Non-traumatic enophthalmos: a review

Automatic Measurement and Comparison of Normal Eyelid Contour by Age and Gender Using Image-Based Deep Learning

Purpose

This study aimed to propose a fully automatic eyelid measurement system and compare the contours of both the upper and lower eyelids of normal individuals according to age and gender.

Design

Prospective study.

Participants

Five hundred and forty healthy Chinese aged 0 to 79 years in a tertiary hospital were included.

Methods

Facial images in the primary gazing position were used to train and test the proposed automatic system for eye recognition and eye segmentation. According to the 10-millimeter diameter circular marker, measurements were transformed from pixel sizes into factual distances.

Main Outcome Measures

Midpupil lid distances (MPLDs) every 15° of all participants were automatically measured in both genders (30 males and 30 females in each age group) by the proposed deep learning (DL)-based system. Intraclass correlation coefficients (ICCs) were performed to assess the agreement between the automatic and manual margin reflex distances (MRDs). The eyelid contour, eyelid asymmetry, and palpebral fissure obliquity were analyzed using MPLD, temporal-versus-nasal MPLD ratio, and the angle between the inner and outer canthi, respectively.

Results

The measurement of MRDs by the automatic system excellently agreed with that of the expert, with ICCs ranging from 0.863 to 0.886. As the age of the participants increased, the values of MPLDs reached a peak in those in their 20s or 30s and then gradually decreased at all angles. The temporal sector showed greater changes in MPLDs than the nasal sector, and the changes were more significant in females than in males. The maximum value of palpebral fissure obliquity appeared before 10 years in both genders and remained relatively stable after the 20s (P > 0.05).

Conclusions

The proposed DL-based eyelid analysis system allowed automatic, accurate, and comprehensive measurement of the eyelid contour. The refinement of eyelid shape quantification could be beneficial for future objective assessment preocular and postocular plastic surgery.

Financial Disclosures

The authors have no proprietary or commercial interest in any materials discussed in this article.

Acquired enophthalmos in idiopathic orbital inflammatory disease

Purpose

To describe a rare case of acquired enophthalmos in a patient with idiopathic orbital inflammatory disease after treatment with systemic corticosteroids.

Observations

Orbital socket contracture produces a non-traumatic enophthalmos and is most frequently reported as a consequence of orbital trauma or metastatic fibrosis. A previously healthy 64-year-old male presented with 3-month history of binocular diplopia and left proptosis, hypoglobus, supraduction deficit, and compressive neuropathy. Imaging techniques showed a left orbital mass; laboratory tests and biopsy of the mass lead to the diagnosis of idiopathic orbital inflammatory disease. Systemic corticosteroids were administered and, surprisingly, the patient developed left enophthalmos with eyelid retraction.

Conclusions and Importance

Although extremely unusual, orbital socket contracture can cause enophthalmos and visual morbidity in patients with idiopathic orbital inflammatory disease treated with corticosteroids.

360 Degrees Endoscopic Access to and Through the Orbit

The treatment of pathologies located within and surrounding the orbit poses considerable surgical challenges, due to the intricate presence of critical neurovascular structures in such deep, confined spaces. Historically, transcranial and craniofacial approaches have been widely employed to deal with orbital pathologies. However, recent decades have witnessed the emergence of minimally invasive techniques aimed at reducing morbidity. Among these techniques are the endoscopic endonasal approach and the subsequently developed endoscopic transorbital approach (ETOA), encompassing both endonasal and transpalpebral approaches. These innovative methods not only facilitate the management of intraorbital lesions but also offer access to deep-seated lesions within the anterior, middle, and posterior cranial fossa via specific transorbital and endonasal corridors. Contemporary research indicates that ETOAs have demonstrated exceptional outcomes in terms of morbidity rates, cosmetic results, and complication rates. This study aims to provide a comprehensive description of endoscopic-assisted techniques that enable a 360° access to the orbit and its surrounding regions. The investigation will delve into indications, advantages, and limitations associated with different approaches, while also drawing comparisons between endoscopic approaches and traditional microsurgical transcranial approaches.

Normative globe position values on orbital computed tomography in Australians

OBJECTIVE

To determine normal globe position values, interzygomatic distance (IZD), and globe axial length and width on computed tomography in an Australian cohort.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients who underwent computed tomography of the orbits. Patients with bilateral disease, previous orbital surgery, or poor scan quality were excluded.

METHODS

An axial slice through the midglobe was used to conduct the globe position measurements. Anterior globe position was defined as the perpendicular distance from the anterior globe margin to the interzygomatic line and posterior globe position as the perpendicular distance from the posterior globe margin to the interzygomatic line.

RESULTS

The normal measurements (mean ± SD) were IZD, 97.4 ± 4.1 mm; anterior globe position, 18.8 ± 2.8 mm; posterior globe position, 6.2 ± 2.9 mm; axial globe length, 24.9 ± 1.1 mm; and axial globe width, 25.9 ± 1.2 mm. A significant positive correlation was seen between the IZD and the anterior globe position (r = 0.15, p = 0.03), axial globe length (r = 0.33, p < 0.01), and axial globe width (r = 0.30, p < 0.01).

CONCLUSION

This normative globe position data may be used to diagnose radiologic exophthalmos or enophthalmos.

Prediction of exophthalmos by body mass index for craniofacial reconstruction: consequences for cold cases

It is inconvenient for a forensic practitioner to gather population-specific data before performing a facial reconstruction. The inconvenience may defeat the point of creating the reconstruction. The objective of this study was to evaluate a non-population-dependent method of determining exophthalmos. The protrusion of the eyeball is known to vary with the contents of the orbital cavity based on bony orbital resorption or increased or decreased fat contents, as well as according to relative eyeball size. Of use are available statistics on body mass index, and this is discussed within the context of eyeball protrusion. A weak positive correlation (0.3263) between the body mass index of the country where the study originated, and the degree of exophthalmos was found. The results suggest that eyeball protrusion rates can be established according to body mass index, and this framework may be more useful considering conventional police practices.

Acute Enophthalmos After Lumbar Puncture in a Patient with Type 1 Neurofibromatosis Related Sphenoid Wing Dysplasia

A 19-year-old woman with type 1 neurofibromatosis related sphenoid wing dysplasia underwent a lumbar puncture (LP) after an unexplained syncopal event. The cerebrospinal fluid work-up was unremarkable. However, 30-hours post LP, she developed marked enophthalmos ipsilateral to the calvarial dysplasia. The enophthalmos gradually resolved within 72 hours. We surmise that the patient's enophthalmos was due to an LP induced decrease of intracranial pressure in conjunction with the orbital bone anomaly.

The Facial Aging Process From the "Inside Out"

The normal course of aging alters the harmonious, symmetrical, and balanced facial features found in youth, not only impacting physical attractiveness but also influencing self-esteem and causing miscommunication of affect based on facial miscues. With this evidence-based paper, the authors aim to provide a comprehensive overview of the latest research on the etiology and progression of facial aging by explaining the aging process from the “inside out,” that is, from the bony platform to the skin envelope. A general overview of the changes occurring within each of the main layers of the facial anatomy is presented, including facial skeleton remodeling, fat pad atrophy or repositioning, changes in muscle tone and thickness, and weakening and thinning of the skin. This is followed by an in-depth analysis of specific aging regions by facial thirds (upper, middle, and lower thirds). This review may help aesthetic physicians in the interpretation of the aging process and in prioritizing and rationalizing treatment decisions to establish harmonious facial balance in younger patients or to restore balance lost with age in older patients.

Orbital varix: A rare case of unilateral exophthalmos, case report

The etiologies of unilateral exophthalmos are multiple, rarely represented by an intra- or extra-conical vascular mass. Orbito-palpebral varixes are rare (2% of orbital masses) and represent a main cause of unilateral intermittent exophthalmos, often of an inflammatory nature. We report a Case of right orbito-palpebral varix in a 65-year-old adult, with no particular history, evolving for 2 years. The ophthalmological examination showed a right palpebral mass, extended to the right external canthus, with palpebral collateral circulation, moderate right ptosis with exophthalmos, non-axial, non-pulsatile, without thrill, painless, without complication, without visual deficit. A vascular mass was suspected and MRI revealed a right orbito-palpebral varix with temporal extension, confirmed by ANGIO-MRI. The latter also allowed to search for a cerebral venous malformation, an encephalocele or a bone defect, associated and also to eliminate differential diagnoses (tumor, arteriovenous fistula …). Color Doppler ultrasound in the proclive position confirmed the diagnosis of orbital varices. A preventive low-dose anticoagulant treatment was started to avoid thrombosis, with therapeutic abstention in the absence of complications. A rigorous monthly follow-up in consultation is ensured. Orbito-palpebral varices are characterized by an extensive posterior intra-orbital character, often during their evolution and imposes a strict surveillance. In Case of complication (thrombosis, hemorrhage, pain, compressive signs of the optic nerve), surgical removal or sclerosis of the varix can be envisaged with disappointing results (recurrence, hemorrhage).

The Association of Zygomaticomaxillary Complex Fractures with Naso-Orbitoethmoid Fractures in Pediatric Populations

BACKGROUND

Naso-orbitoethmoid fractures associated with ipsilateral zygomaticomaxillary complex fractures are more challenging injuries than zygomaticomaxillary complex fractures alone. However, there is a paucity of information on this complex fracture pattern in the pediatric population. This study investigated the cause, treatment, and outcomes of combined zygomaticomaxillary complex and naso-orbitoethmoid fractures versus isolated zygomaticomaxillary complex fractures in pediatric patients.

METHODS

This was a 25-year retrospective cohort study of pediatric patients who presented to a single institution with zygomaticomaxillary complex fractures. Baseline patient demographics and clinical information, and concomitant injuries, treatment/operative management, and postoperative complications/deformities were recorded and compared between patients with combined zygomaticomaxillary complex and naso-orbitoethmoid fractures and patients with isolated zygomaticomaxillary complex fractures.

RESULTS

Forty-nine patients were identified to have had zygomaticomaxillary complex fractures in the authors' 25-year study period, of whom 46 had adequate clinical documentation and follow-up. Seventeen patients had combined zygomaticomaxillary complex-naso-orbitoethmoid fractures, of whom six had panfacial fractures. Both patient groups (zygomaticomaxillary complex only and combined zygomaticomaxillary complex-naso-orbitoethmoid fractures) were similar in terms of demographics. However, a significantly greater proportion of combined fracture patients experienced postoperative complications compared to isolated zygomaticomaxillary complex fracture patients, even after excluding those with panfacial fractures (87.5 percent versus 35.3 percent; p < 0.001). Enophthalmos (37.5 percent) and midface growth restriction (37.5 percent) were the two most common complications/deformities in all combined fracture patients.

CONCLUSIONS

High-impact trauma can lead to zygomaticomaxillary complex fractures with associated naso-orbitoethmoid fractures in children. This injury pattern was found to cause significantly greater postoperative morbidity than isolated zygomaticomaxillary complex fractures alone. Thus, pediatric patients presenting with this complex facial fracture pattern should be closely monitored.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Enophthalmos as the Initial Systemic Finding of Undiagnosed Metastatic Breast Carcinoma

Purpose

To report on the importance of detecting and investigating non-traumatic enophthalmos, which occurred as the first presenting sign of an undiagnosed metastatic breast carcinoma in two patients with no prior history of neoplasia.

Design

Case series.

Observations

The first case consists of a 74-year-old woman with no significant past medical history, who presented with a non-traumatic enophthalmos and ptosis of her left eye, and horizontal diplopia on right-gaze. Imaging revealed an intraconal lesion of her left orbit, with orbital fat atrophy. Transcutaneous anterior orbitotomy was performed for tumor biopsy, and the histopathology study concluded on a diagnosis of orbital metastasis consistent with infiltrative breast carcinoma. Thorough breast imaging and multiple breast biopsies were not able to localize the primary tumor. The second case consists of a 76-year-old woman, with no prior relevant medical history, who presented for progressive enophthalmos and ptosis of her right eye. Imaging revealed an osteolytic lesion of her right frontal bone, and multiple infiltrative lesions implicating both orbits. A biopsy was performed through a transcutaneous anterior orbitotomy and histopathology study lead to a diagnosis of metastatic lobular breast carcinoma. The primary breast tumor was localized using positron emission tomography, and further biopsy confirmed the diagnosis.

Conclusion

Although uncommon, non-traumatic enophthalmos has a broad differential diagnosis. In some rare instances, it may be the initial presentation of orbital metastases in patients with no prior history of cancer, and in the absence of other systemic symptoms. Clinicians must be thorough when assessing and investigating this clinical entity. A comprehensive eye exam, systemic evaluation, orbit imaging, biopsy and immunohistochemistry analysis are essential to promptly diagnose orbital metastases and plan the appropriate treatment.

Orbital Fat Injection: Technique and 5-Year Follow-Up

BACKGROUND

Orbital volume loss, early or late, is common after placement of an orbital implant or dermis fat graft, and there is currently no satisfactory long-lasting solution. Hyaluronic fillers are relatively easy to administer but are prone to migration and are temporary. Cannula-based orbital fat grafting has not gained the status of standard of care because of perceived low likelihood of success in the near term. This paper describes a technique for fat volume augmentation, its rationale, long-term follow-up, and a description of a complication unique to fat grafting in the orbit.

METHODS

Ten consecutive subjects with acquired anophthalmic enophthalmos were enrolled in two IRB (institutional review board)-approved protocols (10.27 and 12.01) undergoing a single session of autologous fat grafting to the orbit using a closed blunt cannula technique. Preoperative photography and non-contrast MRIs (magnetic resonance imaging) were obtained prior, immediately after, and at 1 year after injection. Yearly postoperative photography was performed on subjects with successful results.

RESULTS

Three of five subjects in IRB 10.27 clearly showed a clinically apparent increase in orbital volume at 1 year. One subject who failed to show improvement also sustained inadvertent injection into three extraocular muscles; she subsequently volunteered to enter IRB 12.01. Three of five subjects in IRB 12.01 did benefit, showing volume increase at 1 year, including the subject who had experienced intramuscular injection in 10.27. One subject in IRB 12.01 was lost to follow-up. Of the total of ten subjects enrolled, three showed no improvement and one was lost to follow-up; six subjects showed volume improvement at 1 year with two retaining the correction at 5 years and four showing variable diminution over 2-5 years. With the exception of the subject who sustained injection into extraocular muscles, none experienced complications.

CONCLUSION

A modified technique is recommended for orbital fat injection distinct from methods used elsewhere in the body. Theoretical limits of volumetric enhancement temper expectations in orbital fat grafting and should inform surgical planning. Cannula-based orbital fat grafting can be done safely and result in a gain of orbital fat volume at 1 year and in some cases up to 5 years.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Exophthalmometry with computed tomography]

Bone abnormalities of orbit seen in patients with trauma or radiolesion are accompanied by enophthalmos or exophthalmos. Conventional measurements of eyeball protrusion with Hertel's exophthalmometer or with computed tomography do not provide accurate and reliable data, especially in patients with asymmetry of lateral orbital rims.

PURPOSE

To develop a method of computed exophthalmometry that provides accurate and reliable measurements in patients with various orbital conditions.

MATERIAL AND METHODS

Medical records and computerized axial tomography scans of 25 patients' orbits without false enophthalmos or exophthalmos were analyzed posthoc. First group included 13 patients with trauma or radiolesion of the orbit at the different stages of plastic-reconstructive treatment. Second group consisted of 12 patients with lacrimal duct obstruction and without any orbital bone abnormalities. Eyeball protrusion was measured from a line joining styloid processes of temporal bones according to the developed method.

RESULTS

Comparison of the results of three independent measurements showed that in group 1 mean value varied from 0.40 mm to 10.13 mm and in group 2 - from 0.10 mm to 0.87 mm. Standard deviation (0.00-0.29 mm) and standard error in mean (0.00-0.17 mm) was the same in both groups.

CONCLUSION

The newly developed method of exophthalmometry with the use of computed tomography provides accurate and reliable data in patients with various orbital conditions including asymmetry of lateral orbital rims. Eyeball protrusion with asymmetry not exceeding 0.9 mm does not lead to functional and esthetical abnormalities and may be considered normal. The developed method is easy to setup and use, it can be applied in medical practice for diagnostics, surgery planning and evaluation of postoperative results in patients with various orbital conditions.

Periorbital changes associated with prostaglandin analogs in Korean patients

Background

Prostaglandin analogs (PGAs) are commonly used to treat glaucoma because of their powerful intraocular pressure lowering effect. However, various periorbital changes associated with the use of PGAs have been reported. We investigated the incidence of periorbital changes in Korean patients who were treated with PGAs, and analyzed clinical factors associated with superior sulcus deepening.

Methods

This study included 58 glaucoma patients who were treated with latanoprost, travoprost, or bimatoprost unilaterally. Face photographs were collected, and periorbital changes such as superior sulcus deepening, eyelid pigmentation, ptosis, lid retraction, dermatochalasis, and redness were evaluated by two oculoplastic specialists. For each patient, the contralateral eye served as a control. The frequency of ptosis, dermatochalasis, pigmentation, erythema, and superior sulcus deepening were analyzed. Demographic and ocular factors were compared between patients who showed superior sulcus deepening and those who did not.

Results

Thirty-one patients (53.4%) showed one or more periorbital changes associated with PGAs. The most common change was superior sulcus deepening (24.1%), followed by eyelid pigmentation (19.0%), eyelid erythema (19.0%), dermatochalasis (10.3%), eyelid retraction (5.2%), and ptosis (3.4%). The age of the patient and the duration of PGA administration was significantly correlated with superior sulcus deepening (p = 0.007, p = 0.002, respectively).

Conclusions

Periorbital changes are frequently seen in patients who use PGAs, and superior sulcus deepening is the most common change in Korean patients. Long-term use of PGAs and old age were associated with superior sulcus deepening.

Enophthalmos and Hemifacial Skeletal Atrophy After Trigeminal Nerve Injury

A 60-year-old woman presented with several years increasing right upper eyelid ptosis. She had undergone surgical decompression of the right trigeminal nerve in the posterior cranial fossa 15 years earlier for trigeminal neuralgia. This left her with permanent numbness in the second and third divisions of the trigeminal nerve. In addition to the ptosis, she was found to have right enophthalmos and a smaller right face. CT scans showed a smaller midfacial skeleton on the right and a depressed orbital floor. The changes were different to those seen in silent sinus syndrome. Photographs taken over many years showed the facial changes were acquired and came on gradually many years after the trigeminal nerve injury. It is possible that trigeminal nerve injury may lead to trophic changes in the facial skeleton, but these have not been previously reported.

Silent sinus syndrome: an underdiagnosed entity

We describe a case of a 33-year-old Caucasian woman with right facial asymmetry and no sinonasal symptoms. She was referred to the ophthalmology department as having right palpebral ptosis. On physical examination, she presented painless enophthalmos and hypoglobus of the right eye. The MRI of the brain only showed sinonasal inflammatory signs of the right maxillary sinus. The CT scan revealed opacification of the right maxillary sinus, with retraction of the sinus walls. We confirmed the diagnosis of silent sinus syndrome. The patient underwent functional endoscopic sinus surgery. One year after surgery, despite clinical and aesthetic improvement, slight enophthalmos remained, but there were no other complications. In our case, the diagnosis of facial asymmetry as ptosis led to an initial imaging investigation to exclude neurological causes. Silent sinus syndrome should be included in the differential diagnosis of facial asymmetry. Despite the clinical suspicion, the diagnosis can only be confirmed by imaging studies.

Acquired enophthalmos with systemic lupus erythematosus

Ocular involvement sometimes occurs with systemic lupus erythematosus (SLE) but enophthalmos with SLE is rare. We report a case of enophthalmos with SLE. A 25-year-old male was admitted for two weeks of fever, sore throat, arthralgia, chest pain and right arm weakness with pain. We diagnosed him with SLE with malar rash, arthritis, pleural effusion, proteinuria, leukopenia, positive antinuclear antibody, anti-dsDNA, and lupus anticoagulant. The patient was prescribed high-dose prednisolone and hydroxychloroquine 400 mg. One week after discharge, he complained about a sensation of a sunken right eye. CT showed right enophthalmos, a post-inflammatory change and chronic inflammation. Proteinuria increased to 3.8 g/day after the patient stopped taking prednisolone. Cyclophosphamide therapy was administered for three months without improvement. We decided to restart prednisolone and change cyclophosphamide to mycophenolate mofetil. Proteinuria decreased but enophthalmos remains as of this reporting.

The temporoparietal adipofascial flap for the correction of recurrent idiopathic enophthalmos

Enophthalmos, the posterior displacement of a normal-size ocular globe relative to the orbital cavity, is usually repaired using autogenous grafts or alloplastic materials. We present the case of a 40-year-old man with bilateral idiopathic enophthalmos whose symptoms recurred 8 years after initial successful surgical repair. We describe the successful and safe use of a bilateral temporoparietal adipofascial flap in the treatment of recurrent idiopathic enophthalmos.

The volumetric change of orbital fat with age in Asians

Lower eyelid prominence occurs as an aging process. Several causes of age-related lower eyelid prominence including herniated excessive intraorbital fat or fat atrophy, weakening of supporting components, and globe descent have been proposed. However, actual occurrence of excessive intraorbital fat herniation is still controversial. We measured volume of total orbital fat (OF) and fat anterior to the inferior orbital rim (IORF) using computed tomography (CT) to evaluate volumetric change of orbital fat with age in Asians. A total of 130 patients (65 men and 65 women) were evaluated, and volumes of OF and IORF were measured. OF and IORF volumes increased until the 60 years of age, and then decreased in both male and female groups. IORF/OF ratio increased with age, and, unlike fat volume, there was no decline after 70 years of age. Increase of orbital fat volume contributed to lower eyelid prominence. Reduction of anterior orbital fat volume could improve age-related lower eyelid prominence, and conservative fat excision in lower blepharoplasty can be useful in management of lower eyelid prominence.

Neuro-ophthalmology of orbital disease

In this chapter the presentation and management of common orbital diseases are discussed. An accurate clinical history and assessment are essential, with computed tomography being the imaging of choice. Magnetic resonance imaging provides detail of intrinsic optic nerve disease and orbital apical or intracranial pathology, and ultrasonography is valuable in assessing anterior orbital masses, in particular vascular lesions. Inflammatory lesions require a tissue biopsy before immunosuppression is instituted. Exceptions to this principle are scleritis, myositis, thyroid eye disease, and characteristic orbital apex syndrome, in which delay in immune suppression may jeopardize visual outcome. The term "orbital pseudotumor" is now obsolete. The management of active thyroid eye disease includes immunosuppression and low-dose orbital radiotherapy. Urgent orbital decompression is indicated in the presence of nonresponsive optic neuropathy, and inactive disease is managed by decompression for exophthalmos, and correction of muscle imbalance and lid retraction. Subacute lacrimal gland inflammation, unresponsive to a few weeks of nonsteroidal treatment, may be due to underlying carcinoma and a specialist opinion should be sought without delay. Pleomorphic adenoma, with typical features on imaging, should always be excised intact to avoid subsequent pervasive malignant disease.

Ocular findings in patients with systemic sclerosis

OBJECTIVE

To evaluate the frequency and characteristics of ocular manifestations in outpatients with systemic sclerosis.

METHODS

In this cross-sectional study, 45 patients with systemic sclerosis were enrolled. Data regarding demographics, disease duration and subtype, age at diagnosis, nailfold capillaroscopic pattern and autoantibody profile were collected, and a full ophthalmic examination was conducted. Parametric (Student's t-test) and nonparametric (Mann-Whitney U test) tests were used to compare continuous variables. Fisher's exact test was used to compare categorical data. P values < 0.05 were considered significant.

RESULTS

Twenty-three subjects (51.1%) had eyelid skin changes; 22 (48.9%) had keratoconjunctivitis sicca, 19 (42.2%) had cataracts, 13 (28.9%) had retinal microvascular abnormalities and 6 (13.3%) had glaucoma. Eyelid skin changes were more frequent in patients with the diffuse subtype of systemic sclerosis and were associated with a younger age and an earlier age at diagnosis. Cataracts were presumed to be age-related and secondary to corticosteroid treatment. There was no association between demographic, clinical or serological data and keratoconjunctivitis sicca. The retinal microvascular abnormalities were indistinguishable from those related to systemic hypertension and were associated with an older age and a severe capillaroscopic pattern.

CONCLUSIONS

Eyelid skin abnormalities and keratoconjunctivitis sicca were the most common ocular findings related to systemic sclerosis. Some demographic and clinical data were associated with some ophthalmic features and not with others, showing that the ocular manifestations of systemic sclerosis are characterized by heterogeneity and reflect the differences in the implicated pathophysiological mechanisms.

[Orbital varix presenting with enophthalmos. A case report]

We report a 23-year-old patient, presenting with enophthalmos in the left eye. The ophthalmologic examination was normal, except a 3-mm enophthalmos measured using the Hertel's exophthalmometer and an intermittent proptosis observed through the Valsalva maneuver. Orbital imaging tests disclosed a retroocular vascular lesion. A carotis arteriography was performed, and it revealed a tumor with vascular elements presumed to be orbital varix. Ultrasound Doppler examination showed a nonechogenic lesion with an increasing volume during Valsalva. Based on these findings, the tumor was diagnosed as orbital varix. We decided to manage the patient conservatively, in the absence of complications such as proptosis with corneal exposure, optic nerve compression, or esthetically unacceptable appearance. Orbital varix is a vascular anomaly, accounting for 2 % of orbital tumors. It generally presents with an intermittent exophthalmos or orbital hemorrhages. The development of enophthalmos associated with varices, such as reported in our case, is rare.