Orbital metastases

Orbital metastasis, although uncommon, is a condition optometrists should consider in a patient presenting with proptosis, ptosis, diplopia, or a lid mass with a history of cancer. However, in as many as 19% of cases, patients have no prior or concurrent history of systemic cancer when presenting with ophthalmic symptoms. If suspecting an orbital metastasis, neuroimaging is important, as well as a referral to the patient's primary care provider, oncologist, and ophthalmologist.

Three patients with orbital metastasis are discussed. The first was a 55-year-old white man who initially presented with a left ptosis of unclear etiology. Magnetic resonance imaging of his orbits and an orbital biopsy found metastatic esophageal adenocarcinoma. Radiotherapy and chemotherapy were initiated, but the patient died shortly afterward. The second patient was a 49-year-old black man who also presented with a ptosis of the right upper eyelid. An area of the retina appeared elevated; ophthalmic B-scan and computed tomography of the orbits confirmed the presence of a mass, determined to be metastatic lung carcinoma to the right orbit. A course of radiotherapy was initiated, but the patient died 3 days after completing therapy. The last case was a 77-year-old white man with a history of metastasis to the left orbit from non-Hodgkin's lymphoma. On examination, he had proptosis of the left eye, initially thought to be caused by a recurrence of the metastasis. However, a computed tomography scan showed a new meningioma in the same orbit, and treatment was started. The proptosis improved, and the patient continues to be followed up regularly.

Any patient with proptosis and/or ptosis with a history of cancer should be evaluated for orbital metastasis. Optometrists should keep in mind that an orbital metastasis may represent the initial manifestation of undiagnosed systemic cancer. Prognosis can be poor, and thus treatment is sometimes palliative in nature, intending to slow the progression of the disease instead of providing a cure.