Ewha Med J.  2017 Jul;40(3):136-139. 10.12771/emj.2017.40.3.136.

Unilateral Ptosis with Bilateral Incomplete Ophthalmoplegia as the Initial Presentation in Metastatic Cancer

Affiliations
  • 1Department of Neurology, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea. pkd1165@ewha.ac.kr
  • 2Department of Ophthalmology, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea.

Abstract

Orbital metastases are rare and predominantly unilateral occurrences. Bilateral metastases affecting the extraocular muscles are extremely rare. A few case reports of bilateral metastases to extraocular muscles described binocular diplopia with conspicuous bilateral external ophthalmoplegia as an initial symptom. We report a case in which unilateral ptosis was an initial symptom and bilateral incomplete ophthalmoplegia was found on initial neurologic examination in invasive ductal carcinoma of the breast. The patient had hormone receptor-positive breast cancer, and so was treated by hormonal therapies and closely monitored. The presence of a secondary orbital lesion presents many difficulties of differential diagnosis and treatment. A thorough neurologic examination to detect ocular manifestations is most important for localization and broad differential diagnosis including mechanical orbital metastatic lesion.

Keyword

Orbital neoplasms; Neoplasm metastasis; Neurologic examination; Carcinoma, ductal, breast

MeSH Terms

Breast
Breast Neoplasms
Carcinoma, Ductal
Carcinoma, Ductal, Breast
Diagnosis, Differential
Diplopia
Humans
Muscles
Neoplasm Metastasis
Neurologic Examination
Ophthalmoplegia*
Orbit
Orbital Neoplasms
Telescopes

Figure

  • Fig. 1 Extraocular muscles examination (A) and orbit magnetic resonance imaging (MRI) findings (B). Extraocular movement examination reveals slightly limited abduction and adduction in the right eye, and slightly limited elevation and abduction in the left eye. Left eye ptosis is evident with margin reflex distance 1 of 3 mm. Axial and coronal section of the orbit MRI shows enhancing mass (0.9×1.2×2.1 cm) in the right lateral rectus muscle of the right eye. There are enhancing masses in left medial rectus muscle of the left eye and intraconal lesion around left medial rectus muscle. Coronal section of the orbit MRI shows enhancing mass (6.7×2.5×1.5 cm sized) in left superior lateral extraconal area, which suggests the high probability of metastasis.


Reference

1. Vlachostergios PJ, Voutsadakis IA, Papandreou CN. Orbital metastasis of breast carcinoma. Breast Cancer (Auckl). 2009; 3:91–97.
Article
2. Ng E, Ilsen PF. Orbital metastases. Optometry. 2010; 81:647–657.
Article
3. Jiang H, Wang Z, Xian J, Ai L. Bilateral multiple extraocular muscle metastasis from hepatocellular carcinoma. Acta Radiol Short Rep. 2012; 1:arsr.2011.110002.
Article
4. Murthy R, Gupta A, Hegde S, Honavar SG. Bilateral multiple extraocular muscle metastasis from breast carcinoma. Indian J Ophthalmol. 2011; 59:381–382.
Article
5. Kouvaris JR, Gkongkou PV, Papadimitriou CA, Papacharalampous XN, Antypas CE, Balafouta MJ, et al. Bilateral metastases to extraocular muscles from lobular breast carcinoma. Onkologie. 2008; 31:387–389.
Article
6. Spitzer SG, Bersani TA, Mejico LJ. Multiple bilateral extraocular muscle metastases as the initial manifestation of breast cancer. J Neuroophthalmol. 2005; 25:37–39.
Article
7. Slamovits TL, Burde RM. Bumpy muscles. Surv Ophthalmol. 1988; 33:189–199.
Article
8. Allred DC, Harvey JM, Berardo M, Clark GM. Prognostic and predictive factors in breast cancer by immunohistochemical analysis. Mod Pathol. 1998; 11:155–168.
9. Keane JR. Bilateral ocular paralysis: analysis of 31 inpatients. Arch Neurol. 2007; 64:178–180.
10. Kim IS, Choi JB, Rah SH, Lee SY. Classification of ptosis in Korea. J Korean Ophthalmol Soc. 2005; 46:1262–1269.
11. Ahmad SM, Esmaeli B. Metastatic tumors of the orbit and ocular adnexa. Curr Opin Ophthalmol. 2007; 18:405–413.
Article
12. Shields JA, Shields CL, Brotman HK, Carvalho C, Perez N, Eagle RC Jr. Cancer metastatic to the orbit: the 2000 Robert M. Curts Lecture. Ophthal Plast Reconstr Surg. 2001; 17:346–354.
13. Liu D. Complications of fine needle aspiration biopsy of the orbit. Ophthalmology. 1985; 92:1768–1771.
Article
14. Harbeck N, Gnant M. Breast cancer. Lancet. 2017; 389:1134–1150.
Article
15. Kemp Z, Jones A. A shift in the treatment of hormone receptor and human epidermal growth factor receptor 2-positive metastatic breast cancer. Adv Ther. 2011; 28:603–614.
Article
Full Text Links
  • EMJ
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr