Enophthalmos is a pathological condition of the eyeball, in which it is excessively trapped in the orbital cavity. Clinically manifested by diplopia, scotomas, impaired eye mobility, decreased visual acuity. Diagnosis of enophthalmos is based on the results of external examination, palpation, exophthalmometry, radiography, Doppler ultrasound in In-mode, CT, visometry. Treatment tactics are determined by etiology. A decrease in the volume of retrobulbar fiber is an indication for the introduction of a suspension of adipocytes or implantation of artificial materials. With the traumatic genesis of the disease, bone fragments are repositioned, with the inflammatory process, antibacterial and corticosteroid therapy is carried out.
Enophthalmos is a disease in ophthalmology characterized by the displacement of the eyeball to the posterior part of the orbit. The pathology was first described by the English surgeon V. Leng in 1889, when he diagnosed a displacement of the eyeball by 8 mm in the post-traumatic period. The congenital variant of the pathology occurs with the same frequency among males and females. Often this type of disease is diagnosed in early childhood.
Oenophthalmos of traumatic origin is more often detected in middle-aged men. The senile form of pathology develops due to an involutional decrease in the volume of retrobulbar fiber. It is found in patients older than 60 years. There are no features of the geographical prevalence of the disease.
There are congenital and acquired forms of enophthalmos.
- Congenital causes. An increase in the size of the sagittal axis from the posterior pole to the apex of the orbit is observed in the congenital form of enophthalmos, anomalies in the development of the skull bones. The development of the disease may be due to a decrease in the size of the eyeball caused by microphthalmos.
- Subatrophy. Chronic inflammation, age-related involution, hemorrhages, trophic disorders or lipodystrophy lead to atrophic or sclerotic changes in the soft tissues of the orbit.
- Injuries. The most common cause of the occlusion of the eyeball is a fracture of the bone structures of the orbit. Often this is caused by traumatic damage to its lower wall, which occurs in the area of the subglacial opening. Enophthalmos is one of the symptoms of a fracture of the zygomatic bone. Depending on the direction of displacement of fragments, exo- or enophthalmos may develop in gunshot wounds. Eye socket injuries are often accompanied by soft tissue atrophy, which further aggravates the process.
- Tumors of intraorbital localization. During the course of the malignant process in the cavity of the eye socket (retinoblastoma), exophthalmos develops, which after surgical treatment and radiation therapy can be replaced by enophthalmos. This disease is part of the symptom complex of the Claude-Bernard-Horner triad, in which there is also a drooping eyelid and myosis. The cause of the pathology is damage to the sympathetic nerves of the cervical spine.
- Extraorbital pathological processes. The provoking factors are compression by an aneurysm, enlarged thyroid gland, lymph nodes, malignant or benign neoplasms.
- Other reasons. Cases of the development of enophthalmos with severe exhaustion of the body (cholera, anorexia, paraneoplastic syndrome), myxedema, peritonitis and in the period of agony are described.
Symptoms of enophthalmos
From a clinical point of view, there are early, late and imaginary forms of the disease. Often, enophthalmos is a monocular pathology, the asymmetric location of the eyeballs is revealed when the eyeball is sunk by 1 mm or more. The early variant develops in the zone of displacement of bone fragments almost immediately after injury. Only posttraumatic edema of retroorbital fiber can mask clinical manifestations.
The appearance of a late form of enophthalmos is caused by hypoplasia and sclerotic changes in soft tissues, atrophy of the oculomotor muscles. It is more often observed after inflammation, hemorrhage or lesion of the cervical sympathetic trunk. The clinic of imaginary enophthalmos is more characteristic of congenital microphthalmos. Patients with enophthalmos complain of double vision, loss of areas of the visual field. The decrease in visual acuity is caused by damage to the optic nerve or retina during injury.
If enophthalmos is part of the Claude-Bernard-Horner symptom complex, patients complain of concomitant drooping of the upper eyelid with a slight elevation of the lower one, which leads to narrowing of the eye slit. Concomitant symptoms are sweating disorders, injection of conjunctival vessels and hyperemia of the facial skin on the affected side. The pupil’s reaction to light is also disrupted due to pupil constriction. Less often, enophthalmos is an ophthalmological manifestation of Parry-Romberg syndrome.
In most cases, enophthalmos is accompanied by a violation of the trophic oculomotor muscles, which, with the progression of the disease, leads to their atrophy. At the same time, patients note a limitation of eye mobility, a constant narrowing of the pupil. Depending on the localization of the pathological process in trauma, the development of strabismus is possible. Also, enophthalmos is a cosmetic defect in which, against the background of deep–set eyes, specific folds form on the upper eyelids due to the retraction of the orbital-palpebral furrow.
Diagnosis of enophthalmos is based on the results of external examination, palpation, exophthalmometry, radiography, computed tomography (CT), ultrasound diagnostics (Doppler ultrasound) in In-mode.
- External inspection. Reveals the displacement of the eyeball deep into the narrowing of the eye slit, deepening of the skin fold over the upper eyelid. Subcutaneous emphysema and increased soreness are determined by palpation with the traumatic origin of enophthalmos. The method of exophthalmometry allows you to diagnose the retention or depression of the eyeball by at least 1 mm. This examination is carried out in patients with suspected enophthalmos in order to establish a diagnosis and choose further treatment tactics.
- Radiography of orbits. It is shown to all patients with enophthalmos at the stage of early diagnosis, the technique allows visualizing fracture lines and areas of displacement of bone fragments. CT of the orbit is carried out to establish the etiology of the disease and assess the extent of the lesion. The axial projection reveals the displacement of the eyeball to the posterior parts of the orbit, bone fragments, areas of hemorrhage and atrophy of muscle tissue and retrobulbar tissue. Both methods provide information about radiopaque damaging agents (metal parts, bullets).
- Sonography. If with enophthalmos it is not possible to determine the exact localization of the trigger, it is necessary to conduct ultrasound in B-mode, which allows you to detect foreign bodies made of wood or glass.
Assessment of visual function. The visometry method evaluates the degree of visual acuity reduction.
Treatment of enophthalmos
The tactics of treatment of enophthalmos depends on the etiology of the disease. Conservative therapy of enophthalmos after injury is performed only in patients with minor manifestations (posterior displacement less than 2 mm) without interposition of the inferior rectus extraocular muscle and in the absence of double vision. Treatment tactics are reduced to prescribing a course of antibacterial drugs and corticosteroids.
Oral administration of non-narcotic analgesics is recommended to eliminate the pain syndrome. Edema can be eliminated by instillation of hypertonic saline solutions. Inflammatory processes of the eyeball or retrobulbar fiber are an indication for the appointment of broad-spectrum antibacterial agents and detoxification therapy.
In case of pathology due to a decrease in the volume of fiber of the retrobulbar space, it is recommended to inject a suspension of adipocytes after their preliminary aspiration from subcutaneous adipose tissue in the anterior abdominal wall of the patient. This procedure allows you to reposition the eyeball without developing allergies and rejection reactions. Surgically, with enophthalmos, implants made of solid silicone, titanium or polymer compounds can be inserted into the retrobulbar space.
Oenophthalmos of traumatic origin with a depression of more than 2 mm is an indication for the reposition of bone fragments. Surgical intervention is performed by subciliary, transconjunctival or transantral access. With minimal manifestations of damage to the fundus of the eye socket, a minimally invasive operation is performed using endoscopic techniques.
Prognosis and prevention
There is no specific prevention of enophthalmos. Non-specific preventive measures are reduced to compliance with safety rules at work (wearing protective glasses and helmets), timely diagnosis and treatment of inflammatory processes in the orbital cavity. Frequent inflammation of the retrobulbar fiber or eyeball, in addition to specific treatment, requires correction of the diet with the inclusion of food rich in vitamins and trace elements, normalization of sleep and rest. If you suspect enophthalmos, you need to be examined by an ophthalmologist with mandatory exophthalmometry, visometry. The prognosis for this disease is favorable for life and working capacity, however, in advanced cases, complete loss of vision is possible.