Facial plast Surg 2017; 33(06): 606-612
DOI: 10.1055/s-0037-1608781
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Secondary Repair of Posttraumatic Enophthalmos and Extraocular Movement Disorders

Kausar Ali1, Kelly P. Schultz1, Douglas P. Marx2, Larry H. Hollier1, Edward P. Buchanan1
  • 1Department of Surgery, Baylor College of Medicine, Houston, Texas
  • 2Cullen Eye Institute, Baylor College of Medicine, Houston, Texas
Further Information

Address for correspondence

Larry H. Hollier, MD
Department of Surgery, Baylor College of Medicine
6701 Fannin, Suite 610.00, Houston, TX 77030-3411

Publication History

Publication Date:
01 December 2017 (online)

 

Abstract

Enophthalmos, or recession of the eye posteriorly and inferiorly, is a potential sequela of orbital trauma and a source of significant cosmetic and functional concern. Late enophthalmos occurs when early reconstruction of the bony orbit fails to completely restore normal orbital shape and volume, resulting in aesthetic deformity and persistent diplopia. In this article, we provide a framework for evaluation of posttraumatic enophthalmos and outline the surgical principles of secondary repair necessary to optimize globe position. With implementation of proper craniofacial exposure, osteotomy, and orbital reconstruction, surgeons may achieve significant improvement in both the aesthetic and functional sequelae of enophthalmos.


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Posttraumatic enophthalmos is a disturbance in the balance between orbital soft tissue contents and bony volume, resulting in posterior displacement of the ocular globe.[1] [2] Disfiguring enophthalmos, characterized by a flattened malar eminence, pseudoptosis, accentuated supratarsal fold, and sunken globe, is both a significant aesthetic concern for patients and a reconstructive challenge for physicians.[2] [3]

Early intervention is crucial to prevent posttraumatic enophthalmos; however, diagnoses are often missed in the acute period due to significant soft tissue edema or concomitant life-threatening injuries.[4] In other cases of late enophthalmos, orbital displacement is acutely diagnosed but inaccurately corrected during primary surgery.[5] Debilitating diplopia may subsequently occur secondary to extraocular muscle entrapment and soft tissue displacement. A framework for the evaluation of posttraumatic enophthalmos and the proper technique of secondary repair may improve these patients' initial management and surgical outcomes.

Anatomic Considerations

The functional and aesthetic considerations in posttraumatic enophthalmos correction necessitate a thorough understanding of the bony orbital anatomy. The orbital is best conceptualized as a pyramid or cone on an elliptical base, composed of a roof, a floor, lateral and medial walls, a base, and an apex.[1] [6] [7] The complex may be further described in three anteroposterior sections.[1] [6]

The floor of the orbital complex, formed by the maxillary and zygomatic bones, serves as the roof of the maxillary sinus and is the most commonly injured orbital structure, followed by the medial orbital wall and the lateral orbital wall.[1] [7] The medial orbital wall is formed by the lacrimal bone, orbital portion of the frontal bone, and orbital plate of the ethmoid bone, which together separates the orbit and the anterior sphenoid sinus.[8] The thick lateral orbital wall is formed by the frontal process of the zygomatic bone and orbital surface of the greater wing of the sphenoid bone.[7] The lateral wall is a large determinant of the anteroposterior location of the globe due to the direct alignment of the eye's vertical axis with the lateral orbital rim.[2] The roof of the orbit is a thin plate of frontal bone that acts as a barrier between the orbit and the brain ([Fig. 1]).[7]

Zoom Image
Fig. 1 Illustration of the orbit, including globe position, muscles, anterior and posterior ethmoid arteries, and orbital bones.

Traumatic forces most often damage the anterior and middle thirds of the orbit.[6] The thick anterior third of the bony orbit begins at the orbital rim and gradually thins as it extends posteriorly. This section has a concave shape to accommodate the contour of the eyeball and surrounding soft tissue. Disturbances to the anterior segment often result in an isolated alteration of ocular projection due to a lack of significant change in the volume of the bony orbit.[3]

The middle third of the orbit is composed of the thinnest bone and functions largely as a protective cushion for the globe and the optic nerve.[1] Within this middle section, the orbital floor and medial wall create an “inferiomedial bulge” posterior to the globe that plays a large role in globe position. The most posterior third of the orbit is composed of thicker bone housing the inferior and superior orbital fissures and the optic foramen, through which the optic nerve passes at the junction of the orbital roof and medial wall.[6] [7]

The globe is suspended in a sling of supportive ligaments that insert between the walls of the bony orbit. The medial and lateral canthal ligaments are the strongest components of the ligamentous sling and function largely to keep the eyelid tangent to the globe.[6] The complex interconnections between ligaments prevent full understanding of the distinct roles of individual structures, but it is clear that, together, they provide insufficient forward force to prevent posterior drift of the globe in cases of orbital trauma.[9]

Orbital fat, thought to play a contributory role in globe position and enophthalmos, is distributed in both the extramuscular and intramuscular orbital compartments. This tissue increases in density and is located almost entirely intraconally posteriorly, leaving the extraocular muscles in close proximity to the orbital walls.[8]

To properly restore the integrity of the bony orbit and avoid collateral damage during posttraumatic enophthalmos repair, the surgeon must be aware of the delicate relationship of the orbit to various orbital structures as well as the many factors contributing to globe position.


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Mechanisms of Enophthalmos

Enophthalmos was once thought to be the result of orbital fat atrophy and scar contracture; however, current literature suggests that in cases of posttraumatic enophthalmos, the volume of soft tissue is relatively stable while the volume of the bony orbit increases significantly.[9] [10] With this increase in orbital volume, the globe is able to recede posteriorly into the enlarged and rounded-out retrobulbar space. For posttraumatic enophthalmos to occur, the injury must be of significant force to cause a disturbance in the bony architecture, with subsequent ligament compromise and displacement of intramuscular orbital soft tissue.[8] [10]

Orbital trauma often results in a “blow-out” fracture involving the medial orbital floor and inferior medial wall.[1] In this instance, the conical shape of the orbital complex becomes more spherical, increasing the orbital volume and allowing posterior and inferior displacement of the globe. Herniation of intramuscular cone fat through defects in the bony orbit reduces the globe's forward support and further enables its posterior displacement.[8]

Enophthalmos can occur in the setting of isolated orbital fractures or more complex facial fractures. Zygomaticomaxillary fractures produce a significant risk for enophthalmos as they involve displacement of the lateral orbital wall and rim, resulting in enlargement of the bony orbit posterior to the globe's equator. Naso-orbital-ethmoidal (NOE) fractures can also disrupt the bony architecture of the conical orbit, leading to increased orbital volume and globe recession.[10]

Posttraumatic enophthalmos can manifest early or late. Early cases occur immediately after trauma as a result of orbital wall destabilization and herniated soft tissue contents. Late cases result when there is either inadequate primary repair or delayed repair due to missed diagnosis, inability to operate secondary to concomitant life-threatening injury, or patient preference.[10] Suboptimal outcomes of primary repair are often due to imprecise bony union, improper graft or implant contouring and sloping, insufficient posterior extension of bony repair to properly support the globe, or failure to address the bony structures of the orbit entirely.[10] In some instances, enophthalmos can manifest gradually as postoperative and posttraumatic edema subsides, and surrounding orbital tissue remodel.[11] These delayed cases are particularly difficult to repair due to soft tissue scarring and contracture in the affected area.[1] [10]


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Clinical Evaluation

Physical Examination

A thorough physical assessment is the first step in the evaluation of a patient for potential enophthalmos. Primary examination should begin with an overall facial assessment of the brows, lids, and medial and lateral canthi both individually and in relation to the contralateral structures.[3] Narrowing of the palpebral fissure, upper lid ptosis, and deepening of the superior tarsal fold are clinical indicators that should increase suspicion for enophthalmos ([Fig. 2]).[1] Globe position should then be examined in relation to the orbital rim and mid-line facial structures.[6] Relative anteroposterior position of the globe and hypoglobus is best assessed from an inferior angle ([Fig. 3]). In many patients with facial trauma, the clinician may observe the migration of the soft tissue of the cheek inferiorly and medially, accentuating the posterior displacement of the malar eminence and apparent enophthalmos.[3] [6] Enophthalmos is clinically noticeable with at least 2 mm of displacement and can be disfiguring with greater than 5 mm of recession. Compromise of more than 25% of the orbital floor also results in notable enophthalmos.[1]

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Fig. 2 Anterior-posterior photograph of a patient with left orbital posttraumatic enophthalmos. Note the narrowing of the palpebral fissure and the appearance of ptosis as compared with the right eye.
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Fig. 3 Inferior or worm's-eye view of the face to reveal enophthalmos of the left eye. Note the difference in globe projection between the left and right eyes.

Hertel exophthalmometry is useful in defining the degree of enophthalmos once edema has subsided. This tool measures the distance between the lateral orbital rim and anterior corneal surface, which is approximately 16–17 mm in normal individuals.[1] Globe recession is defined as mild (2 mm), moderate (3–4 mm), or severe (greater than 5 mm), but measurements are only accurate if the lateral orbital rim is intact.[4] [6] In cases of a displaced lateral orbital rim, Naugle exophthalmometry is used to compare relative differences in globe position between the normal and affected eye.[10] Soft tissue swelling may compensate for globe recession initially and make enophthalmos difficult to clinically detect, so the examiner must wait until edema has subsided to obtain accurate exophthalmometry measurements.

After evaluation of globe position, the physician should proceed with a functional examination. A preoperative ophthalmology consult is often indicated. The patient should be assessed for diplopia, visual acuity and field disturbance, relative afferent pupillary defect, limitation of extraocular muscle movements, orbicularis oculi function, lacrimal system obstruction, and paresthesias, particularly in the distribution of the infraorbital nerve.[4] Diplopia on peripheral gaze and applanation tonometry showing an increased intraocular pressure greater than 4 mm Hg in the direction of limited gaze raise concern for soft tissue entrapment and necessitate further investigation.[1] [10]


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Imaging

Imaging is routine in trauma workups, particularly when the physical examination is concerning for enophthalmos or facial fracture. Cases of enophthalmos have characteristic deformities on plain radiography and computed tomography (CT), but minimal information regarding the extent of injury is ascertained from plain films alone. CT imaging is the gold standard in diagnosis of posttraumatic enophthalmos and identification of injuries that may progress to enophthalmos.[9] Coronal, sagittal, and axial views in thin sections of the face are best for assessing position of a deformed globe and sites of orbital defects.[4] Common findings on imaging include disruption in the orbital floor, enlargement of the posterior orbit, and soft tissue entrapment; however, enlargement may be seen without bone defects, and these cases are consistently undertreated.[9]

Volume analysis of CT images will reveal the severity of injuries. Quantitative measurement of the degree of bony and soft tissue displacement may be estimated in three dimensions by stereo X-ray photogrammetry (stereology). Dimensions of the orbital soft tissue are often in range of preinjury values secondary to edema or scar tissue deposition in retrobulbar tissues, while the size of the bony orbit increases significantly in proportion to the degree of clinical enophthalmos ([Fig. 4]).[9]

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Fig. 4 Coronal CT image of orbital differences after traumatic insult.

Other imaging modalities may confirm CT findings, but are not necessary for diagnosis. Three-dimensional multiplanar reconstruction can illustrate changes in ligament and fat displacement and aids in surgical planning,[8] [10] while magnetic resonance imaging (MRI) can reveal muscular fibrosis in cases of persistent diplopia and enophthalmos following initial fracture repair.[12]


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Goals and Indications of Repair

The primary goal of enophthalmos repair is the restoration of orbital volume and globe position to the premorbid state. Careful preoperative planning allows the surgeon to conceptualize the surgical approach necessary to stabilize the orbit, correct orbital volume, and shape, and reposition the globe within the reconstructed space.

Surgical repair is optimal 1 to 2 weeks after the inciting trauma when periorbital edema has diminished.[13] Aesthetic and functional concerns of enophthalmos are best addressed early after diagnosis to avoid complications of delayed repair, such as fibrosis, soft tissue changes, and malunion.[11] The significant scarring associated with long-standing globe displacement and previous reconstructive surgery is a challenge for secondary reconstruction. In these cases, operative reports describing the primary surgery and preoperative imaging to locate implants or grafts are critical in creating a reconstructive strategy.[1] [11]

Surgical management of primary enophthalmos is indicated in patients with an orbital floor disruption exceeding 2 cm in diameter, bony volume changes exceeding 5% of orbital volume, significant fat and soft tissue displacement, or in those with clinical evidence of muscle entrapment.[1] [9] [12] Indications for surgical repair of late enophthalmos, due to delayed diagnosis or suboptimal primary repair, include those of acute cases as well as unacceptable facial asymmetry or diplopia.[11] Patients with orbital displacement greater than 2 mm within six weeks of injury or diplopia that does not clear within two weeks of injury should be considered for surgery.[13] Ideally, the surgeon should wait for postoperative edema from a primary reconstruction to resolve before performing the secondary repair. This allows accurate assessment of the patient's degree of residual enophthalmos and the amount of correction necessary to restore both function and aesthetic appearance.[11]


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Surgical Technique

Secondary enophthalmos repair technique will vary with the cause of late correction, the size and location of initial fracture, and the reconstructive materials used in the primary repair.[4] In all cases, the reconstruction sequence includes exposure of previously placed implants and any residual bony orbital defects, orbital rim repair if necessary, reintegration of entrapped soft tissue, reconstruction of orbital wall defects, and soft tissue repair.

Exposure

Adequate surgical exposure and subperiosteal dissection are necessary for complete evaluation of the deformity and repair. Several incision options are available depending on the structures requiring visualization and reconstruction. Orbital floor and medial orbital wall fractures are usually accessed via a transconjunctival incision. A transcaruncular or retrocaruncular extension will increase exposure of the medial orbital wall.[1] Transconjunctival incisions are popular as they do not leave a conspicuous scar and can be used for endoscopic visualization and safe dissection of posterior regions of the orbit that are otherwise difficult to evaluate intraoperatively.[14] A lower lid subciliary incision, often used in blepharoplasty, is an alternative technique used to expose large orbital floor defects; however, this approach can be accompanied by an increased risk of ectropion and visible scar formation.[1]

The superior orbital rim and NOE segments are exposed via a coronal incision. This method is dependable for direct access to the lateral orbit, medial orbit, supraorbital rim, and zygomatic arch, but drawbacks include potential damage to the frontal branch of the facial nerve and a large scar within the hair bearing scalp.[3] [10]

More complex facial injuries requiring exposure of multiple sites around the orbit will require not only the common orbital approaches, but also a coronal incision and an upper gingival buccal sulcus incision.[6] These multiple approaches are common in patients who sustain orbital fractures that are associated with other facial fractures.


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Orbital Rim Repair

Orbital rim repair is a critical first step in orbital reconstruction since small discrepancies can create large increases in orbital volume and subsequent globe recession.[15] In secondary repair, malpositioned orbital rim segments should be osteotomized, realigned, and stabilized with plates and screws to provide a foundation for orbital wall reconstruction.[1] [10] The zygomatic arch and zygomaticosphenoid interface are critical landmarks to position three-dimensionally as they reflect the accurate restoration of the lateral orbit, malar prominence and facial width.[1] [6] The maxillary buttresses and frontal bone may also require rigid fixation with miniplates depending on the extent of the injury.[16] If the injury is severe enough to cause extensive comminution or malposition, interpositioned bone grafts or alloplastic implants can be fixated to restore orbital rim continuity and stability.[1] [2]


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Reintegration of Entrapped Orbital Contents

Prior to any reconstruction of the internal orbit, herniation of extraocular muscle and fat through orbital wall defects should be reduced. Employment of Loupe magnification during subperiosteal dissection ensures reintegration of all soft tissue orbital contents without damage to surrounding lacrimal structures.[1] Herniated orbital fat can heal to the mucosa of the paranasal sinuses, making dissection in delayed repair particularly extensive and strenuous. Temporary placement of silicone sheeting between the soft tissues and the orbital defect prevents reherniation and facilitates placement of the graft or implant without entrapment of extraocular muscles and orbital fat.[1]


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Orbital Wall Reconstruction

Once the orbital rim is realigned and orbital contents are mobilized, the internal orbit can be reconstructed to premorbid condition. Proper technique involves isolation of intact bony edges surrounding the defect and use of a graft or implant to bridge the gap.[3] This reestablishes continuity in the orbital wall, provides adequate mechanical support for orbital soft tissues, and achieves the desired volumetric effect for enophthalmos repair. In cases of secondary repair, it may be necessary to osteotomize or refracture orbital wall components that underwent malunion to properly restore normal orbital shape and volume.[1] [10]

Both autogeous grafts and alloplastic implants may be employed in orbital wall reconstruction.[17] The choice of construct will depend on the size and location of the defect, the curvature required to restore orbital shape, and the risk of implant infection (determined by the degree of paranasal sinus exposure).[3]

Autologous reconstruction involves harvested bone or cartilage grafts. Bone grafts add stability to the bony orbit and carry a low risk of infection or extrusion.[1] These grafts are fixed to the orbital rim with lag screws, small plates, or wires, and can be layered for additional thickness in the correction of orbital volume;[10] however, revascularization of the bone graft allows integration into the orbital skeleton and may result in unexpected postoperative distortion.[3] Grafts taken from areas of dense cortical bone, such as the calvarium, tend to resorb less than grafts composed of predominantly cancellous bone, such as the iliac crest, but can be too rigid to properly mold and carry a risk of soft tissue impingement.[17] Dense bone must be sectioned in to pieces and fixed together by malleable titanium microplates to create the desired curves of the orbit.[10] Other bone donor sites include the ribs,[17] nasal septum,[18] and anterior maxillary sinus wall.[19] Donor site morbidity should always be considered prior to graft harvest.

Autologous costal cartilage grafts may be used in severe cases of late enophthalmos.[17] [20] Small cartilage pieces allow for fine adjustments in orbital volume and globe projection, but carry a risk of postoperative resorption. To best recreate the original orbital shape and restore orbital stability, sliced wedges of cartilage are positioned in the subperiosteum of the orbital walls.[17] Cartilage chips may also be placed posterolaterally to encourage forward globe movement in cases where the globe is displaced primarily posteriorly without a vertical component. Preoperative calculations will ensure that an adequate amount of cartilage graft is harvested to completely correct globe recession (5 mL of graft volume results in ∼3.5 mm of forward globe movement).[17] Surgeons may elect to overcorrect enophthalmos by approximately 2–3 mm to compensate for postoperative periorbital edema and resorption of autologous grafts.[2] [4] [14]

When autologous grafting cannot be performed, alloplastic implants are an acceptable alternative. They have the advantage of being easily contoured to the curved orbital wall and prefabricated from three-dimensional preoperative imaging. Although alloplastic implants come with the risk of extrusion or displacement in the orbit, they do not resorb and can provide reliable shape and volume. Commonly used alloplastic materials include tantalum, polytetrafluoroethylene, silicone, titanium, and porous polyethylene.[10] The alloplastic matrix of porous polyethylene is engineered to undergo fibrovascular integration, reducing the graft's risk of migration.[1] Wedged slices of porous polyethylene are commonly inserted behind the globe or over a primary implant to provide the volume correction necessary for late enophthalmos and hypoglobus.[11]

A stable foundation for fixation of alloplastic implants or bone grafts may not be present in cases of significant orbital comminution.[16] For these complex injuries, reconstruction requires a stepwise approach and use of a malleable, metallic implant, such as titanium mesh.[21] The titanium implant is molded to reproduce the normal anatomic curvature of the orbital cone and placed over a large defect in the bony orbit. Once fixated, the mesh serves as a foundation for the surgeon to reconstruct the bony orbit with secondary bone grafts.[16] This technique effectively converts large orbital injuries into multiple, easily manageable defects and achieves the desired volumetric effect necessary for enophthalmos repair.


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Soft Tissue Repair

For optimal functional and aesthetic results, soft tissue elements must be appropriately addressed following skeletal reconstitution of the orbit. Freedom of orbital soft tissue contents should be checked throughout surgery via forced duction test.[21] Subperiosteal dissection around the pathologic areas prevents tethering of the globe secondary to scar contracture.[3] [4] Prior to closure, all soft tissues and extraocular muscles should be resuspended in an effort to preserve ocular motility and orbital support.[10] The lateral and medial canthi should be reapproximated if a canthotomy was performed.[3] A Frost stitch is recommended to minimize the risk of ectropion (from subciliary incisions) or entropion (from transconjunctival incisions).[10]


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Alternative Techniques of Repair

Rapid advancements in surgical tools and techniques have introduced new accurate methods of posttraumatic enophthalmos repair that are not currently standard practice. Promising alternative techniques include prefabrication of titanium mesh implants from images of the contralateral orbit, use of navigation guided surgery in implant positioning, periorbital soft tissue augmentation, and incremental tissue expansion.

Prefabricated titanium mesh implants, custom designed from mirrored three-dimensional CT images of the normal contralateral orbit, have been shown to reduce orbital volume by 65% and correct the degree of enophthalmos by at least 50%.[22] Posttraumatic enophthalmos correction can be done using medical modeling software to create a custom built implant. The implant is made based on the orbital volume differences between the two eyes and fashioned to fit exactly into the deformity ([Figs. 4] [5] [6] [7]). The use of navigation-guided surgery in positioning of titanium mesh implants has proven to be more accurate than traditional approaches. He et al[15] report a 91% improvement in globe projection using navigational technology compared with 74% improvement with the traditional repair. Navigational technology may also be particularly useful in precise three-dimensional alignment of the zygoma in complex cases lacking a foundation for accurate orbital wall reconstitution.[23]

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Fig. 5 3D reconstruction of posttraumatic enophthalmos. The deformity is mainly located where the medial and inferior orbital walls meet.
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Fig. 6 Coronal Image with reconstructed orbital walls based on the contralateral orbit.
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Fig. 7 3-D reconstruction with custom implant inserted into the defect.

Fracture reduction and use of alloplastic orbital implants do not always completely correct enophthalmos, particularly in secondary repair operations. In these cases, augmentation of periorbital soft tissue may be necessary to improve globe projection. Periocular dermal filler injections, composed of hyaluronic acid or calcium hydroxylapatite, may be used in cases of minor facial asymmetry (less than 3 mm globe displacement) to provide bulk in orbital volume.[11] Alternatively, Cervelli et al[24] suggest the use of autologous fat transplantation for retrobulbar volume augmentation.

Incremental tissue expansion has also been described in correction of delayed posttraumatic enophthalmos. Once desired orbital projection is reached, the subperiosteal tissue expander is replaced with cancellous iliac bone to maintain the volumetric effects.[25] Incremental tissue expansion can precisely correct orbital volume to within 1 mm of contralateral eye position, as described by Honda et al,[25] but there is concern for increased ocular pressure with subsequent compressive optic neuropathy and peripheral vision loss.[26] Therefore, careful expansion and long-term follow-up are necessary to ensure the preservation of vision and ocular motility.


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Complications

Secondary repair of enophthalmos does not require routine postoperative imaging.[4] [11] Clinical examination and long-term follow up are often sufficient in monitoring the degree of correction and the development of potential complications.

The most concerning complications of enophthalmos repair are functional in nature. Such complications include optic nerve injury, retrobulbar hemorrhage, extraocular muscle injury, persistent diplopia, lacrimal dysfunction, and posttraumatic neurologic dysfunction.[10] Retrobulbar hemorrhage often manifests as severe eye pain, proptosis, elevated intraocular pressure, vision loss, and a relative afferent pupillary defect. Urgent orbital decompression via lateral canthotomy or inferior cantholysis is required to avoid permanent blindness.[11] In some cases of overcorrection, the increased postoperative orbital pressure may result in compressive optic neuropathy and extraocular dysmotility, necessitating immediate surgical attention.[20]

When postoperative diplopia persists, the surgeon should allow six months for spontaneous return of ocular motility before considering revision surgery. Persistent diplopia is difficult to correct in a repeat procedure due to significant fibrosis and limited globe mobility associated with a long-standing malpositioned globe.[10]

The need for revision procedures due to asymmetry and imperfect aesthetic results is the most common, expected complication of enophthalmos repair. Recurrent enophthalmos may manifest several months after repair secondary to inadequate scar release around the fractures sites, insufficient reconstruction of the orbital shape, soft tissue atrophy, or scar contracture.[4] Proptosis can also occur from overcorrection but is less common due to some degree of soft tissue compressibility and fat atrophy.[17] Practically, it is better to err on the side of overcorrection since slight exorbitism is more aesthetically acceptable than enophthalmos.


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Conclusion

Posttraumatic enophthalmos presents a significant aesthetic and functional concern. In cases requiring secondary repair, it is imperative to recreate the premorbid conical shape and volume of the orbit in an effort to restore globe position and ocular motility. The unique geometry of the internal orbit warrants precise reconstructive techniques, as small errors in repair lead to suboptimal cosmetic and functional results. Successful reconstruction requires adequate exposure, mobilization of orbital soft tissue, and proper placement of implants or grafts that stabilize the internal orbit while providing the volume augmentation necessary for correction of enophthalmos.


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No conflict of interest has been declared by the author(s).


Address for correspondence

Larry H. Hollier, MD
Department of Surgery, Baylor College of Medicine
6701 Fannin, Suite 610.00, Houston, TX 77030-3411


Zoom Image
Fig. 1 Illustration of the orbit, including globe position, muscles, anterior and posterior ethmoid arteries, and orbital bones.
Zoom Image
Fig. 2 Anterior-posterior photograph of a patient with left orbital posttraumatic enophthalmos. Note the narrowing of the palpebral fissure and the appearance of ptosis as compared with the right eye.
Zoom Image
Fig. 3 Inferior or worm's-eye view of the face to reveal enophthalmos of the left eye. Note the difference in globe projection between the left and right eyes.
Zoom Image
Fig. 4 Coronal CT image of orbital differences after traumatic insult.
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Fig. 5 3D reconstruction of posttraumatic enophthalmos. The deformity is mainly located where the medial and inferior orbital walls meet.
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Fig. 6 Coronal Image with reconstructed orbital walls based on the contralateral orbit.
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Fig. 7 3-D reconstruction with custom implant inserted into the defect.