The differential diagnosis for an adult patient who presents with enophthalmos includes orbital blow-out fracture, silent sinus syndrome, scirrhous breast carcinoma metastases, localized scleroderma, and postirradiation atrophy. For example, orbital blow-out fractures can lead to enophthalmos when there is persistent orbital fat herniation through orbital wall defects or persistently displaced fracture fragments that lead to orbital cavity expansion (Fig. 54.2). While a history of trauma may be given, patients may not always recall this. Silent sinus syndrome consists of enophthalmos secondary to orbital vault expansion associated with atelectasis of the ipsilateral maxillary sinus. It can also develop after orbital trauma that damages the ostiomeatal complex. The maxillary sinus is often completely opacified, and the infundibulum is collapsed (Fig. 54.3). Scirrhous breast carcinoma metastases to the orbit can lead to retraction of the globes rather than proptosis due to desmoplastic fibrosis. These metastases can appear as infiltrative enhancing lesions (Fig. 54.4).