Lõm mắt sau chấn thương: tái tạo ổ mắt trong trường hợp điều trị muộn Post-traumatic enophthalmos: secondary orbital reconstruCTion

Enophthalmos, or posterior displacement of the globe, is an important potential sequela of orbital trauma, particularly when fractures involving the orbital floor or walls are not adequately identified and reconstructed during the initial treatment.

Post-traumatic enophthalmos is not simply a problem of the globe itself. It is frequently the result of alteration of the complex three-dimensional anatomy of the orbit.

Why can orbital trauma cause enophthalmos?

The orbit is a complex three-dimensional bony structure. When the orbital floor or medial wall is fractured, disruption of the bony boundaries can increase the volume of the orbital cavity.

At the same time, orbital soft tissues may herniate or become displaced through the defect into the maxillary or ethmoid sinuses.

The combination of increased bony orbital volume and displacement of orbital soft tissues can result in posterior displacement of the globe and clinically apparent enophthalmos.

Post-traumatic atrophy of orbital fat may also contribute to the deformity in some patients, but it represents only one component of a multifactorial process.

Orbital fractures may occur in isolation or as part of more extensive facial injuries, including zygomaticomaxillary complex (ZMC) fractures, maxillary fractures, and naso-orbito-ethmoidal (NOE) fractures.

When enophthalmos becomes sufficiently pronounced, particularly at approximately 2 mm or greater, the asymmetry between the two eyes may become clinically noticeable and have a significant aesthetic impact.

A challenging case of delayed post-traumatic enophthalmos

A 25-year-old female patient had previously undergone treatment for facial trauma at another institution.

She subsequently presented to the National Hospital of Odonto-Stomatology, Hanoi, for removal of her osteosynthesis hardware and requested correction of persistent post-traumatic enophthalmos.

CT examination demonstrated a complex orbital defect involving both the orbital floor and medial wall.

An additional challenge was the delayed presentation.

In secondary cases, displaced orbital tissues may have developed fibrosis and adhesions, while normal anatomical landmarks can be more difficult to identify than in an acute fracture. Consequently, accurate restoration of the three-dimensional orbital anatomy becomes considerably more challenging.

Why does timing matter?

Not every orbital floor or wall fracture requires surgical reconstruction, and the timing of intervention must be determined according to multiple clinical factors, including visual function, ocular motility, diplopia, tissue entrapment, defect size, and globe position.

However, when orbital reconstruction is indicated, appropriate assessment and management during the earlier stages of injury are generally more favorable than correction of an established late deformity.

Once post-traumatic enophthalmos has developed, treatment becomes a secondary orbital reconstruction, which is technically considerably more demanding.

Restoring the three-dimensional anatomy of the orbit

The objective of orbital reconstruction is not simply to “push the eye forward.”

The fundamental goal is to identify the disrupted or missing bony anatomy, release displaced soft tissues, and restore the shape and volume of the orbit as closely as possible to its pre-injury anatomy.

This is why careful CT assessment and a detailed understanding of three-dimensional orbital anatomy are particularly important in delayed orbital reconstruction.

During my surgical training and clinical work in Japan, I had the opportunity to gain substantial exposure to the assessment and management of orbital trauma. This experience, together with knowledge acquired through international meetings focusing on maxillofacial trauma and reconstruction, was particularly valuable in the management of this challenging case.

Following secondary orbital reconstruction, the patient's enophthalmos showed significant improvement.

Nevertheless, in complex orbital injuries treated at a delayed stage, expectations must remain realistic. The objective is to achieve the greatest possible restoration of orbital anatomy, globe position, and facial symmetry rather than to assume that the original pre-traumatic anatomy can always be completely reproduced.

The images presented demonstrate the patient's CT findings before and after secondary orbital reconstruction.