Unmasking metastatic lung cancer through orbital apex syndrome

A female patient in her sixth decade of life presented with a 7-day history of progressive diminution of vision and restricted ocular motility associated with fever, headache and vomiting. On general examination, she was febrile (temperature 100.4°F) and had enlarged submandibular lymph nodes, along with multiple nodules on the scalp and upper back. At baseline, ocular examination revealed visual acuity of 20/30 in the right eye and hand movements close to the face in the left eye. A relative afferent pupillary defect was noted in the left eye. The Hirschberg test revealed left esotropia (15°^°) with an abduction deficit, suggestive of left sixth cranial nerve paresis. Fundus examination was unremarkable. A provisional diagnosis of left orbital apex syndrome (OAS) was made. A comprehensive work-up in neurology and dermatology was performed. Contrast-enhanced MRI of the brain and orbit suggested an asymmetrically enhancing lesion of the cavernous sinus, soft tissue involvement of the left orbital apex and a nodule involving the white matter of the left parietal lobe. Hormone analysis suggested a decreased level of thyroid-stimulating hormone, follicular-stimulating hormone and luteinising hormone. Fine needle aspiration cytology of a submandibular lymph node and nodules of the scalp and upper back was suggestive of metastatic mucin-secreting adenocarcinoma. Tumour marker analysis revealed raised CEA and CA 125. Further, a positron emission tomography scan revealed active lesions in the lungs with multiorgan spread, supporting the diagnosis of primary lung carcinoma with disseminated metastases manifesting as OAS. In view of the poor prognosis, the patient refused further treatment and succumbed to her condition 1 month following her diagnosis.This case highlights the importance of recognising subtle ocular signs, as they can be indicative of underlying life-threatening conditions. Early detection and thorough investigation of such symptoms are crucial, as they can lead to the identification of serious systemic diseases, such as metastatic cancer, that may otherwise be overlooked.