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T. Wong, R. A. Egan, W. T. Shults, J. Ng, J. L. Weissman; Paradoxical Enophthalmos and Orbital Breast Metastasis. Invest. Ophthalmol. Vis. Sci. 2007;48(13):3587.
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An orbital mass usually causes proptosis. Metastatic scirrhous carcinoma of the breast, however, causes enophthalmos rather than proptosis. Enophthalmos on neuroimaging in the setting of an orbital mass may be the only clue to the diagnosis despite previous negative orbital biopsies. We present three patients where the diagnosis rests on the high suspicion of the ophthalmologist and neuroradiolgist due to the paradoxical nature of an orbital mass causing enophthalmos.
We have three patients with biopsy proven scirrhous breast metastasis to the orbit with enophthalmos shown on neuroimaging. In all three cases, the diagnosis of breast metastasis was not obvious. In the first case, enophthalmos was only obvious on neuroimaging and not on clinical exam. In the last two cases, the patients initially had biopsies which did not show breast carcinoma. High clinical suspicion prompted repeat biopsies to show the pathology. Neuroimaging showing enophthalmos in the setting of an orbital mass is highly suspicious for metastatic breast carcinoma (Figure 1).
In summary, enophthalmos (or the lack of proptosis) in the setting of an orbital mass on CT or MRI should suggest a diagnosis of metastatic scirrhous carcinoma of the breast, and encourage another biopsy if prior biopsy results did not disclose cancer.
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