Enophthalmos as a sign of metastatic breast carcinoma

Abstract

A 70-year-old woman, who had undergone a right mastectomy 17 years earlier for breast adenocarcinoma, presented with gradual deterioration of vision in her left eye and intermittent diplopia of at least 1-year duration. Her visual acuity was 20/40 in the left eye and 20/20 in the right. Enophthalmos, ptosis, induration of the periorbital skin, restricted eye movements and incomplete eyelid closure were seen on the left side, along with conjunctival injection with punctate corneal staining, indicative of ocular surface exposure (Figure 1).Orbital computed tomography (Appendix 1, available at www.cmaj.ca /lookup /suppl /doi :10 .1503 /cmaj.120726/-/DC1) showed an ill-defined mass in the left antero-superior orbit. The biopsy results were consistent with estrogen-receptorpositive and HER2-negative metastatic breast carcinoma (Appendix 1). In the absence of metastatic disease elsewhere, the patient was started on letrozole. She may require orbital radiotherapy if her disease progresses.Enophthalmos has many causes, including orbital fractures, silent sinus syndrome, orbital fat atrophy, orbital varices, orbital inflammation with fibrosis, and orbital tumours.1 Orbital metastases are relatively uncommon, accounting for 1%-13% of orbital tumours.2 Scirrhous (or fibrosing) breast carcinoma is the most common tumour that metastasizes to the orbit; it causes enophthalmosis by retraction of the orbital contents.2,3 A long latency period, averaging 4.5-6.5 years, usually exists between the initial diagnosis of breast carcinoma and the detection of orbital metastases. 2A careful history and examination, assisted by orbital imaging (computed tomography or magnetic resonance imaging), are essential for diagnosing orbital metastases. 4 Enophthalmos may indicate the presence of metastatic breast cancer and may occur even if the primary lesion is occult.5 Histopathologic examination should be considered, even for patients with a known history of systemic cancer, before planning treatment.

Isolated enophthalmos: an uncommon gateway to orbital tumors in pediatrics: 9 month-old female presenting with isolated enophthalmos as the unique sign of a metastatic orbital tumor: a case report

“…Exophthalmos is the most commonly known symptom of orbital tumors in adults and children [ 2 ] and is, usually easy to recognize, and always brings to mind the possibility of a neoplasm. Conversely, if a few cases have been described in adults [ 1 , 3 – 5 ], there is only very little knowledge of the association between enophthlamos and orbital tumors in children [ 2 ] ; because of the scarcity of both entities and the difficulty in clinically objectivizing this symptom. In fact, enophthalmos is a posterior displacement of the eyeball within the orbit but its diagnosis is tricky because there is no agreement on a clear definition, especially in children.…”

“…Fitting into this category are adult cases of enophthalmos, which can reveal various types of orbital neoplasms. Affected patients are usually females with breast cancer [ 1 , 5 ]. When the musculature is invaded, areas of fibrosis are created causing posterior traction of the eyeball.…”

“…When the musculature is invaded, areas of fibrosis are created causing posterior traction of the eyeball. In such cases, enophthalmos is usually not isolated and is associated with a palpable mass, impaired eye motility, diplopia, orbital pain, drooping of the upper eyelid etc.. [ 1 , 3 – 5 ]. Third: fat atrophy (such as in senile fat atrophy and orbital varices) might induce an eyeball displacement by shrinking the orbital content [ 4 , 5 ].…”

“…However, more scarce signs need to be recognized. Among these, enophthalmos has already been described in adults [ 1 ] but has never been reported as a sole indicator of orbital neoplasms in pediatrics. We report the first case of a pediatric metastatic neuroblastoma revealed by enophthalmos alone and stress the importance of this sign as a revealing symptom of orbital tumors in children.…”