Enophthalmos: Symptoms, Types, Causes and Treatment

Enophthalmos, a condition marked by the posterior displacement of the eyeball within the orbit, can be subtle yet significant. Often mistaken for other eye disorders or overlooked entirely, enophthalmos is more than just a cosmetic concern—it can signal underlying structural, traumatic, or even systemic disease. Understanding its symptoms, types, causes, and available treatments is crucial for timely diagnosis and optimal patient outcomes. This article provides a comprehensive overview, synthesizing current clinical research and expert recommendations.

Symptoms of Enophthalmos

When enophthalmos develops, its symptoms can initially be subtle, leading to delayed recognition. However, as the condition progresses, patients may notice both cosmetic and functional changes. Early identification of key signs can be crucial, especially when enophthalmos is the first hint of a more serious underlying issue, such as trauma or metastatic disease.

Presentation	Description	Clinical Note	Source(s)
Sunken Globe	Posterior displacement of the eye	Often subtle, may be missed	4, 7, 9
Deep Sulcus	Hollowing above upper eyelid	Cosmetic concern	4, 7
Pseudoptosis	Apparent drooping of the eyelid	May mimic true ptosis	4, 7
Diplopia	Double vision	Especially with motility issues	1, 4
Ocular Motility Limitation	Restricted eye movements	May result from mass or fibrosis	1, 4
Eyelid Retraction	Abnormal upper or lower lid position	Can expose the eye	4
Exposure Keratopathy	Corneal dryness & irritation	Due to incomplete eyelid closure	4
Mass Effect	Palpable orbital mass or displacement	May indicate tumor or varix	1, 7

Table 1: Key Symptoms of Enophthalmos

Recognizing Enophthalmos

Enophthalmos is defined as the backward displacement of a normal-sized eyeball within the orbital socket. This may manifest as a sunken appearance, often accompanied by a deep upper eyelid sulcus and sometimes an apparent drooping of the eyelid (pseudoptosis) 4, 7. Because these changes can be gradual, patients and even clinicians may overlook them initially.

Functional and Cosmetic Symptoms

• Cosmetic: The most noticeable symptom is a “sunken” eye. The deepening of the superior sulcus (the groove above the upper eyelid) often draws the patient’s attention first 4.
• Functional: In some cases, enophthalmos can cause diplopia (double vision) or restrict ocular motility if the underlying cause involves mass effect or fibrosis 1, 4. Eyelid retraction and exposure keratopathy may also occur, leading to dryness, irritation, or even impaired vision if not addressed 4.
• Subtlety and Misdiagnosis: Enophthalmos is frequently subtle; a study found that only 23% of patients were correctly referred with enophthalmos as the diagnosis, highlighting the risk of misdiagnosis 7. This underscores the importance of a thorough and systematic ocular examination.

When Symptoms Signal More

Sometimes, enophthalmos is the first sign of a serious underlying condition, such as a metastatic tumor, chronic sinus disease, or systemic illness 1, 9. In these instances, early recognition can be life-saving. Thus, any new onset of ocular asymmetry, diplopia, or “sunken” eye should prompt detailed evaluation.

Types of Enophthalmos

Enophthalmos is not a single disease but rather a clinical sign with multiple subtypes, each reflecting a different underlying mechanism or cause. Understanding the distinctions among these types is vital for accurate diagnosis and targeted management.

Type	Main Mechanism	Common Contexts	Source(s)
Traumatic	Increased orbital volume	Orbital wall fracture, injury	5, 6, 8, 14
Non-traumatic	Fat atrophy, bone loss, retraction	Aging, systemic disease, tumors	4, 7, 9
Infiltrative	Mass effect or fibrosis	Tumors, metastases	1, 7, 9
Functional	Restriction of orbital tissues	Fibrosis, chronic inflammation	1, 4

Table 2: Types of Enophthalmos

Traumatic Enophthalmos

Traumatic enophthalmos most often results from orbital fractures—especially “blow-out” fractures of the orbital floor or medial wall. The injury leads to increased orbital volume, allowing the globe to sink backward. Displacement or changes in orbital soft tissue, loss of bone, and ligament support are key contributors 5, 6, 8, 14. Post-surgical or post-enucleation changes can also produce this type.

Non-Traumatic Enophthalmos

This category encompasses numerous causes unrelated to trauma. Key mechanisms include:

• Orbital fat atrophy (seen in aging, radiotherapy, scleroderma, or other degenerative processes)
• Bony orbital changes (as in congenital asymmetry, sphenoid wing dysplasia, or chronic sinus disease)
• Retraction due to fibrosis or chronic inflammation 4, 7, 9.

Infiltrative Enophthalmos

Here, the cause is infiltration of the orbit by tumors or metastatic disease, which can either directly displace the globe or lead to fibrosis and contracture. In some cases, the infiltrative process is the initial clue to an underlying systemic malignancy 1, 7, 9.

Functional Enophthalmos

This rare subtype occurs when orbital tissues are pulled back by chronic scarring or contracture, often following inflammation or surgery. Though less common, it can significantly impact ocular function and appearance 1, 4.

Causes of Enophthalmos

The causes of enophthalmos are diverse, spanning traumatic, structural, degenerative, neoplastic, and inflammatory origins. Pinpointing the underlying etiology is essential, as management and prognosis vary widely.

Category	Example Conditions	Mechanism of Enophthalmos	Source(s)
Traumatic	Orbital fractures (“blow-out”)	Increased orbital volume	5, 6, 8, 14
Structural	Orbital asymmetry, sphenoid wing dysplasia	Loss of bony support	2, 4, 7
Degenerative	Fat atrophy (aging, radiotherapy)	Loss of orbital fat	4, 7
Neoplastic	Tumor/metastasis (e.g., breast cancer)	Infiltration, fibrosis	1, 7, 9
Inflammatory	Chronic sinusitis, scleroderma	Retraction, bone loss	4, 7, 9
Vascular	Orbital varix	Volume changes, displacement	7, 9
Infectious	Sinus mucocele (silent sinus syndrome)	Collapse of orbital wall	7, 9

Table 3: Major Causes of Enophthalmos

Traumatic Causes

• Orbital Fractures: The most common cause is trauma, particularly fractures of the orbital floor or medial wall. These injuries increase the orbital volume and allow the eye to sink backward 5, 6, 8, 14.
• Post-Surgical: Enophthalmos can also follow orbital surgery, especially if bone or support structures are removed or not adequately reconstructed.

Structural and Developmental Abnormalities

• Congenital Orbital Asymmetry: Some individuals are born with unequal orbital sizes, predisposing to enophthalmos 7.
• Sphenoid Wing Dysplasia: Seen in neurofibromatosis type 1 (NF1), where underdevelopment or absence of the sphenoid wing compromises orbital support, leading to gradual enophthalmos 2, 7.

Degenerative and Fat Atrophy

• Aging: Loss of orbital fat with age is a benign but common contributor 4.
• Radiotherapy: Post-irradiation atrophy, especially after treatment for orbital or sinus tumors, can cause progressive fat loss and enophthalmos 7.
• Scleroderma: Localized scleroderma may cause fat and soft tissue atrophy in the orbit 7.

Neoplastic and Infiltrative Disorders

• Orbital Tumors: Both primary and metastatic tumors can infiltrate the orbit, causing fibrosis and retraction. Notably, breast cancer metastases are a well-documented cause 1, 7, 9.
• Silent Sinus Syndrome: Chronic maxillary sinus atelectasis can collapse the orbital floor, resulting in enophthalmos 9.

Inflammatory and Vascular Causes

• Chronic Sinusitis: Long-standing inflammation can erode bone and alter orbital volume 9.
• Orbital Varix: Abnormal vascular channels can change in size, occasionally leading to globe displacement 7, 9.

Rare and Miscellaneous Causes

Other causes include maxillary mucoceles, microphthalmos (developmentally small eye), and post-irradiation changes 7. In all cases, careful assessment is needed to distinguish among the possibilities.

Treatment of Enophthalmos

Treating enophthalmos requires not just addressing the cosmetic concern but also the underlying cause. Management strategies range from observation and monitoring to advanced surgical reconstruction. The chosen approach depends on the type, cause, severity, and patient needs.

Approach	Indication	Method/Technique	Source(s)
Observation	Mild, stable cases	Clinical monitoring	4, 9
Treat Underlying Cause	Tumor, infection, inflammation	Medical/surgical management	1, 9
Surgical Repair	Traumatic, structural defects	Orbital reconstruction, implants	5, 6, 8, 14
Volume Augmentation	Fat atrophy, tissue loss	Autologous/cartilage grafts	14
Illusion Techniques	Limited surgical risk	Lid surgery, contour adjustment	8
Long-term Follow-Up	Progressive conditions	Serial imaging, ophthalmic exams	2, 4

Table 4: Main Treatment Approaches for Enophthalmos

Observation and Conservative Management

• Mild or Non-Progressive Cases: When enophthalmos is mild, stable, and not functionally significant, observation with regular follow-up may suffice 4, 9. This is especially true in elderly patients with age-related fat loss.

Treating the Underlying Cause

• Neoplastic: Infiltrative causes such as metastatic tumors require systemic therapy (e.g., chemotherapy, radiotherapy) and sometimes orbital surgery. Early detection is key, as enophthalmos may be the first sign of a life-threatening disease 1, 9.
• Infectious/Inflammatory: Sinus disease or inflammation should be treated medically or surgically to prevent further orbital changes 9.

Surgical Reconstruction

• Orbital Volume Restoration: In traumatic cases or those with significant structural defects, surgery aims to restore orbital volume. This may involve:
  • Reduction of herniated tissue
  • Implantation of alloplastic (synthetic) or autogenous (patient’s own) material to rebuild the orbital floor or wall 5, 6, 8.
• Cartilage Grafting: For chronic or severe cases, autologous diced cartilage grafts can be used to augment orbital volume during reconstructive surgery. This technique has shown good functional and aesthetic outcomes 14.

Volume Augmentation and Illusion Techniques

• Soft Tissue Augmentation: In cases of fat atrophy, volume can be restored with fat grafts or cartilage 14.
• Palpebral Fissure and Contour Adjustment: When surgery poses risk to vision, alternative lid or contour procedures can create the illusion of normal globe position without altering orbital volume 8.

Long-term Monitoring

• Progressive Disorders: Conditions like sphenoid wing dysplasia in NF1 can progress over years. Regular imaging and clinical assessment are necessary to monitor for changes and intervene as needed 2, 4.

Key Considerations

• Functional Vision: Preservation of vision is paramount. Some reconstructive procedures risk compromising the eye, so the risks and benefits must be carefully weighed 8.
• Timely Intervention: Early surgical intervention after trauma may prevent the development of late enophthalmos, especially when CT imaging predicts at-risk cases 6.
• Multidisciplinary Care: Enophthalmos often requires coordination between ophthalmology, otolaryngology, neurosurgery, oncology, and plastic surgery, particularly in complex or systemic cases 1, 9.

Conclusion

Enophthalmos is a deceptively subtle sign with a broad differential diagnosis and significant implications for patient health and quality of life. Understanding its various forms, causes, and management options ensures the best possible outcomes for affected individuals.

Key Takeaways:

• Symptoms include a sunken eye, deep upper eyelid sulcus, pseudoptosis, diplopia, and possible motility issues.
• Types of enophthalmos are classified as traumatic, non-traumatic, infiltrative, and functional, each with distinct mechanisms.
• Causes range from orbital trauma and congenital anomalies to tumors, fat atrophy, and chronic inflammatory or vascular conditions.
• Treatment is tailored to the cause and severity, spanning observation, medical management, surgical reconstruction, and volume augmentation, with a focus on preserving function and appearance.

Prompt recognition and a multidisciplinary approach are central to effective care in patients presenting with enophthalmos.