54 Enophthalmos
CLINICAL EXAMINATION
The patient should be examined for evidence of ocular pain which can cause retraction of the globe. Thus a corneal lesion such as an ulcer or laceration, and severe uveitis or a lens luxation can all cause sufficient ocular pain to contract the retractor oculi muscle such that the globe sinks and the nictitans membrane becomes elevated. An ocular discharge is likely to be present in painful eyes – varying from serous epiphora to overt purulent material. This should be differentiated from the accumulation of mucus seen at the medial canthus in patients with deep set eyes (see Case example 12.1 on medial canthal pocket syndrome). Pupil size should be checked – a miotic pupil in an enophthalmic eye should suggest Horner’s syndrome, especially if the eye is not inflamed with no evidence of uveitis. The patient should be examined in bright and dim light, and the degree of anisocoria assessed. It will be more noticeable in the dark, as the affected pupil fails to dilate. The other signs of Horner’s syndrome, namely ptosis and elevation of the nictitans membrane, will usually be present, together with the enophthalmos and miosis, and all result from damage to the sympathetic supply to the eye.