Globe Retraction Clinical Presentation

Obtain a complete history, including age at onset of signs and symptoms, duration of symptoms, progression or improvement of symptoms, rapidity of progression, and review of systems for other medical conditions, as follows:

• Acute versus chronic

• Mechanism of injury - Fist, ball, motor vehicle accident, metallic foreign body

• Past ocular and medical history - Previous ocular or orbital trauma, previous eye surgery, other ocular conditions (eg, amblyopia, glaucoma, retinal detachment), family history of cancer, known primary tumor, previous surgeries (eg, biopsies or urogenital tract procedures), history of radiotherapy to orbit

Ophthalmic symptoms

Ophthalmic symptoms may include the following:

• Diplopia - Strabismus, globe displacement, restriction of extraocular movements, traumatic optic nerve or ocular motor nerve palsy, floor fracture, convergence retraction nystagmus

• Narrowing of palpebral fissure - Ptosis (ie, mechanical, neurogenic, myogenic), narrowing during adduction, pseudoptosis (globe retraction/enophthalmos), Duane syndrome

• Pain - Hemorrhage and edema, perineural invasion, or orbital tumor

• Decreased vision - Optic nerve compression, traumatic optic neuropathy, concurrent ocular injury, amblyopia

• Anomalous head position - Stereopsis, binocularity

Complete ophthalmologic examination (defer if obvious globe rupture)

A complete ophthalmologic examination includes the following:

• Vision and pupils - Amblyopia, ocular trauma, traumatic optic neuropathy, relative afferent pupillary defect, anisocoria

• Extraocular motility and alignment - Traumatic ocular motor cranial nerve palsy, entrapment of extraocular muscles, pain with extraocular movements, severity of strabismus, lack of abduction (Duane type I), lack of adduction (Duane type II), lack of both adduction and abduction (Duane type III), presence of upshoots or downshoots in adduction, multiple motility deficits (posterior traction and tethering of globe in scirrhous breast carcinoma)

• External examination - Infraorbital anesthesia, enophthalmos of globe (Hertel exophthalmopathy), globe ptosis, narrowing of palpebral fissure with adduction, blepharoptosis or pseudoptosis, deep superior sulcus, preauricular or submandibular adenopathy, restrictive enophthalmos (eg, scirrhous breast carcinoma), pseudoenophthalmos due to contralateral exophthalmos

• Intraocular pressure -Angle-recession glaucoma, secondary glaucoma from orbital mass

• Anterior segment - Evidence of previous trauma (eg, corneal scar, angle recession, corectopia, phacodonesis, iridodonesis, lens rupture, lens subluxation)

• Posterior segment - Retinal detachment, chorioretinal scarring, hemorrhage, optic nerve pallor, optic nerve avulsion

Duane retraction syndrome is a congenital condition that is believed to be due to aberrant innervation of extraocular muscles.

Abnormal synergistic innervation between medial and lateral rectus muscles causes co-contraction of 2 muscles resulting in globe retraction during attempted adduction.

Abnormal synergistic innervation between medial and vertical rectus muscles may explain upshooting and downshooting eye movements.

Blunt trauma is the most common cause of orbital blowout fractures.

Iatrogenic causes such as prior orbital decompression surgery or sinus surgery may cause enophthalmos.

Risk factors for breast cancer include the following:

• Increasing age

• Family history - Especially first- and second-degree relatives with premenopausal cancer (including paternal relatives)

• Early menstruation/late menopause

• Nulliparity

• Premalignant breast lesions or previous carcinoma in 1 breast (especially premenopausal)

• Obesity

• History of previous radiation therapy to chest

Physical examination should assess for the following:

• Evidence of trauma elsewhere
• Other cranial neuropathies
• Evidence of prior breast carcinoma or metastatic disease

Complications may result from the following:

• Delayed diagnosis
• Inadequate imaging
• Surgical complications