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[Diplopia as first symptom of a bronchogenic carcinoma]
I M Velten1, G C Gusek-Schneider, B Tomandl
1Augenklinik mit Poliklinik, Universität Erlangen-Nürnberg. isabel.velten@augen.med.uni-erlangen.de
Patients:
In about 30% of patients with orbital metastases, these metastases are detected before the primary tumour is known. Less than 5% of orbital metastases are located in extraocular muscles. We report on a patient with diplopia caused by diminished abduction of the left eye as first symptom of a bronchogenic carcinoma.
Patient:
A 86-year-old patient presented with a newly developed diplopia. On examination, the left eye showed a diminished abduction, ptosis and miosis. Pharmacological testing revealed peripheral Horner's syndrome. On cranial magnet resonance tomography, the lateral rectus muscle belly was enlarged. A chest X-ray showed a large tumour (6 cm in diameter) of the left upper lobe with multiple metastases to the lungs. Further examinations revealed a large cell bronchogenic carcinoma with metastases to the lungs, adrenal glands, and the lateral rectus muscle.
Conclusions:
Diplopia caused by metastases to extraocular muscles is rare as first sign of a bronchogenic carcinoma. The combination of peripheral Horner's syndrome with diminished abduction of the homolateral eye primarily suggests a lesion of the cavernous sinus. The bronchogenic carcinoma could not be causative for Horner's syndrome in the patient presented here, however an undetected tumor-infiltration of the postganglionic region cannot be excluded. This case demonstrates that in all patients with newly developed diplopia and Horner's syndrome, even in absence of orbital signs, apart from a ophthalmological examination detailed radiographic or magnetic resonance tomographic imaging is necessary of both skull base and orbita.
Insights
Orbital metastases from bronchogenic carcinoma are rare, especially as the first symptom. This case highlights diplopia and Horner's syndrome as initial signs, necessitating thorough imaging for early diagnosis.
Area of Science:
- Ophthalmology
- Oncology
- Neurology
Background:
- Orbital metastases are uncommon, with only 30% diagnosed before the primary tumor.
- Extraocular muscle involvement in orbital metastases is rare, affecting less than 5% of cases.
Observation:
- An 86-year-old patient presented with new-onset diplopia and diminished abduction in the left eye.
- Examination revealed ptosis, miosis, and peripheral Horner's syndrome, with MRI showing an enlarged lateral rectus muscle.
Findings:
- The patient was diagnosed with large cell bronchogenic carcinoma with widespread metastases.
- The diplopia was attributed to metastasis within the lateral rectus muscle, a rare presentation.
Implications:
- This case underscores the importance of considering bronchogenic carcinoma in patients with unexplained diplopia and Horner's syndrome.
- Comprehensive imaging of the skull base and orbits is crucial, even without apparent orbital signs, for timely diagnosis and treatment.