Exophthalmos-Enophthalmos
Orbital Position Abnormalities - Overview
Abnormal positioning of the globe within the orbit can indicate various systemic and local pathologies. Early recognition is crucial for appropriate management.
Key Points
- Exophthalmos: Forward displacement of globe
- Enophthalmos: Posterior displacement of globe
- Both can be unilateral or bilateral
- Requires prompt evaluation in pediatric cases
Exophthalmos (Proptosis)
Definition
Anterior displacement of the globe beyond the orbital rim. In children, any asymmetry >2mm is significant.
Etiologies in Children
- Orbital Tumors
- Rhabdomyosarcoma (most common primary orbital malignancy)
- Neuroblastoma metastasis
- Optic nerve glioma
- Lymphangioma
- Capillary hemangioma
- Inflammatory Conditions
- Orbital cellulitis
- Orbital pseudotumor
- Thyroid eye disease (rare in children)
- Developmental Conditions
- Craniosynostosis syndromes
- Crouzon syndrome
- Apert syndrome
Clinical Features
- Red Flags
- Rapid onset
- Associated pain
- Decreased vision
- Color vision changes
- Resistance to retropulsion
- Associated Signs
- Exposure keratopathy
- Conjunctival injection
- Diplopia
- Optic nerve compression
Enophthalmos
Definition
Posterior displacement of the globe within the orbit. Significant if >2mm compared to fellow eye.
Pediatric Causes
- Congenital Conditions
- Linear scleroderma (Parry-Romberg syndrome)
- Microphthalmos
- Congenital facial hemiatrophy
- Acquired Conditions
- Orbital trauma with fracture
- Silent sinus syndrome
- Orbital fat atrophy
- Metastatic Neuroblastoma (late stage)
Clinical Features
- Deepened superior sulcus
- Apparent ptosis
- Narrowed palpebral fissure
- Usually unilateral
Assessment & Imaging
Clinical Measurement
- Hertel Exophthalmometry
- Normal values vary by age and race
- Newborn: 10-12mm
- Children: 14-20mm
- Difference >2mm is significant
- Digital Photography
- Standardized views
- Serial monitoring
Imaging Studies
- CT Orbit
- Bony details
- Orbital contents
- Sinuses evaluation
- MRI Orbit
- Soft tissue details
- Optic nerve evaluation
- Intracranial extension
- Ultrasound
- Dynamic assessment
- Vascular lesions
- No radiation exposure
Management Approach
Exophthalmos Management
- Emergency Management
- Vision-threatening cases
- Orbital compartment syndrome
- Lateral canthotomy if needed
- Specific Treatment
- Based on underlying cause
- Antibiotics for infection
- Steroids for inflammation
- Chemotherapy for malignancy
Enophthalmos Management
- Conservative Care
- Observation in mild cases
- Lubricants for exposure
- Regular monitoring
- Surgical Options
- Orbital implants
- Volume augmentation
- Fracture repair if needed
Complications Prevention
- Regular corneal protection
- Vision monitoring
- IOP monitoring
- Color vision assessment
