Late Post-Traumatic Enophthalmos

Commonly caused by:

• Orbital floor and/or medial wall fractures leading to increased orbital volume
• Orbital fat atrophy or loss of support (periosteum, ligament, septa, etc.) from trauma or surgery
• Inadequate or absent repair of the initial orbital fracture
• Implant malposition or migration in previously repaired cases

Epidemiology

• Delayed sequela of large orbital fractures
• Enophthalmos is often not apparent acutely due to edema and hemorrhage
• Delayed presentation typically occurs weeks to months after injury
  Affects both children and adults; more common in men due to higher trauma incidence
• Even in case of large fractures, late enophthalmos is uncommon
• 11 of 44 (25%) of fractures patients with enophthalmos showed improvement in radiologic findings demonstrating smoothening of bony contour, joining of bony edges, reduction in orbital content herniation, features of neobone formation, and reduction in both total orbital and fracture volumes (Ophthalmology, 2018).

Patient History

• Elicit a detailed and extensive history of the mechanism of facial or orbital trauma (e.g., assault, fall, motor vehicle accident)
• Initial swelling with later development of facial asymmetry
• May occur with diplopia, especially in upgaze with orbital floor fracture
• Sunken eye appearance noted by patient or family
• Prior orbital surgery or attempted fracture repair

Clinical Features

• Unilateral enophthalmos (≥2 mm compared to contralateral side)
• Displacement of canthus or globe position
• Asymmetric palpebral fissure height
• Restricted extraocular movements, especially with vertical or horizontal diplopia
• Often no pain or visual acuity changes
• Deepened superior sulcus
• May have infraorbital nerve hypoesthesia
• May have palpable step-off deformity, malar flattening or bony asymmetry

• Inadequate initial fracture repair
• Large orbital wall defect (>2 cm²)
• As an approximation, volumetric expansion of 1 cm3 correlates with 0.8 mm of induced enophthalmos (BJO 1994; 78:618).
• Multiple orbital wall involvement
• Implant malposition or resorption
• Fat atrophy due to ischemia or fibrosis
• Delayed diagnosis or referral

• Silent sinus syndrome
• Post-surgical orbital volume changes (e.g., tumor resection)
• Orbital trauma
• Orbital varix
• Parry-Romberg syndrome (hemifacial atrophy)
• Orbital fat atrophy (idiopathic or post-radiation)
• Chronic maxillary sinusitis with orbital wall erosion
• Scleroderma or trauma-induced fibrosis

Natural History

• Enophthalmos progresses over weeks to months as edema resolves and orbital remodeling occurs
• May stabilize or slowly worsen with time
• Orbital floor remodeling can become fibrotic and contracted, complicating later surgery
• Functional (diplopia) and cosmetic (facial asymmetry) issues often emerge late
• Of 9 of 41 (21.9%) patients with late “significant” post traumatic enophthalmos, only 50% were sufficiently concerned with their appearance to choose delayed surgical repair (Ophthalmology, 2018)

Medical Management

• Observation is appropriate if enophthalmos is mild (<2 mm) and non-progressive
• Prism glasses for diplopia
• Retrobulbar injection of hyaluronic acid gel (OPRS, 2018; J Craniofac Surg, 2020)
• Repeat CT Imaging is essential to determine defect size and orbital volume

Indications

• Enophthalmos ≥2 mm
• Symptomatic diplopia
• Significant cosmetic asymmetry
• Hypoglobus with globe displacement

Approach

• CT-based planning to assess defect and orbital volume
• Implant placement or revision:
  • Titanium mesh, porous polyethylene, or patient-specific implants (J Pers Med, 2022)
  • Orbital enophthalmic wedges (Craniomaxillofac Trauma  Reconstr, 2025)
• Augmentation with orbital fat graft or dermal fat graft in select cases (OPRS, 2018)
• Navigation-assisted surgery in complex or revision cases (J Plast Reconstr Aesthet Surg 2021)
• Repair more than 6 weeks after injury can still have good outcomes, but prognosis is more varied. (OPRS 2015)
• Additional reports have indicated that outcomes of fractures in which repair was delayed might be similar to those of more acutely repaired fractures among oculoplastic surgeons (Dal Canto, Ophthal Plast Reconstr Surg 2008)

• Orbital hemorrhage
• Residual enophthalmos (implant incorrect placement or incomplete volume correction)
• Diplopia (restrictive or neurogenic)
• Implant malposition or migration
• Infection or hematoma
• Scarring or lid malposition (especially in subciliary approaches)

1. AAO, Basic and Clinical Sciences Course. Section 6: Pediatric Ophthalmology and Strabismus; Section 7: Oculofacial Plastic and Orbital Surgery, 2024-2025.
2. Young SM, Kim YD, Kim SW, Jo HB, Lang SS, Cho K, Woo KI. Conservatively Treated Orbital Blowout Fractures: Spontaneous Radiologic Improvement. Ophthalmology. 2018 Jun;125(6):938-944. doi: 10.1016/j.ophtha.2017.12.015. Epub 2018 Feb 3. PMID: 29398084.
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6. Spalthoff S, Dittmann J, Zimmerer R, Jehn P, Tavassol F, Gellrich NC. Intraorbital volume augmentation with patient-specific titanium spacers. J Stomatol Oral Maxillofac Surg. 2020 Apr;121(2):133-139. doi: 10.1016/j.jormas.2019.09.006. Epub 2019 Sep 16. PMID: 31536820.
7. Vosloo L. The Intraoperative Fabrication of PMMA Patient-Specific Enophthalmos Wedges and Onlays for Post-Traumatic OZC Reconstruction. Craniomaxillofac Trauma Reconstr. 2025 May 29;18(2):29. doi: 10.3390/cmtr18020029. PMID: 40567490; PMCID: PMC12192465.
8. Chen H, Zhang Q, Qiu Q, Yang Z. Autologous Fat Graft for the Treatment of Sighted Posttraumatic Enophthalmos and Sunken Upper Eyelid. Ophthalmic Plast Reconstr Surg. 2018 Jul/Aug;34(4):381-386. doi: 10.1097/IOP.0000000000001028. PMID: 29369151.
9. Shyu VB, Chen HH, Chen CH, Chen CT. Clinical outcome following intraoperative computed tomography-assisted secondary orbital reconstruction. J Plast Reconstr Aesthet Surg. 2021 Feb;74(2):341-349. doi: 10.1016/j.bjps.2020.08.049. Epub 2020 Aug 25. PMID: 32948495.
10. Scawn RL et al. Outcomes of Orbital Blow-Out Fracture Repair Performed Beyond 6 Weeks After Injury. Ophthal Plast Reconstr Surg. 2015