasis of cancer (spread of cancerous cells away from the point of origin) like the prostate, breast, lung, skin, parotid gland, or gastrointestinal tract.

What Are the Signs and Symptoms of Enophthalmos?

The signs and symptoms include:

• Dry eye.

• Double vision.

• Facial asymmetry.

• Ptosis (drooping eyelids).

• Deep superior sulcus (grooves on the upper eyelid).

• Difficulty in focusing.

• Cosmetic concerns.

How To Diagnose Enophthalmos?

Enophthalmos can be diagnosed in the following ways:

• The physician can identify enophthalmos by simply looking at the individual, especially if it involves one eye.

• A complete medical history and an eye examination will be done.

• Exophthalmometry may be performed to measure how far the eye sticks out from the orbital socket.

• Magnetic resonance imaging (MRI) may be done. This technology employs the use of magnets, computers, and radio waves to obtain images of tissues and body parts.

• Computed tomography (CT) scan integrates the use of computers and X-rays to obtain three-dimensional images of the tissues and body parts.

How Can Enophthalmos Be Treated?

The treatment protocol should include assessing the patient's complete medical and ocular history along with the analysis of the progression of the symptoms. Previous photographs, if taken, can help analyze the progression of the symptoms. A full eye examination, including the assessment of ocular movements, visual fields, and changes in visual acuity, should be noted. The treatment modalities are as follows:

• Traumatic injuries can be managed conservatively if the patient is not willing to undergo orbital surgery or in those where surgery is not necessary due to the small size of the fracture, or in the absence of major clinical symptoms like diplopia (double vision) as a result of post-traumatic enophthalmos.

• If a patient presents with oculocardiac reflexes like continuous vomiting, syncope (temporary loss of consciousness), and bradycardia (slow heart rate), as in a pediatric population, then it is necessary to operate in the acute stage.

• Surgery is indicated in cases of cosmetic corrections where enophthalmos is obvious to visual assessment. The degree to which enophthalmos can be apparent is determined by underlying facial and orbital anatomy, age, and race. Surgical management can be aided by CT scans with the help of an 'enophthalmos estimate line'. It is a virtual line that is drawn between the most distal part of the fractured portion to the original position of the fracture segment. This can help predict the level of enophthalmos that one will experience over time.

• Surgery aims to resolve diplopia and correct the ocular motility to near-normal conditions. Surgical methods involve the placement of metal plates for the reduction of fractures. Surgery also includes the placement of orbital floor implants to withhold the contents of the orbit. Very rarely, fat injections to support the globe may be incorporated.

• The above techniques can also be followed in patients with Silent sinus syndrome (a very uncommon condition that involves the asymptomatic spontaneous collapse of the walls of the sinus and the orbital floors) as they can enlarge the opening to the maxillary sinus and enhance the drainage of any stagnated fluids, thereby decompressing the sinus. By promoting aeration of the sinus, this procedure can minimize enophthalmos by 2 mm (millimeter).

What Are the Complications of Surgical Management of Enophthalmos?

The complications are as follows:

• Vision loss.

• Facial asymmetry.

• Limitation of ocular movement or residual diplopia.

• Iatrogenic worsening of enophthalmos.

• Entropion (inward turning of the margin of the eyelid) or ectropion (outward turning of the lower eyelid).

Conclusion:

Enophthalmos is a condition in which the eyes appear sunken and can be due to trauma or other conditions. One can avoid enophthalmos by using protective equipment while driving and refraining from engaging in physical fights. The prognosis of enophthalmos is based on the cause of the condition. Young people who are treated for Silent sinus syndrome or fractures have a very good prognosis. One must seek medical attention following any accidents or blows to the face or if one experiences double or blurred vision.