Destruction of the orbit and globe by recurrence of basal cell carcinoma

Basal cell carcinoma (BCC) is the most common skin malignancy and represents 90% of eyelid malignancies. Of those that occur on the eyelids, most involve the lower lid. Risk factors for BCC include environmental and genetic factors. There are several clinical presentations, the 2 main forms of which are 1) nodular and 2) morpheaform (or sclerosing). Several treatment options exist, including surgical excision, cryotherapy, radiotherapy, laser surgery, chemotherapy, and photodynamic therapy. The average rate of recurrence is 5%, depending on the type of BCC, the size, the location, and therapeutic approach.

The patient described in this case report had basal cell carcinoma of the upper right lid 4 to 5 years prior to examination. At that time the patient was treated with surgical excision and radiotherapy. Subsequently, he had not received any eye care since the initial surgery to remove the malignancy. His entering complaint was drainage and an odor emanating from his right eye. The upper lid was retracted and had a lesion suspicious for BCC. The globe was keratinized, inflamed, and proptotic. He was referred to the oculoplastics service to confirm the recurrence of BCC. They found that the BCC had infiltrated the right globe and the retro-orbital region and probably invaded the adjacent bony margins. He had extensive surgery to remove the tumor and subsequent skin grafting.

BCC, when treated early, has excellent surgical outcomes. However, there is no procedure that has a zero recurrence rate. BCC, although rarely metastatic, can be invasive. This case underscores the importance of proper follow-up protocol for all surgical patients as well as patient education that reinforces the importance of follow-up care and self-monitoring on the part of the patient.