Delayed onset enophthalmos and hypoglobus mimicking silent sinus syndrome following midface trauma

Craniomaxillofacial trauma is primarily diagnosed and managed by oral and maxillofacial surgeons. Among the cases encountered, midface fractures involving orbital walls are highly prevalent. In these fractures, involvement of the orbital walls, particularly floor of the orbit, can lead to considerable aesthetic and functional limitations. From a maxillofacial perspective, indications for surgical repair of orbital floor encompass marked decrease in ocular motility, fracture affecting more than 50% of surface area, an increase in orbital volume exceeding 18% and enophthalmos greater than 2 mm. In the absence of these discernible signs, surgical intervention is not generally indicated. However, in this case, an early adolescent with a history of midface trauma and minimal orbital floor fracture 8 months earlier presented with progressively delayed onset enophthalmos and hypoglobus closely resembling features of silent sinus syndrome. The enophthalmos and hypoglobus were corrected by placing custom-made non-resorbable high-density polyethylene implant in the orbital floor. Postoperative follow-up demonstrated aesthetically and functionally satisfactory outcomes.

Ten-Year Follow-Up of Orbital Volume Augmentation With Calcium Hydroxyapatite Filler in Postenucleation Socket Syndrome

PURPOSE

To describe the efficacy and persistence of injectable calcium hydroxyapatite (CAHY) to correct orbital volume deficit in postenucleation socket syndrome.

METHODS

An observational study was conducted as a clinical review of all patients in the authors' practice who received injectable CAHY placed in the extraconal and intraconal space to increase orbital volume with a 10-year follow up. The amount of CAHY to be injected was defined according to the degree of orbital volume deficit. Patients previously treated with radiotherapy or with a conjunctival fornix insufficient to accommodate the external prosthesis were excluded. All the patients with at least 10 years of follow up were included in the study.

RESULTS

Thirty-one postenucleation socket syndrome patients received injectable CAHY for orbital volume augmentation, with a 10-year follow up. The mean amount of preoperative relative enophthalmos measured by Hertel's exophthalmometry was 14.16 ± 2.15. An increase in the mean orbital volume of 3.35 ± 0.91 at 6 months and 2.97 ± 1.35 at 10 years was obtained. The mean follow-up was 219 ± 18 months (range, 184-240). Patients demonstrated clinical and cosmetic improvement that was observed to continue for 10 years. The complications were peribulbar ecchymosis, 2 extrusions of the internal prosthesis, and 2 ptosis.

CONCLUSIONS

Injectable CAHY provides safe, simple, repeatable, and cost-effective technique to treat volume deficiency in the enophthalmic orbit in the long term. The volume augmentation obtained with this semipermanent filler demonstrated a lasting effect in the orbit with negligible loss of volume at 10 years.

Orbital Vascular Malformations: Relationship Between Enophthalmos and Clinically Apparent Distensibility with Valsalva

PURPOSE

Determining the hemodynamic characteristics of an orbital vascular malformation is a critical step in management. The purpose of this study is to assess the relationship between enophthalmos and clinically apparent distensibility of orbital vascular malformations, to optimize imaging and treatment.

METHODS

In this cross-sectional cohort study consecutive patients at a single institution were screened for study entry. Data extracted included age, sex, Hertel measurements, presence or absence of distensibility during the Valsalva maneuver, whether lesions were primarily venous or lymphatic based on imaging, and location of the lesion relative to the globe. Enophthalmos was defined as ≥ 2 mm difference from the opposite side. Parametric and nonparametric statistics were used, and linear regression was performed to examine factors predictive of Hertel measurement.

RESULTS

Twenty-nine patients met the inclusion criteria. Relative enophthalmos ≥2 mm was significantly associated with distensibility ( p = 0.03; odds ratio = 5.33). Distensibility and venous dominant morphology were the 2 most important factors associated with enophthalmos on regression analysis. The relative position of the lesion anterior or posterior to the globe did not have a significant bearing on baseline enophthalmos.

CONCLUSIONS

The presence of enophthalmos increases the likelihood that an orbital vascular malformation is distensible. This group of patients was also more likely to be characterized by venous dominant malformations. Baseline clinical enophthalmos may serve as a useful surrogate marker for distensibility and venous dominance, which may be useful in guiding the selection of appropriate imaging.

Silent sinus syndrome: potentially misleading features that should be recognized

OBJECTIVE

Silent sinus syndrome (SSS) usually manifests clinically as hypoglobus and enophthalmos. Patients may experience different symptoms and may present to an assortment of specialties and delay diagnosis and management. The objective of this article was to describe the different and sometimes misleading signs and symptoms of SSS to improve the level of suspicion and reduce time to diagnosis.

METHODS

A retrospective consecutive audit of the records of all patients diagnosed with SSS between 2015 and 2019 in the Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust. Demographic and clinical data including presentation, diagnosis, and symptoms were obtained from the patients' medical files.

RESULTS

Ten patients were included; mean age was 42.5 ± 11.5 years (range, 16-56 years). Four patients were initially referred to an ophthalmologist with globe asymmetry, diplopia, eyelid asymmetry, or retraction. Three patients were initially referred to an ear, nose, and throat specialist with facial asymmetry or infraorbital paraesthesia. Two patients were referred from the maxillofacial department with an incidental finding, and the last patient was seen initially by the neurology team with headaches.

CONCLUSION

SSS has a variable presentation. Patients may have common or misleading signs. Patients may attend different clinics and subspecialties, and physicians should be aware of the broad range of presenting signs in this condition to prevent delay in diagnosis and further morbidity.

Silent Sinus Syndrome: A Case Report

To describe a case of silent sinus syndrome in the perspective of imaging studies, on 2 January 2020 we present this case of a 26-year-old Bangladeshi man with unilateral right facial asymmetry and no sino-nasal symptoms. He was referred to the Ophthalmology Department with complain of right palpebral ptosis and facial asymmetry for 7 months. On physical examination, painless enophthalmos and hypo globus of the right eye was seen. The computed tomography scan of the paranasal air sinuses showed opacification of the right maxillary sinus along with retraction of the walls of the sinus. Regardless of the clinical doubt, the conclusion can only be given by imaging studies, radiologist play a key role here.

Predictors of enophthalmos among adult patients with pure orbital blowout fractures

The aim of this study was to determine the predictors of post-traumatic enophthalmos (PE) in relation to the internal orbital changes following pure orbital blowout fractures. The design was a 10-year retrospective cross-sectional study analysing 629 medical records and computed tomography (CT) data of patients with orbital fractures from January 2008 to January 2017. Demographic, etiology, co-morbidity and clinical characteristics were obtained from the medical records. Assessment of the PE, fracture site and size, intraorbital structures and muscle change were performed using the Digital Imaging and Communications in Medicine (DICOM) viewer software, OsiriX v5.8.2. Of the 629 patients with orbital fractures, 87 were pure orbital blowout fractures. Demographic pattern showed that males outnumbered females in the series, with male: female ratio of 5.7:1. The mean age was 37.2 ± 14.7 and the main etiology was motor vehicle accident. Orbital floor fracture was the most common fracture location (67.8%). The involvement of the posterior ledge and inferior orbital fissure showed statistical significant difference with PE (Fisher's exact test, p = 0.03). Binary logistic regression showed that after controlling for age, patients with fracture size of more than 150 mm2 had three times the odds of sustaining a PE, (adjusted odds ratio (AOR) = 3.01 (95% CI 1.17-7.92). Fracture size larger than 150 mm2 was a radiological predictor of PE. Additional research investigating further on the role of concurrent fracture of the posterior ledge and inferior orbital fissure is advocated.

Bilateral Parry-Romberg Syndrome Associated with Retinal Vasculitis

PURPOSE

To describe an unusual case of bilateral progressive facial hemiatrophy (Parry-Romberg syndrome (PRS)) associated with retinal vasculitis.

METHODS

In a 37-year-old man with bilateral PRS, retinal vasculitis of the right eye was evident on fundus examination and fluorescein angiography. Right temporalis muscle biopsy and needle electromyography of the masseter muscles were performed. The patient underwent immunosuppressive therapy and retinal laser photocoagulation.

RESULTS

Biopsy specimens showed large fibrosis with focal lymphohistiocytic infiltration of the muscle fibers. Electromyographic findings are consistent with a primary muscle disease. Visual acuity improved from 20/25 to 20/20 in the right eye with a follow-up of one year.

CONCLUSIONS

The evidence of retinal vasculitis and the histologic findings of facial changes observed in this PRS case could support the pathogenetic model of a chronic inflammatory process as a plausible explanation for progressive facial hemiatrophy.

Silent sinus syndrome--report of a case

INTRODUCTION

The "silent sinus syndrome" is a rare entity that was first described in 1964 and given this name 30 years later. Although it is well described both from clinically and radiologically point of view we consider that its rarity still makes it a subject for report.

CASE PRESENTATION

A 46-year-old patient was admitted for facial asymmetry, diplopia, unilateral left enophthalmos, and inferior displacement of the eye globe, and decreased occlusal pressure in left dentate region. CT scan revealed interior bulging of all left maxillary sinus walls with osteolysis and intense opacification, enlargement of the left middle meatus especially in the posterior part and lateralization of the uncinate process. Nasal endoscopy with 00 rigid scope visualized mild deviation to the right of the nasal septum, enlargement of the left middle meatus by the lateral deviation of the left intersinusal septum and uncinate process. Surgery was scheduled and performed a left maxillary sinus antrostomy. Histopathological examination on the biopsies revealed inflammation. A complete study was performed to assess the elements of inflammation. Postoperative course was simple. Follow-up visit at three and six months, showed significant regression of diplopia and improved facial aspect.

CONCLUSIONS

Silent sinus syndrome is a well-defined clinical entity with characteristic imagistic findings. Surgical intervention that restores sinus drainage will interrupt the pathogenesis of the disease and lead to its progressive regression. Topographic associations and density of inflammatory elements analyzed in relation with neoforming vessels suggest their implication in reparatory angiogenesis characteristic to chronic inflammation. Modulating activity in the frame of inflammatory process, of the T-lymphocytes and especially of T-lymphocytes may represent a target for the therapeutic management. Surgery can and should be performed by an endoscopic approach.

Correlation between the rate of asymmetry volume of maxillary sinuses and clinical symptomatology in the silent sinus syndrome: A retrospective study about 13 cases

OBJECTIVES

The "silent sinus syndrome" (SSS) also known as imploding antrum syndrome or chronic maxillary sinus atelectasis consists of painless enophthalmos and inward retraction of the ipsilateral maxillary sinus walls. The aims of the present study were: i) to look for a correlation between the level of volume asymmetry of the maxillary sinuses and the presence of ophthalmological and rhinosinusitis signs, ii) to determine the benefits of a middle meatal antrostomy in SSS cases, and iii) to evaluate the preventive role of neuronavigation surgery in the morbidity of this specific surgery.

MATERIALS AND METHODS

We retrospectively analyzed the data of 13 patients operated on for a SSS by middle meatal antrostomy, with the aid of neuronavigation in 7 cases. The median follow up was 30 months. No reconstruction of the orbital floor was performed. Morphometric analysis and modeling of the sinus volume from the preoperative CT scanners were performed to assess the impact of the loss of sinus volume on the symptoms.

RESULTS

all patients displayed a retraction of the orbital floor. There was a significant correlation between the magnitude of the decrease in sinus volume and clinical manifestations. Surgical treatment allowed rhinosinusitis symptom disappearance in 53% of patients. Ophthalmological symptoms did not decrease, but stayed stable after the surgical treatment. When neuronavigation surgery was performed, no complications were observed.

CONCLUSION

SSS symptoms correlated with the reduction of volume of the maxillary sinuses. This measure may be related to the severity of the disease. The middle meatal antrostomy seemed sufficient to stop the evolution of the SSS, avoiding the occurrence of severe enophthalmos. Neuronavigation surgery helped preventing serious eye complications.

Sphenoid sinus expansion: a radiographic sign of intracranial hypotension and the sunken eyes, sagging brain syndrome (an American Ophthalmological Society thesis)

PURPOSE

To test the hypothesis that in patient with sunken eyes, sagging brain syndrome, bone remodeling is not limited to the orbits. Volumetric analysis of the sphenoid sinus is performed in this study.

METHODS

In this university-based retrospective case-control study, the dimensions of the sphenoid sinus were measured in four patients (2 males, 2 females; mean age 26.3 years, range 16-38 years) out of five individuals identified with sunken eyes, sagging brain syndrome. Three measurements were taken: the distance between the orbital apices, the posterior extension of the sphenoid sinus posterior to the orbital apices, and the maximal horizontal width. The mean of each was determined and compared to that of the control group (5 males, 5 females; mean age 35.6 years, range 23-45 years).

RESULTS

Posterior extension and width of the sphenoid sinus were markedly larger in the enophthalmic patients than in the control group: posterior extension (26.3 ± 4.1 mm vs 13.4 ± 6.3 mm, P=.0015, Student's t test), width (39.2 ± 8.7 mm vs 25.1 ± 6.9 mm, P=.0035, Student's t test). Mean distance between the orbital apices was slightly greater (36.3 ± 1.7 mm vs 34.1 ± 2.1 mm, P=.047, Student's t test).

CONCLUSIONS

Skull remodeling occurring in association with intracranial hypotension after ventriculoperitoneal shunting is not limited to the orbits. In this study we have demonstrated expansion of the sphenoid sinus. This finding adds to our knowledge and understanding of the scope of the sunken eyes, sagging brain syndrome and elucidates a clinically useful radiographic sign.

[Silent sinus syndrome (clinical case). New potential for enophthalmos correction]

Silent sinus syndrome (SSS) is a rare condition presenting with spontaneous enophthalmos and hypoglobus caused by volume reduction of maxillary sinus due to centripetal collapse of its walls. A case of SSS manifested during pregnancy in 43 years old patient is presented. In 16 months after manifestation of symptoms endoscopic sinus surgery was performed with no postoperative improvement of ocular symptoms. Intraorbital injection of stabilized hyaluronic acid gel was performed for correction of globe position. In control ultrasound examination color Doppler mapping revealed improvement of regional blood flow on the side of injection.

[Enophthalmos in an orbital tumor]

Enophtalmus is an unusual sign of the orbital tumors often represented by proptosis. One patient with enophtalmus and intraorbital tumor and aplasy is presented. The treatment of choice of orbital tumor is complete surgical excision and careful follow-up. Considering the more aggressive course followed by recurrent tumor, correct diagnosis and management is essential.

Functional outcome after non-surgical management of orbital fractures--the bias of decision-making according to size of defect: critical review of 48 patients

The treatment of mild and moderate fractures of the orbital wall is controversial. Apart from clinical signs, the size of the defect is often used to aid the decision about treatment. We hypothesised that variables would be present that had an impact on the position and motility of the globe but were independent of the size of the defect, and prevented a balanced judgement of the outcome of conservative treatment. Between January 2000 and December 2007, 48 of 127 patients were included in this retrospective study to analyse the functional outcome of orbital fractures managed without operation. Selection was dependent on the availability of complete clinical records, post-traumatic computed tomographic (CT) scans (axial and coronal sections) and ophthalmic examination. All 48 defects were analysed and allocated to categories of a semiquantitative classification. The area of fracture of each defect was calculated with an integral calculus or geometrical formula and correlated with the associated category. Category A included all orbital walls as a single unit (A1) and combined fracture patterns (A2 and higher). Category B described isolated fractures of the medial wall. There was a significant correlation between classes A1 and A2 (p<0.01) and absolute area of the fracture (0.98 (0.4)cm(2) and 2.42 (0.8)cm(2)). Diplopia was most often seen in fractures in category B1 (the anterior third of the medial wall) and the post-traumatic position of the globe significantly correlated with the area of the fracture (p=0.04). The degree of diplopia was less severe in fractures of the posterior portion of the orbit (zones 2 and 3) compared with fractures of the anterior orbit, even if the defect was larger. The conservative management of category A1-3 and B1-3 fractures up to 2.42 (3.15)cm(2) showed no functional impairment, provided that enophthalmos was less than 2mm and there was no entrapment of periorbital tissue or extraocular muscles. We found good correlation between enopthalmos and the size of the fracture, but not for diplopia or motility of the eye. We conclude that conservative management of an orbital fracture in which the defect is less than 3cm(2) has a low risk of permanent functional damage if enophthalmos is less than 2mm and entrapment of soft tissue or muscles is excluded.

[Enophtalmos of the anophtalmic socket: incidence of the orbital morphology and therapeutic implications. Clinical study of 86 cases]

AIM OF THE STUDY

From a light asymmetry to a sunken eye aspect, a great disparity between the results after anophtalmic socket rehabilitation is noticeable: what are the factors involved in the degree of residual enophtalmos following excision of the eye? The litterature's response is based on physiopathological considerations around intraorbital architectural disturbance. We propose a geometrical approach related to the existence of different morphological types of orbit.

PATIENTS AND METHOD

Eighty-six records of eviscerated and enucleated patients have been studied and submitted to a statistical analysis. A preliminary study has defined four types of orbit depending on the shape and operture of the orbital "window": two opposite types IA and III, a type II intermediate and a particular one, the type IB. A classification of enophtalmos' degree allows to analyze the parameters chosen and to identify the predictive factors.

RESULTS

The statistical analysis confirms the incidence of the orbital morphology on the degree of enophtalmos but do not support the theories based on the intraorbital septal architecture changes. Depending on the orbital shape and the container-content relation, the volume loss is more visible on the whole orbitopalpebral surface of opened and high orbit but remains centered on the anteroposterior position of the implant of a closed and lengthened orbit. At the contrary to the type III, the type IA is not favorable for the anophtalmic patient and predispose to a higher degree of enophtalmos. This new approach has therapeutic implications on primary and secondary surgery for volume loss replacement.

CONCLUSION

The success of anophtalmic socket rehabilitation is influenced by the orbital morphological type that has to be considered in the therapeutic strategy.

[Silent sinus syndrome--two cases report]

INTRODUCTION

Silent Sinus Syndrome (SSS) is a rare pathology, characterized by retraction of the maxillary sinus walls, leading to enophthalmos, sometimes diplopia and midfacial depression. It is usually not associated with sinonasal symptoms. Sinus ventilation and drainage stops its progression, but usually cannot reverse the process. This empiric treatment supports the Hypoventilation Theory that would explain the pathogenesis of this disorder.

MATERIALS & METHODS

We describe two cases of SSS. A 65 year-old-man complaining of enophthalmos with an insidious onset whose CT-Scan confirmed SSS. After he was submitted to drainage surgery, the ocular asymmetry showed slight improvement. The second case describes a 34 year-old-woman with a sudden onset enophthalmos associated with diplopia, in only 5 days. She didn't have nasal or sinus related symptoms. CT-scan revealed SSS due to maxillary and ethmoidal sinus. Early endoscopic surgery enabled reversal of enophthalmos and correction of diplopia.

Silent sinus syndrome: a rare presentation after botulinum toxin injection

Silent sinus syndrome is a unique diagnosis characterized by spontaneous enophthalmos and hypoglobus resulting from collapse of the orbital floor secondary to chronic subclinical sinusitis. Although reported in the ophthalmology and otolaryngology literature, there is no mention of silent sinus syndrome in the plastic surgery literature. The authors present a case report, along with a brief overview of silent sinus syndrome, so that knowledge of this rare but potentially devastating clinical entity may supplement plastic surgeons' differential to ensure proper diagnosis and treatment.

[Clinical and roentgenological manifestations of the silent sinus syndrome]

Analysis of the results of the examination and treatment of four patients presenting with the silent sinus syndrome provided materials for the generalized characteristic of clinical and roentgenological manifestations of this condition.

Enophthalmos caused by an orbital venous malformation

Orbital vascular malformations usually present with proptosis. We report a case where a patient with an orbital venous malformation presented with enophthalmos. Since many underlying orbital pathologies, including orbital metastases, can cause enophthalmos, it is important to investigate patients properly. Computed tomographic imaging of the orbit remains the most useful tool in the management of patients with enophthalmos.

Orbital Sarcoidosis Manifesting with Enophthalmos

PURPOSE

To describe a case of orbital sarcoidosis manifesting with enophthalmos.

METHODS

A 60-year-old woman presented with right enophthalmos. She had a palpable mass in her anterior orbit inferiorly. She underwent a complete ophthalmic evaluation, magnetic resonance imaging, and histopathologic examination.

RESULTS

A magnetic resonance imaging scan disclosed an orbital, extraconal mass, with displacement of the orbital floor. A biopsy specimen of the mass demonstrated a granulomatous inflammation without caesation necrosis. Workup revealed hilar lymphadenopathy, pleural nodule, and splenomegaly. The patient was treated with corticosteroids, with subsequent involution of the mass and disappearance of enophthalmos.

CONCLUSION

Although orbital sarcoidosis usually manifests with proptosis or palpebral swelling, enophthalmos should be considered as ophthalmic manifestation of sarcoidosis.

Silent sinus syndrome

We present a case of silent sinus syndrome (SSS) who underwent unilateral surgical endoscopic maxillary meatotomy. Orbital floor reconstruction is delayed after follow up. Enophthalmos recovered 8 months after the surgery and radiologic findings improved. SSS is a clinical entity that should be kept in mind in the differential diagnosis of enophthalmos and can be treated successfully via endoscopic approach.

Radiology and endoscopic findings of silent maxillary sinus atelectasis and enophthalmos

OBJECTIVES

The objective of this study is to discuss the presentation and surgical management of patients presenting with silent maxillary sinus atelectasis with enophthalmos (SMSAE).

STUDY DESIGN AND METHODS

We performed an analysis of prospectively collected data on patients with maxillary sinus opacification and associated enophthalmos from 1999 to 2003. Patients were evaluated based on physical examination, nasal endoscopy, and computed tomographic findings.

RESULTS

Sixty-four patients were identified with unilateral maxillary sinus opacification. Of these, 7had radiographic evidence of maxillary sinus volume reduction. Of these 7 patients, 5 had maxillary sinus atelectasis with enophthalmos, the components constituting SMSAE. The mean age of the patients was 42 years (range, 22-65). None of the patients had any history of nasal trauma or developmental defects before presentation. All 5 patients with SMSAE had uncinate retraction on nasal endoscopy. Uncinate retraction was not seen in the 2 patients without enophthalmos (chi(2) = 7, P= .008). All 7 patients with maxillary opacification were treated with endoscopic sinus surgery, with resolution of their maxillary sinus obstruction at 2 years' follow-up. Only 1 of 5 patients with SMSAE requested orbital floor reconstruction after sinus surgery performed by the oculoplastic service with resolution of enophthalmos.

CONCLUSION

All patients with SMSAE had evidence of uncinate process retraction on nasal endoscopy, whereas patients without enophthalmos did not, and the difference was statistically significant. Surgical treatment is the mainstay of therapy for this condition, with resolution of maxillary opacification at 2 years' follow-up.

[Silent sinus syndrome in child]

INTRODUCTION

Silent sinus syndrome (SSS) is rare clinical entity described in ophthalmology and otolaryngology literature. It is characterized by spontaneous and progressive enophthalmos and hypoglobus caused by maxillary collapse in the setting of chronic maxillary sinus hypoventilation. The authors report an unusual case of SSS in child.

MATERIAL AND METHODS

A 15 year old boy presented with 6 months history of developing of right cheek deformity with no clinically signs and symptoms of chronic rhinosinusitis. According to nasal endoscopy and CT and NMR scans the silent sinus syndrome was recognized. What is the most important, the deformity of anterior maxillary wall was the main problem and complaint. The patient underwent surgical endoscopic uncinectomy with medial antrostomy.

RESULTS

The performed treatment successfully corrected both the cheek and the upper eyelid sulcus deformity. The control CT scans performed 3 months after surgery showed normal sinus ventilation with wide medial antrostomy.

CONCLUSIONS

Silent sinus syndrome in a child is characterized by more active resorption and remodeling of anterior maxillary wall with clinically visible deformity. The goal of the treatment is restoration of normal maxillary sinus aeration and this guaranty further normal sinus development.

Diagnosis and management of enophthalmos

Enophthalmos is a relatively frequent and misdiagnosed clinical sign in orbital diseases. The knowledge of the different etiologies of enophthalmos and its adequate management are important, because in some cases, it could be the first sign revealing a life-threatening disease. This article provides a comprehensive review of the pathophysiology, evaluation, and management of enophthalmos. The main etiologies, such as trauma, chronic maxillary atelectasis (silent sinus syndrome), breast cancer metastasis, and orbital varix, will be discussed. Its objective is to enable the reader to recognize, assess, and treat the spectrum of disorders causing enophthalmos.

[Enophthalmos correction in complex orbital floor reconstruction : computer-assisted, intraoperative, non-contact, optical 3D support]

In the case of displacement of the globe such as enophthalmos induced by trauma, the patient is affected on both counts: function and aesthetics. To prevent double vision or conspicuous asymmetry, exact correction of the globe position is required. The aim of this case report is to demonstrate an intraoperative computer-assisted, non-contact, optical 3D procedure for identification of the globe position to aid in placing the eyeball in the position required in complex reconstruction of the orbital floor. A 33-year-old man presented with a sunken eye on the right side in the horizontal and vertical plane 6 months after having undergone surgery elsewhere for a zygomatico-orbital fracture, also including the orbital floor. The patient was affected by double vision and a noticeable defective globe position. In planning the correction of the globe position, a three-dimensional image of the face with opened eyes was made with the optical sensor. Automatic comparison of symmetry revealed enophthalmos of 4 mm on relative en- and exophthalmometry. The decision was made to lift the orbital floor with a split calvarial bone graft. During surgery the position of the globe was also controlled by the three-dimensional optical technique. At the end of surgery there was exophthalmos of 1 mm. Six weeks after surgery the patient was not affected by any double vision. After 3 and 24 months enophthalmos was 1 mm. This case demonstrates how the non-ionizing, non-contact, optical 3D technique can help in planning, intraoperative transformation, and clinical monitoring to identify the correct position of the corneal vertex in complex orbital floor reconstruction.

Ectopic Brain in the Orbit With Congenital Adduction Deficit and Simultaneous Abduction

An 11-month-old girl was referred to us with enophthalmos and restriction of ocular movement in the right eye. There was restriction of supraduction and adduction with synergistic divergence on left gaze. MRI revealed a multiloculated cystic mass in the right inferior orbit. There was an atrophic and misinserted inferior rectus muscle and only a vestigial right medial rectus muscle. Excisional biopsy of the orbital cystic mass was performed. Microscopic examination disclosed that the mass was brain tissue composed of arachnoid tissue, brain parenchyma, choroid plexus, and dura mater. Our report describes a rare case of ectopic brain in the orbit that was combined with anomalies of the extraocular muscles.

Orbital Fractures Complicated by Late Enophthalmos: Higher Prevalence in Patients With Multiple Trauma

PURPOSE

To present our experience with orbital fracture treatment outcomes in patients with multiple trauma and those suffering localized orbital trauma.

METHODS

Retrospective data review of all patients examined for ocular motility problems and/or enophthalmos following orbital trauma in a 4-year period.

RESULTS

Forty-three patients were included in the study: 31 (72%) had localized orbital trauma (LOT) and 12 (28%) had concomitant traumatic insults to other organs (MT). More orbital walls were affected in MT patients than in LOT patients, and the incidence of zygomatic fracture was higher in MT patients. Late enopthalmos was much more prevalent in the MT group compared with the LOT group. Differences of outcome of extra ocular motility disturbance between groups in our series did not reach statistical significance.

CONCLUSIONS

The findings of more walls affected and higher incidence of zygomatic fractures in MT patients probably represent a stronger impact of the original insult, causing both more damage to other organs and more severe damage to the orbit. The increased rate of late enophthalmos in MT patients may be associated with their primary presentation to the emergency room with potentially life-threatening injuries. Under such circumstances, thorough ophthalmologic examination is nearly impossible, both because the patient cannot cooperate sufficiently and because medical priorities dictate concentration on taking care of the injuries threatening life. The lack of a thorough ophthalmic examination prevents early comprehensive treatment.

A importância da enoftalmia senil no desenvolvimento do entrópio involucional

PURPOSE

To observe the role of senile enophthalmos in involutional entropion.

METHODS

Prospective clinical study comparing a population of 30 white patients above 65 years with involutional entropion (Group I) of an age- and race-matched control group (Group II). All age and exophthalmometric values were analyzed by a statistical study.

RESULTS

The average age was 77.7 years in Group I and 75.7 years in Group II. Eyes with involutional entropion are no more likely to have enophthalmos (15.22 mm) than is the involved contralateral eye (15.11 mm) or normal eyes of an age- and race-matched control group (15.13 mm).

CONCLUSION

There is no correlation between involutional entropion and senile enophthalmos.

Silent sinus syndrome: a mechanical theory

We present the case of a progressive enophthalmos, 23 years after an orbital floor fracture treated conservatively. Imaging demonstrated orbital fat herniation into the pterygopalatine fossa and a collapse of the maxillary sinus walls. We hypothesise that some "silent sinus syndrome" might be caused by an aspiration phenomenon resulting from masticatory muscle movements.

[Orbital hernias: new views of the pathogenesis, possibilities of correction]

The paper deals with the basic pathogenetic aspects of development of orbital hernias--the factors of a tarsoorbital fascial change in the presence of the hereditary syndrome of connective tissue hyperplasticity and elevated intraorbital pressure, which affects the volume of orbital fat. The possibilities of a differential diagnosis of orbital hernias and eyelid edemas are considered. There is a biomechanical association of orbital hernias with acquired age-related enophthalmos. The examples of impairments in the tolerance of the optic nerve and in the development of optic neuropathy in enophthalmos are considered. The fact that there may be tarsoorbital fascial lesions, followed by the development of orbital hernias after parabulbar injections is indicated. The author proposes an operation dealing with the reposition of orbital hernias instead of their resection during blepharoplastic interventions.

The hypoplastic maxillary sinus and the orbital floor

PURPOSE OF REVIEW

Hypoplastic maxillary sinus is a relatively rare clinical problem that has a variable presentation. The purpose of this article is to review the recent literature with regard to evaluation and treatment.

RECENT FINDINGS

Most authors suggest that hypoplastic maxillary sinus results from the development of negative pressure resulting from an obstruction of maxillary sinus ventilation. Patients most frequently present with unilateral enophthalmos but some cases may be identified incidentally on imaging studies.

SUMMARY

Hypoplastic maxillary sinus is a rare clinical entity with variable presentation. Evaluation and management are tailored to each individual patient's degree of disease and symptoms.

Acquired unilateral pseudoptosis: a presentation of silent sinus syndrome

BACKGROUND

Acquired unilateral ptosis usually results from either levator palpebrae disinsertion, eyelid disorder, myasthenia gravis, mitochondrial myopathy, Horner's syndrome, or third nerve palsy. In rare cases, an orbital process is responsible for ptosis or pseudoptosis.

HISTORY AND SIGNS

A healthy 31-year-old patient complained for 6 months of right eyelid ptosis. On examination, there was 1 mm right upper eyelid ptosis and 1 mm of right enophthalmos. Upon downgaze, an apparent right eyelid retraction was present. Magnetic resonance imaging showed filling and retraction of the right maxillary sinus with inferior displacement of the right orbital floor.

THERAPY AND OUTCOME

Surgical management was performed with a favourable outcome.

CONCLUSIONS

Silent sinus syndrome is an asymptomatic chronic maxillary sinus atelectasis, resulting in ipsilateral enophthalmos, hypoglobus, and occasionally eyelid pseudoptosis. Silent sinus syndrome should be incorporated in the differential diagnosis of acquired unilateral ptosis.

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.

Intraoperative Noncontact, Nonionizing, Optical 3D Exophthalmometry During Repositioning of Dislocated Globes: First Results

PURPOSE

This study reports on the intraoperative use of noncontact, nonionizing, optical 3-dimensional (3D) exophthalmometry during the repositioning of dislocated globes as a result of trauma.

PATIENTS AND METHODS

Ten patients (4 female, 6 male, 41.4+/-15.2 years) with a relative enophthalmos of the globe as a result of zygomatic fractures were included in the study. Preoperatively, en- and exophthalmometry data were assessed from axial CT slices and optical 3D imaging. 3D data were analyzed twice for the assessment of measurement errors. Intraoperatively, optical en- and exophthalmometry was carried out to control the globe position. Surgery was considered successful when the relative en- or exophthalmos no longer exceeded 2 mm. Optical 3D en- and exophthalmometry data were reassessed 5 days and 3 months after surgery.

RESULTS

Method error was 0.184 mm for optical 3D en- and exophthalmometry. The preoperatively assessed en- and exophthalmometry data determined from axial CT scans and from optical 3D images did not differ significantly statistically (P=.538). When the preoperative en- and exophthalmometry data were compared to the values assessed at the end of surgery, a significant improvement in globe position was found (P=.005). Although a relative en- or exophthalmos of 2 mm was not exceeded in any of the patients 3 months after surgery, en- and exophthalmometry data differed significantly statistically from the data assessed at the end of the operation (P=.005).

CONCLUSIONS

Intraoperative optical en- and exophthalmometry is an effective means to support the surgeon in objectively optimizing the globe position with small measurement errors.

Giant epidermoid cyst as an unusual presentation of hypoglobus and ptosis

A 24-year-old man presented with a large right frontal epidural epidermoid cyst that resulted in right hypoglobus and right upper eyelid ptosis. CT and MRI revealed a bone-destroying mass involving the right frontal bone and eroding through the right orbital roof. Complete surgical removal was performed through a frontal craniotomy. After surgery, there was near-complete resolution of the hypoglobus and ptosis.

Orbital Tuberculosis Manifesting With Enophthalmos and Causing a Diagnostic Dilemma

A 60-year-old woman with no known systemic disease was referred with a hard mass in the left orbit and enophthalmos of two months duration. Differential diagnoses of metastasis from an undetected scirrhous carcinoma and sclerosing nonspecific orbital inflammatory disease were considered and a biopsy was performed. Histopathology demonstrated granulomatous inflammation with fibrosis. Subsequent polymerase chain reaction was positive for Mycobacterium tuberculosis deoxyribonucleic acid. There was no evidence of systemic tuberculosis. The patient was treated with four-drug combination anti-tubercular therapy for 6 months. The mass regressed and there was no local recurrence at two years follow-up. Orbital tuberculosis generally manifests with proptosis or osteomyelitis. However, enophthalmos may be caused by the fibrosing variant. Biopsy with histopathologic and microbioloic evaluation is essential to distinguish it from other more common causes of an orbital mass with paradoxical enophthalmos such as metastatic scirrhous carcinoma and sclerosing nonspecific orbital inflammatory disease.

The silent sinus syndrome

Silent sinus syndrome is a rare clinical entity typically characterized by spontaneous and progressive enophthalmos and hypoglobus caused by an alteration of the normal orbital architecture and function from maxillary collapse in the setting of the chronic maxillary sinus hypoventilation. The authors report an unusual case revealed by mild dental pain, present the imaging (before, during and after the development of the disease), discuss the different theories related to pathogenesis and comment the treatment.

Wide clinical variability among 13 new Cockayne syndrome cases confirmed by biochemical assays

Cockayne syndrome is a multi-systemic, autosomal recessive disease characterised by postnatal growth failure and progressive multi-organ dysfunction. The main clinical features are severe dwarfism (<-2 SD), microcephaly (<-3 SD), psychomotor delay, sensorial loss (cataracts, pigmentary retinopathy, and deafness), and cutaneous photosensitivity. Here, 13 new cases of Cockayne syndrome are reported, which have been clinically diagnosed and confirmed using a biochemical transcription assay. The wide clinical variability, ranging from prenatal features to normal psychomotor development, is emphasised. When cardinal features are lacking, the diagnosis of Cockayne syndrome should be considered when presented with growth retardation, microcephaly, and one of the suggesting features such as enophthalmia, limb ataxia, abnormal auditory evoked responses, or increased ventricular size on cerebral imaging.

Absent upper eyelid skin crease: a sign of hypoglobus

The association of an absent upper eyelid skin crease on downgaze with hypoglobus has not been described in the literature before. Herein a case of silent sinus syndrome that demonstrates this sign is described. The possible mechanism of such a sign is discussed.

Late enophthalmos mimicking silent sinus syndrome secondary to orbital trauma

The authors present a retrospective case report of a patient who experienced late enophthalmos after blunt orbital trauma. A 27-year-old man presented with subacute onset of enophthalmos, hypoglobus, superior sulcus deformity, and computed tomography evidence of a collapsed maxillary sinus 6 months after sustaining an ipsilateral moderately displaced orbital floor fracture. He was taken to surgery for left endoscopic maxillary antrostomy and implantation of an alloplastic orbital floor graft. Two months after surgery, the patient's diplopia, enophthalmos, hypoglobus, and superior sulcus deformity were markedly improved. Reestablishment of maxillary sinus aeration, the orbital floor, and the medial wall successfully relieved the symptoms and signs of maxillary wall implosion. The mechanism of this rare condition, which shares features similar to silent sinus syndrome, is presented.

Parry-Romberg Syndrome

The authors report an unusual case of Parry-Romberg syndrome (PRS). Magnetic resonance imaging and computed tomography scan of the craniofacial region and surgical correction of enophthalmos were performed. Results after the operative intervention included persistent palpebral edema and ecchymosis and transient choroid vasculitis of the right eye, highlighted with echography and fluorescein angiography. The fundus oculi examination showed retinal choroid folds. Immunological test results were weakly positive. The authors conclude enophthalmos, associated with right side hemi atrophy, and the transient choroids vasculitis support the diagnosis of PRS. Furthermore, it is suggested the case had an autoimmune etiology, rather than a hemi facial asymmetry caused by a facial trauma that occurred in puberty.

Bilateral progressive enophthalmos as the presenting sign of metastatic breast carcinoma

A 51-year-old woman, without systemic symptoms, complained of slowly progressive receding eyes. She had severe bilateral enophthalmos and markedly restricted extraocular movements in all fields of gaze. Computed tomography showed an infiltrative homogenous mass filling both orbits. Gynecologic and systemic investigation revealed bilateral lobular breast carcinoma, without metastasis to other organs. She was started on chemotherapy and 2 years after the diagnosis remains in good general health, despite persistence of severe enophthalmos. This case serves to emphasize that bilateral progressive enophthalmos may be the presenting sign of metastatic breast carcinoma even when local symptoms in the breast are absent. Clinicians should be aware of this sign to establish an early diagnosis and treatment.

Hertel exophthalmometry versus computed tomography and optical 3D imaging for the determination of the globe position in zygomatic fractures

It has been the aim of the present study, to introduce the combination of computed tomography and optical 3D imaging to exophthalmometry and to compare the resulting data to the classic Hertel method. Twenty patients without orbital pathology and 12 patients were included in the study, who were subjected to a preoperative computed tomography. Optical 3D images of the facial surface were assessed and Hertel exophthalmometry was carried out to determine protrusion. In patients with zygomatic fractures the assessment of optical 3D images and Hertel values was repeated 5 days after surgery. Preoperative axial CT slices and postoperative optical contours through the globes were superimposed and the change in protrusion was determined. The protrusion values assessed either by CT, Hertel exophthalmometry or optical 3D imaging for patients without orbital pathology did not show any statistically significant differences between each other. For zygomatic fractures, Hertel exophthalmometry revealed more pronounced protrusion data in four of five cases of a posterolaterally dislocated lateral orbital rim and a higher degree of enophthalmos in cases without dislocation of the lateral orbital rim than it could be proved in the CT slices. The differences between optical measurements and CT data were minimal in patients with zygomatic fractures. The combination of computed tomography as baseline measurement and optical 3D imaging for the follow-up examinations reveal more realistic data in cases of zygomatic fractures than Hertel measurements and should be preferred.

Enophthalmos as initial manifestation of occult, mammogram-negative carcinoma of the breast

A patient with enophthalmos was found to have occult metastatic breast carcinoma to the orbit despite normal findings on breast examination and mammogram. Enophthalmos can be a sign of serious systemic disease and should be appropriately investigated. Despite radiologically interpreted normal orbital and breast imaging, the clinician should rule out underlying subclinical malignancy and consider orbital biopsy.

Relative en- and exophthalmometry in zygomatic fractures comparing optical non-contact, non-ionizing 3D imaging to the Hertel instrument and computed tomography

AIM

It is the aim of the present study to introduce non-contact, non-invasive optical 3D imaging to relative exophthalmometry and to compare the resulting data to exophthalmometry values assessed by the Hertel instrument and computed tomography.

PATIENTS AND METHODS

20 patients (3 female, 17 male, 44.4+/-16.6 years) without orbital pathology, who were examined by computed tomography of head and neck for the exclusion of different diseases, and seven patients (1 female, 6 male, 40.1+/-14.4 years), who received routine orbital computed tomography because of zygomatic fractures, were included in the study. Optical 3D images of the facial surface were assessed and Hertel exophthalmometry was carried out to determine the relative globe position. In patients with zygomatic fractures the assessment of optical 3D images and Hertel values was repeated 5 days after surgery.

RESULTS

For patients without orbital pathology relative exophthalmometry data were 1.4+/-1.1 mm for the Hertel instrument, 0.9+/-1.0 mm for computed tomography and 0.5+/-0.5 mm for optical 3D imaging. The values for Hertel exophthalmometry and computed tomography did not differ statistically significantly (p(Herteldifferencepreop/CTdifferencepreop)=0.284), while there was a significant difference between Hertel exophthalmometry and optical 3D imaging (p(Herteldifferencepreop/opticaldifferencepreop)=0.008). In the cases of zygomatic fractures, Hertel exophthalmometry revealed less pronounced relative differences in globe position than CT and optical 3D imaging data (Hertel 0.7+/-1.1 mm, CT 1.9+/-1.0 mm, optical 3D imaging 1.9+/-1.0 mm). Postoperatively, relative Hertel exophthalmometry showed an increased value revealing a more pronounced enophthalmos (1.7+/-1.0 mm), while the corresponding value of the optical 3D images decreased as a sign for normalization of the globe position (1.1+/-0.7 mm).

CONCLUSION

Because of its reliance on the lateral orbital rims Hertel exophthalmometry can lead to an under- or overestimation of enophthalmos, when soft tissue oedema or a dislocation of the orbital rim are present. The combination of computed tomography as baseline measurement and optical 3D imaging for the follow-up examinations reveal more realistic data in cases of zygomatic fractures. Therefore, they should be preferred to the determination of Hertel values especially in more complex cases.

Misdiagnosis of Silent Sinus Syndrome

PURPOSE

To review cases of spontaneous enophthalmos erroneously diagnosed as silent sinus syndrome to identify other inflammatory disorders with a similar clinical presentation.

METHODS

Retrospective observational case series. Chart reviews were performed covering encounters over a 5-year period, searching for patients referred to two physicians with an incorrect diagnosis of silent sinus syndrome. Only cases of acquired enophthalmos of reported nontraumatic or nonneoplastic cause were included. Particular attention was directed toward noting clinical features of upper eyelid position and periocular atrophy.

RESULTS

Nineteen cases of erroneous referral for silent sinus syndrome were identified. Fourteen of these cases were due to tumor, trauma, congenital facial asymmetry, or diffuse facial lipodystrophy. Among the remaining cases, four were diagnosed as Parry-Romberg syndrome and one as linear scleroderma.

CONCLUSIONS

Parry-Romberg syndrome and linear scleroderma must be distinguished from silent sinus syndrome as causes of inflammatory-mediated, spontaneous enophthalmos.

The silent sinus syndrome: a case with normal predisease imaging

The silent sinus syndrome is a cause of spontaneous enophthalmos associated with unilateral chronic maxillary atelectasis. It remains an under-recognised condition in both the ophthalmological and otolaryngological community. We present a case of a 46-year-old lady with a six-month history of enophthalmos to illustrate the clinical features and radiological findings of this condition. Four years prior to presentation, she had normal maxillary sinuses on magnetic resonance imaging.