Description
A woman with a 1-year history of diplopia presented to the Ophthalmology Clinic in June 2014. She had a known history of infiltrating ductal carcinoma of the breast with metastasis to the bone and had undergone chemotherapy for this. On the day of her consultation, her visual acuity was 6/9 bilaterally and she was experiencing diplopia in extreme up and down gazes. She was referred for an MRI of the head and orbits, which revealed multiple metastatic deposits to the multiple extraocular muscles bilaterally (figures 1 and 2) as well as within the brain.
Figure 1.
MRI T1 fatsat post contrast axial slice: demonstrating breast cancer metastatic lesions in the left inferior rectus (red arrow) and right lateral rectus (blue dashed arrow).
Figure 2.
MRI T1 fatsat post contrast coronal slice: demonstrating breast cancer metastatic lesions in the left lateral rectus (blue dashed arrow) and left inferior rectus muscle (red arrow).
Although rare, there are accounts of numerous malignancies with metastasis to the orbits, including breast, lung, genitourinary and gastrointestinal tumours.1 Of these, breast tumours have been reported as the most common malignancy to do so.2 However, bilateral metastasis to more than two extraocular muscles of this tumour, such as in this case, has been acknowledged as being very unusual.3
Patients with metastasis to the extraocular muscles usually present with symptoms of reduced vision, diplopia and pain in the region. Additionally, they may experience proptosis and ptosis.
The diagnosis can only be confirmed histologically. In this case, the patient underwent a muscle biopsy from the left extraocular muscle, which confirmed the diagnosis of breast cancer metastasis. She was treated with whole brain radiotherapy and a follow-up MRI demonstrated she had had a partial response to this. She currently continues management under oncology.
Learning points.
Numerous malignancies are known to metastasise to the orbits, with malignancy of the breast remaining the most common to do so.
Bilateral metastasis to more than two extraocular muscles is a very rare finding.
Clinical suspicion of metastatic spread to the orbits should remain high in patients with a known history of carcinoma who present with relevant symptoms.
Acknowledgments
Dr Nagini Sarvanathan (consultant ophthalmologist) and Dr Ion Boiangiu (consultant oncologist).
Footnotes
Competing interests: None declared.
Patient consent: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.
References
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