Case report

A 57-year-old woman presented with progressive right enophthalmos 2 years following trauma to the right globe. Initially, she had a fall and a severe head trauma, with periorbital oedema and pain. X-rays had shown no orbital or facial fractures and the rest of the clinical examination was normal. No further investigations were performed at this stage. She also suffered from hypothyroidism and chronic obstructive airway disease. Visual acuity was 6/9 bilaterally and the right eye had reduced motility in all directions of gaze, 5 mm enophthalmos and slight ptosis (Figure 1A–C).

CT scan of the orbits showed severe right-sided enophthalmos with generalised loss of extraocular muscle definition and markedly reduced retrobulbar fat space suggestive of diffuse fibrosis encasing the muscle cone. There was no mass lesion surrounding the optic nerve or infiltrating the muscles. Bone contours were normal with no fractures or bone destruction (Figure 1D). A presumed diagnosis of post traumatic orbital fibrosis was made and right orbital biopsy performed. Two incisional biopsies of the orbital lesion were taken under general anaesthetic via an inferior fornix incision and preserved in formalin. No frozen sections were performed.