Unilateral Proptosis Due to Orbital Malignancy and Synchronous Carcinoma Elsewhere

Abstract

Introduction: Unilateral proptosis is usually a diagnostic challenge to an ophthalmologist. Mass lesions constitute a  common cause of unilateral proptosis in elderly individuals in which lymphoproliferative lesions account for 11%  and metastasis  up to 2- 9% of cases. Literature review showed various tumors metastasizing to the orbit but simultaneous presence of two unrelated tumors in a person are extremely uncommon. The authors wish to report the same to highlight the importance of systemic examination in an elderly patient presenting as unilateral proptosis. Case Presentation: A 52 year old man presented with complaints of painless, gradually progressing prominence of his right eye (OD) for 8 months. OD showed about 15 degrees of exotropia. Examination revealed an axial proptosis of 6mm by Hertel’s exophthalmometry. It was non-tender and non - pulsatile. CT scan of the orbit revealed OD proptosis with enhancing soft tissue attenuation lesion involving extraconal and intraconal compartments in superolateral aspect of the right orbit abutting proximal portion of the right optic nerve. Lacrimal gland could not be distinguished separately from the lesion Lacrimal gland biopsy revealed stratified squamous epithelium with subepithelial infiltration by monomorphic population of small lymphoid cells and few immunoblasts suggesting a low grade lymphoproliferative lesion. Immunohistochemical study confirmed a diagnosis of small lymphocytic lymphoma. Abdominal ultrasound performed for assessment of intraabdominal lymph nodes or visceral enlargement showed diffuse thickening. An endoscopic antral biopsy revealed gastric adenocarcinoma on histopathological examination. Conclusion: Diagnosis of two synchronous neoplasms of different etiopathogenesis at two sites and exclusion of metastasis is a significant and under-recognized clinical problem. This case highlights the importance of high index of clinical suspicion and thorough systemic examination in the evaluation of a case of unilateral proptosis in an elderly male.