Enophthalmos (posterior displacement of the globe of the eye) after orbital trauma?

From the Guidelines

Enophthalmos after orbital trauma should be surgically corrected if it causes functional or aesthetic concerns, with the optimal timing of repair being within 2 weeks for cases with significant fat or periorbital tissue entrapment, large floor fractures, hypoglobus, and progressive infraorbital hypoesthesia, as recommended by the most recent guidelines 1. The surgical procedure involves:

• Accessing the orbital floor through a transconjunctival or subciliary incision
• Identifying and repairing any orbital floor fractures
• Placing an implant (e.g., porous polyethylene, titanium mesh) to restore orbital volume
• Carefully repositioning the globe Post-operative care includes:

• Antibiotic eye drops (e.g., moxifloxacin 0.5%, 4 times daily for 1 week)
• Oral antibiotics (e.g., amoxicillin/clavulanate 875/125 mg, twice daily for 5-7 days)
• Cold compresses for the first 48 hours
• Head elevation while sleeping for 1 week Patients should be monitored for complications such as infection, implant malposition, or persistent diplopia, with follow-up appointments at 1 week, 1 month, and 3 months post-surgery being typical, as suggested by the adult strabismus preferred practice pattern 1. The use of CT orbits is recommended for evaluating orbital trauma, as it is the most accurate method in detecting fractures and can provide information for the detection of soft tissue injuries, hemorrhage, and presence of an intraocular foreign body, according to the American College of Radiology 1. In cases where enophthalmos is not severe, observation may be considered, with a short burst of oral steroids potentially hastening recovery and uncovering strabismus that will persist despite resolution of orbital edema/hematoma, as noted in the adult strabismus preferred practice pattern 1. However, delayed repair may be beneficial for restrictive strabismus and unresolved enophthalmos, as stated in the adult strabismus preferred practice pattern 1. It is essential to weigh the benefits and risks of surgical intervention, considering the individual patient's circumstances and the potential for complications, to prioritize morbidity, mortality, and quality of life as the outcome.

From the Research

Enophthalmos after Orbital Trauma

• Enophthalmos, or posterior displacement of the globe of the eye, can occur after orbital trauma, resulting in esthetic and functional morbidity 2.
• A study found that enophthalmos greater than 2 mm should be considered clinically relevant 2.
• The relationship between post-traumatic enophthalmos (PE) and orbital volume (OV) has been assessed, with a mean enophthalmos of 0.80 mm after a 1-cm3 increase in the OV 2.

Prediction and Prevention of Enophthalmos

• Predicting when orbital wall displacement will lead to clinically relevant enophthalmos has been notoriously difficult 2, 3.
• Measurement of the orbital volume could have a role in the decision for surgical or conservative treatment 2.
• Most cases of post-traumatic enophthalmos could be prevented through careful reconstruction during the first operation 3.
• Delayed correction of post-traumatic enophthalmos could be a possible reparative procedure if sufficient release of scar tissue, accurate repositioning of the dislocated orbital bones, and proper intraorbital grafting are performed 3.

Treatment and Management of Enophthalmos

• Treatment modalities and methods of approach are adapted according to the severity of the orbital deformities 4.
• Minor complications of enophthalmos treatment include ectropion, entropion, dystopia, diplopia, and residual enophthalmos 4.
• Rare but severe complications such as intraconal misplacement of the bone graft or retrobulbar hemorrhage with subsequent blindness may be encountered 4.
• The success of enophthalmos treatment depends on adequate dissection and mobilization of the displaced soft tissue, correct repositioning of the dislocated or malunited bony orbit, and proper intra-orbital grafting 4.

Predictors of Delayed Enophthalmos

• A systematic review identified five factors that may affect the development of delayed enophthalmos: linear measurements, involvement of specific intraorbital structures, rounding of the inferior rectus muscle, orbital fracture area, and volumetric analysis stratified by fracture site 5.
• There is a paucity of level I and II evidence driving the current management of orbital fractures that may lead to delayed enophthalmos, and additional prospective trials are needed to improve the quality of care for this patient population 5.