[Unilateral exophthalmos and enophthalmos (a case of enophthalmos in von Recklinghausen's disease)].
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Adolescent↗
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Computer-assisted orbital volume measurement in the surgical correction of late enophthalmos caused by blowout fractures.
PURPOSE: To evaluate the use of computer-assisted volumetric measurement for the prediction of late enophthalmos and for volume estimation of implant material in the correction of late enophthalmos secondary to orbital blowout fractures (BOF). METHODS: This is a prospective observational study of 16 patients. Computer-assisted orbital volume measurements were made with the use of axial CT scans. Hertel exophthalmometry was used for the measurement of enophthalmos. The Lancaster test was used for measurement of diplopia. Autogenous bone or hydroxyapatite composite material was used for the repair of orbital defects and the correction of orbital volume expansion in 16 patients with enophthalmos caused by BOF. The volume of implant material was calculated from the orbital volume increment. Patients were followed for an average of 8 months after surgery. RESULTS: There is a high correlation between the increment of orbital volume and the degree of enophthalmos; 1 cm3 orbital volume increment causes 0.89 mm of enophthalmos. Before surgery, 10 of the 16 patients had moderate enophthalmos (3 to 4 mm) and 6 patients had severe enophthalmos (> or = 5 mm). Six months after surgical intervention, 13 patients (81%) achieved satisfactory results; 3 patients had no enophthalmos and 10 had mild enophthalmos (1 to 2 mm). Three patients had moderate to severe enophthalmos. CONCLUSIONS: The measurement of orbital volume in patients with BOF can be used to predict the degree of late enophthalmos. Use of the orbital volume increment to determine the amount of implant material can improve the therapeutic outcome in the correction of late enophthalmos caused by BOF.
Adult↗
The ophthalmic implications of the correction of late enophthalmos following severe midfacial trauma.
Severe midfacial trauma presents several challenges to the reconstructive surgeon. Acute rigid fixation of the facial skeleton accompanied by bone grafting to restore the confines and volume of the orbit provide the best opportunity for acceptable aesthetic results. The severity of the trauma causes the late postoperative complication of enophthalmos. Injury to orbital structures with subsequent cicatricial change results in significant alteration in extraocular motility with resultant diplopia. There are no reports in the literature which critically evaluate the effect of late enophthalmos correction on extraocular motility, diplopia, and vision in patients who have suffered Le Fort or NOE fractures. A retrospective study is presented which reviews the results of late surgery for the correction of enophthalmos in 40 patients, all of whom had severe "impure" orbital fractures. This study addresses the following questions: (1) Can the globe effectively be repositioned?, (2) Is there a change in subjective diplopia?, (3) Does a change in extraocular motility occur, and if it does, is it predictable?, (4) Is there a risk to visual acuity? and finally, (5) Do the answers to questions 1 through 4 suggest that late surgical intervention for the correction of enophthalmos should be recommended for this patient population? During a 9-year period, 44 patients with severe diplopia trauma received surgery for enophthalmos correction. A review of 40 patients on whom 56 operations were performed is presented. Thirty-eight patients had enophthalmos and 35 had inferior displacement of the globe. Medial displacement of the globe occurred in 11 patients. Twenty-nine patients had diplopia. Six patients had vision too poor on the injured side to have diplopia. Enophthalmos was improved in 32 patients. Dystopia of the globe was improved in 31 cases. However, neither enophthalmos nor dystopia of the globe could be improved with every operation. Only 35 of the 48 operations for enophthalmos for which measurements were available produced an improvement; in 1 case the enophthalmos was thought to be worse postoperatively. Dystopia operations resulted in improvement in 40 of 48 operations; in 2 instances dystopia was worse postoperatively. Diplopia was unchanged by 33 operations, improved by 11 procedures, and worsened by 6. If patients are considered before and after their total reconstruction course, diplopia was improved in 9 of the 29 patients. In seven of these nine, diplopia was eliminated. There was no change in or production of diplopia in 19 patients, and 5 patients had worsening of their double vision.(ABSTRACT TRUNCATED AT 400 WORDS)
Adolescent↗
When is enophthalmos "significant"?
PURPOSE: It is currently unknown how many measurable millimeters of enophthalmos may be noticeable to an observer. Identifying the amount of enophthalmos present may help to guide patients and clinicians in regard to surgical management of enophthalmos. METHODS: The Massachusetts Eye and Ear Infirmary Oculoplastics imaging database was used to select 12 photographs of patients with unilateral enophthalmos whose measurements ranged between 1 mm and 8 mm for the study group and 12 photographs of patients who did not have enophthalmos as the control group. Observers were asked to review each of the photographs from both groups and to comment on whether the appearance was normal or abnormal. RESULTS: There was no statistical difference found when observers reviewed photographs from the control group and patients whose measurements ranged between 1 mm and 2 mm (87%, 83% respondents identifying patients as normal, respectively). Twenty-eight percent of observers found patients with 3 mm and 4 mm of enophthalmos as having a normal appearance (P < 0.001). Ninety-seven percent of observers commented that patients with measurements of 5 mm and 8 mm had an abnormal appearance (P < 0.001). CONCLUSIONS: Patients with 2 mm and less of measurable enophthalmos had a normal appearance as frequently as those without enophthalmos. Nearly all patients with measurements of 5 mm and greater had abnormal appearances. The point at which enophthalmos becomes detectable lies between 3 mm and 4 mm.
Enophthalmos↗
[Late reconstruction and repositioning of enophthalmos of orbital blow-out fractures].
OBJECTIVE: To investigate the surgical technique for late reconstruction and reposition of enophthalmos of orbital blow-out fractures (BOF) and its efficacy, and to evaluate the effectiveness of hydroxyapatite (HA) composite material as orbital implant material. METHODS: Twenty-one patients with enophthalmos of BOF were randomly assigned into 2 groups in which autogenous bone and HA composite material as orbital grafting material were used. Computer orbital three-dimensional measuring technique, Hertel exophthalmometer and Lancaster test were applied. Late reconstruction of the orbit and reposition of the globe were performed on 21 cases during three months to 2 years after injury. Postoperatively, they were followed up for an average of 8 months. RESULTS: In the 21 cases with enophthalmos of BOF, 15 patients presented moderate enophthalmos (3 - 4 mm) and 6 patients presented severe enophthalmos (5 - 6 mm). Three months after operation, the measurements demonstrated that 3 patients had no enophthalmos, 15 patients had mild enophthalmos (1 - 2 mm) and 3 patients had no effect. Sixteen of 21 patients had diplopia preoperatively. Eight patients had satisfactory result, and 8 patients had no change. There was no significant difference between orbital implants of autogenous bone and HA composite material. CONCLUSIONS: Late reconstruction of orbit and reposition of globe for enophthalmos of BOF may obtain satisfactory results. HA composite material is a useful orbital implant material.
Adult↗
Clinical features and treatment of late enophthalmos after orbital decompression: a condition suggesting cause for idiopathic "imploding antrum" (silent sinus) syndrome.
PURPOSE: To review the clinical and radiologic characteristics of a group of patients who experienced late enophthalmos after bone-removing orbital decompression. The surgical management of these patients is presented and a hypothesis proposed to explain the idiopathic "imploding antrum" ("silent sinus") syndrome. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Six patients experienced relative enophthalmos, hypoglobus, and upper eyelid sulcus deformity at between 3 and 6 months after bone-removing orbital decompression for thyroid orbitopathy. Five left orbits and one right orbit were affected. INTERVENTION: All patients underwent middle meatal antrostomy, together with mobilization and elevation of the collapsed orbital contents by firm packing of the affected maxillary antrum through a buccal antrostomy, the pack being removed about 3 weeks after placement. MAIN OUTCOME MEASURES: Symptomatic improvement and reduction in the degree of relative enophthalmos, hypoglobus, and upper eyelid sulcus deformity. RESULTS: Late-onset enophthalmos after orbital decompression was associated with clinical and radiologic features that resemble the idiopathic imploding antrum syndrome. In all patients, the ethmoidal infundibulum was obstructed by prolapsed orbital fat with secondary antral consolidation, and inward bowing of the maxillary walls was present in five of six patients. After antral drainage and packing, there was an improvement in enophthalmos (mean, 2.7 mm; range, 0-4 mm) and all but one globe returned to within 2 mm of exophthalmometry of the contralateral eye. For recurrent enophthalmos in two patients (minor in one patient and marked in the other), later repair of the orbital floor was undertaken through a lower eyelid swinging flap, using porous polythene sheet, with good cosmetic outcome. CONCLUSIONS: Late-onset enophthalmos after bone-removing orbital decompression seems to be the result of obstruction of maxillary antral aeration, with secondary fluid retention and a subatmospheric pressure in the sinus. This iatrogenic condition, associated in most cases with inward collapse of the maxillary walls, provides a guide to a hypothetical mechanism for the idiopathic imploding antrum (silent sinus) syndrome.
Adult↗
Functional indications for enophthalmos repair.
PURPOSE: In general, orbital augmentation to correct enophthalmos is pursued to prevent or address an aesthetic deformity. In some cases, however, functional deficits may accompany enophthalmos and may serve as an indication for surgical intervention. The authors describe a series of patients with such deficits. METHODS: A retrospective review at a tertiary health care center of all patients with enophthalmos was conducted to identify a subset of cases in which the enophthalmos was associated with nonaesthetic, functional deficits that could not be attributed to muscular or neural dysfunction, or soft tissue scarring. RESULTS: Six patients with either traumatic enophthalmos (orbital fractures) or non-traumatic enophthalmos (sinus disease and orbital soft tissue atrophy) demonstrated nonaesthetic ocular dysfunction, including gaze-evoked diplopia, eyelid retraction, lagophthalmos, and exposure keratitis. The symptoms and signs resolved in the three patients who underwent orbital augmentation. CONCLUSIONS: In some patients with enophthalmos and globe ptosis, globe malposition may alter the underlying eyelid mechanics or extraocular muscle alignment, resulting in functional as well as aesthetic problems. In these patients, restoring the native orbital anatomy through orbital augmentation can reverse eyelid malposition, ocular surface exposure, and symptomatic diplopia, avoiding the need for eyelid or strabismus surgery.
Adult↗
Prediction of enophthalmos by computed tomography after 'blow out' orbital fracture.
In 11 patients with blow out fracture of the orbit, measurement of orbital volume using computed tomography (CT) more than 20 days after injury correlated well with enophthalmos measured from the same scans (r = 0.87, p < 0.001, SEE 0.63 mm), with a 1 cm3 increase in orbital volume causing 0.8 mm of enophthalmos. This confirms the cause of enophthalmos after blow out fracture to be increase in orbital volume rather than fat atrophy or fibrosis. In a further 25 patients scanned within 20 days of injury the degree of enophthalmos was less marked than would be predicted from the orbital volume measurement. This was probably because of the presence of oedema, haemorrhage, or both behind the globe which would prevent immediate development of enophthalmos. CT measurement of orbital volume within 20 days of injury may predict the final degree of enophthalmos and identify those patients at risk of late enophthalmos, allowing appropriate early surgical intervention.
Enophthalmos↗
[Orbital volume measurement of enophthalmos of orbital blowout fractures].
OBJECTIVE: To measure the volumetric changes of enophthalmos of orbital blowout fractures, and to study the relation between the change of the orbital volume and the degree of enophthalmos. METHODS: In 16 patients with enophthalmos of orbital blowout fractures, the measurement of orbital volume was carried out during 3 months to 2 years after injury by using the computed tomography (CT), computer image processing and computer orbital three-dimensional measuring method. The relation between the orbital volume discrepancy and enophthalmos was assessed by using Pearson correlation coefficients. RESULTS: There were significant linear correlation between the increment of the orbital volume and the degree of enophthalmos (r = 0.95, P < 0.001), with each 1.0 cm(3) increment in bony volume causing approximately 0.9 mm of enophthalmos. CONCLUSIONS: Orbital blowout fractures can expand the orbital volume. The measurement of orbital volume may predict the risk and the final degree of the enophthalmos at the late stage, thus it may provide useful information in surgical intervention to estimate the size and volume of the orbital implant for an individual case.
Adolescent↗
Treatment of enophthalmos.
This article has focused on the prevention and treatment of enophthalmos. It has stressed that enophthalmos is both a common complication of orbital fracture and a complication that can be difficult to treat. The cause of these failures of primary and secondary treatment is failure to recognize that orbital fractures have two distinct patterns and that neither is secondary to the anterior orbital floor defect. The zygoma fracture is the more common fracture and the most frequent cause of late enophthalmos. When this bone fractures, it does so at its sutural attachments. It is essential to reposition it at a minimum of three locations to achieve correction in three dimensions. The key to adequate reduction is not only to identify the frontozygomatic and zygomaticomaxillary suture at the infraorbital rim, but also to examine the zygomaticomaxillary suture in the region of the anterior maxillary buttress. Frequently, reduction at the first two sutural areas still leaves persistent lateral rotation of the zygoma and marked intraorbital volumetric expansion behind the axis of the globe. Complete reduction at three points will prevent late enophthalmos. Reosteotomy with repositioning of the zygoma and bone grafting to restore proper orbital volume can correct secondary enophthalmos once it develops. True blow-out fractures do occur, but the cause of the enophthalmos is most commonly the concomitant medial wall fracture and the occasional posterior expansion. The key to treatment is proper diagnosis, which is dependent upon CT scanning. Following definition of the exact fracture spots, restoration of intraorbital volume and sealing of the defects are satisfactory to avoid enophthalmos.(ABSTRACT TRUNCATED AT 250 WORDS)
Biomechanical Phenomena↗
Management of spontaneous enophthalmos due to silent sinus syndrome: a case report.
Silent sinus syndrome (SSS) is a rare disease exhibiting unilateral enophthalmos and hypoglobus. A 26-year-old white female presented with right side enophthalmos and hypoglobus. There was no history of previous trauma or maxillary sinus diseases. A CT scan showed an opacified right maxillary antrum with decreased volume and downward bowing of the right orbital floor. From clinical and radiological findings the diagnosis SSS was made. Biopsies were collected from the maxillary sinus for the exclusion of malignancy. Two months later orbital floor reconstruction was carried out. Before antrostomy of the affected maxillary sinus, a relative enophthalmos of 4mm was determined. Five days after antrostomy the value reduced to 2.3mm. During the following 2 months the enophthalmos remained constant. At the end of the operation for orbital floor reconstruction it was 0.1mm. Five days after surgery the relative enophthalmos increased to 0.8mm. The value remained constant during the following 3 months. Initial antrostomy of the affected maxillary sinus may lead to a relevant, spontaneous reduction of enophthalmos. After a minimum period of 2 months a re-evaluation should be made, if a reconstruction of the orbital floor is still necessary for the correction of the globe position.
Adult↗
Use of Vicryl (polyglactin-910) mesh implant for correcting enophthalmos and hypo-ophthalmos. A study of 16 patients.
Vicryl mesh (polyglactin-910) implants were used to reconstruct the orbital floor to correct enophthalmos or hypo-ophthalmos (globe ptosis) in 16 patients. The main advantages of Vicryl mesh over other alloplastic implants is that (a) it is absorbed by host tissue, and, once absorbed, it will not cause long-term complications; (b) it is layered and is cut from folded sheets into the appropriate size, shape, and thickness for the treatment of enophthalmos or hypo-ophthalmos; and (c) it is soft and pliable and, therefore, is unlikely to erode orbital structures. We followed all patients for a minimum period of 6 months after surgery and observed no significant adverse reactions to the mesh; 15 of the patients had good surgical results with a mean improvement of 1.4 mm in enophthalmos and 0.6 mm in hypo-ophthalmos. After surgery, one patient with combined medial wall and floor fractures developed enophthalmos that was 2 mm more severe than the degree of preoperative enophthalmos. Vicryl mesh should be considered an alternative to both nonautogenous implants and autogenous grafts in orbital floor fracture repair especially for correction of mild and possibly moderate degrees of enophthalmos and hypo-ophthalmos.
Adolescent↗
Management of posttraumatic enophthalmos.
Posttraumatic enophthalmos is one of the common sequelae that appears after facial injury and remains a challenge to treat for craniomaxillofacial surgeons. Several theories have been advocated regarding enophthalmos; however, the most well accepted concept is the enlargement of the orbital cavity after displacement due to orbital fractures. Generally, a 1 cm3 increase in orbital volume causes 0.8 mm of enophthalmos. Thorough knowledge of the orbital anatomy is fundamental and critical for the successful surgical correction of enophthalmos because most treatment failures are due to inadequate orbital dissection from fear of injuring the optic nerve and globe. A complete preoperative plan should be built on a comprehensive clinical examination of the periorbital soft tissue and bony components, detailed ophthalmic examination, and high resolution computed tomography scans in the axial, coronal and reformatted sagittal planes. Based on the anatomic deformities, there are two major fracture types including orbital blow out fractures and zygomatico-orbital fractures, resulting in posttraumatic enophthalmos. Treatment modalities and methods of approach are adapted according to the severity of the orbital deformities. Minor complications include ectropion, entropion, dystopia, diplopia, and residual enophthalmos. Rare but severe complications such as intraconal misplacement of the bone graft or retrobulbar hemorrhage with subsequent blindness may be encountered. The success of the procedures depend on adequate dissection and mobilization of the displaced soft tissue, correct repositioning of the dislocated or malunited bony orbit, and proper intra-orbital grafting.
Enophthalmos↗
Enophthalmos following orbital transposition for craniofacial malformations.
This is a retrospective study of the frequency and factors that portend enophthalmos following orbital osteotomies and transposition for craniofacial malformations. Clinically obvious postoperative enophthalmos (POE) was noted in 23 (37.7 percent) of 61 patients undergoing such procedures. Postoperative enophthalmos was observed in 86 percent of Apert patients who had combined anteromedial orbital transposition and in 48 percent of patients with hypertelorbitism who had standard 360-degree osteotomies. In contrast, the incidence of postoperative enophthalmos was 21 percent following frontofacial (monobloc) or subcranial (Le Fort III) advancement. Postoperative enophthalmos also correlated with the occurrence of orbital fracture/fragmentation and with disruption of the periorbita. This study underscores the importance of establishing the correct relationship of the globe to the orbital rim (euophthalmos) while maintaining the spatial position of the eye, especially its anterior projection. Postoperative enophthalmos can be prevented by inserting bone grafts into orbital osteotomy gaps, correcting orbital volume/morphology following floor or wall outfracture/fragmentation, and preserving the periorbital supporting system.
Acrocephalosyndactylia↗
[Enophthalmos caused by orbital metastasis of breast carcinoma].
BACKGROUND: Orbital metastatic disease usually leads to exophthalmos but rarely to enophthalmos. We report a case of a metastasis causing enophthalmos. PATIENT: A 68-year-old woman had mastectomy for breast cancer six years prior to presentation. She complained of double vision when looking sideways. The right eye showed a motility reduction in all directions and a slight ptosis. She had 4 mm enophthalmos, and the eyelids were sunk into the orbit. There were no signs of optic nerve damage. Magnetic resonance imaging showed a retrobulbar mass surrounding the optic nerve and infiltrating the muscles. The space of the orbital fat was reduced. A biopsy confirmed the diagnosis of metastatic breast carcinoma. Histologically, the connective tissue was infiltrated by lymphocytes, and the nuclei of the tumor cells where aligned in a linear "indian file" pattern. 30% of the tumor cells contained the estrogen-receptor protein, 40% the progesterone-receptor protein. The CA-15/3 and CEA levels were elevated. The patient underwent orbital radiation with 50 Gy. During the following 2 months, the enophthalmos increased to 6 mm. DISCUSSION: We suggest the following hypothesis as the cause of enophthalmos in orbital metastases: The tumor growth goes along with fibrosis. Subsequent shrinkage of the connective tissue pulls the eye back into the orbit. The ensuing elevation of tissue pressure leads to atrophy of the retrobulbar fat. The increase of tumor volume is too slow to compensate for the fat atrophy. Slowly progressive enophthalmos with reduced motility is nearly pathognomonic of metastatic scirrhous breast carcinoma. In rare cases, a diffusely infiltrating carcinoma of the gastrointestinal tract may cause a similar picture.
Adenocarcinoma, Scirrhous↗
Orbital volume measurements in enophthalmos using three-dimensional CT imaging.
The purpose of this study was to investigate enophthalmos by measuring the volume of various orbital structures using off-line computer techniques on images generated by a CT scanner. Eleven patients with enophthalmos had CT scans of the orbits consisting of 30 to 40 adjacent 1.5-mm slices. The data from the scans were analyzed on a Nova 830 stand-alone computer system using software programs that allowed measurement of total bony orbital volume, total soft-tissue volume, globe volume, orbital fat volume, neuromuscular tissue volume, and apex-to-globe distance in the horizontal plane. These data were analyzed comparing the volumes in the normal eye with the volumes in the enophthalmic eye in each patient. The analysis demonstrated a statistically significant increase in bony orbital volume in the enophthalmic eye, but the total soft-tissue volume, fat volume, neuromuscular tissue volume, and globe volume were the same as in the normal eye. The apex-to-globe distance, a measure of the degree of enophthalmos, was less in the enophthalmic eye than in the normal eye. These results suggest that in the majority of patients, the cause of posttraumatic enophthalmos is increased bony orbital volume rather than by soft-tissue loss or fat necrosis. (Several patients showed no volume discrepancies, and it is likely that cicatricial contracture is responsible for the enophthalmos in these cases.) This study suggests that the objective of surgery for correction of enophthalmos in patients with a volume discrepancy should be to decrease the volume of the bony orbit and to increase the anterior projection of the globe.
Adipose Tissue↗
Bilateral enophthalmos associated with hydrocephalus and ventriculoperitoneal shunting.
BACKGROUND: Progressive bilateral enophthalmos in the absence of previous trauma is rare. METHODS: Three patients with progressive bilateral severe enophthalmos whose only significant medical history was that of congenital hydrocephalus were treated by ventriculoperitoneal shunt placement. RESULTS: The patients demonstrated severe bilateral enophthalmos with poor eyelid apposition to the globes resulting in superficial keratopathy. Orbital computed tomographic scans confirmed the severe enophthalmos, with apparent reduced orbital fat volume. Orbital bony anatomy appeared normal. CONCLUSIONS: Bilateral progressive enophthalmos may be associated with hydrocephalus and ventriculoperitoneal shunting. The causal mechanism remains speculative.
Adult↗
The relationship between enophthalmos, linear displacement, and volume change in experimentally recreated orbital fractures.
PURPOSE: The purpose of this investigation was to establish the relationship between enophthalmos, linear displacement, and volume change for various patterns of experimentally recreated orbital fractures. MATERIALS AND METHODS: We fabricated an experimental apparatus that permitted uniform displacement of simulated orbital wall fractures. Measurements of linear displacement, volume change, and degree of simulated enophthalmos were taken for 1- and 2-walled displacements. Means and standard deviations were derived, and analysis of variance was used to compare means for statistically significant differences ( P < .05) between groups and among major categories. RESULTS: No statistically significant differences were found for any uniform displacement caused by 1-walled defects or for any given displacement caused by 2-walled defects The linear coefficient for displacement and enophthalmos or for displacement and volume change approached 1.0 for all groups (range, 0.9802 to 0.9999). However, statistically significant differences in mean enophthalmos and mean volume change at uniform displacements were found between 1- and 2-walled defects. CONCLUSIONS: Displacement of 1- and 2-walled orbital defects results in a direct and linear change in both orbital volume and enophthalmos, regardless of the location of the defect.
Enophthalmos↗