Enophthalmos as the Initial Systemic Finding of Undiagnosed Metastatic Breast Carcinoma

PURPOSE: To report on the importance of detecting and investigating non-traumatic enophthalmos, which occurred as the first presenting sign of an undiagnosed metastatic breast carcinoma in two patients with no prior history of neoplasia. DESIGN: Case series. OBSERVATIONS: The first case consists of a 74-year-old woman with no significant past medical history, who presented with a non-traumatic enophthalmos and ptosis of her left eye, and horizontal diplopia on right-gaze. Imaging revealed an intraconal lesion of her left orbit, with orbital fat atrophy. Transcutaneous anterior orbitotomy was performed for tumor biopsy, and the histopathology study concluded on a diagnosis of orbital metastasis consistent with infiltrative breast carcinoma. Thorough breast imaging and multiple breast biopsies were not able to localize the primary tumor. The second case consists of a 76-year-old woman, with no prior relevant medical history, who presented for progressive enophthalmos and ptosis of her right eye. Imaging revealed an osteolytic lesion of her right frontal bone, and multiple infiltrative lesions implicating both orbits. A biopsy was performed through a transcutaneous anterior orbitotomy and histopathology study lead to a diagnosis of metastatic lobular breast carcinoma. The primary breast tumor was localized using positron emission tomography, and further biopsy confirmed the diagnosis. CONCLUSION: Although uncommon, non-traumatic enophthalmos has a broad differential diagnosis. In some rare instances, it may be the initial presentation of orbital metastases in patients with no prior history of cancer, and in the absence of other systemic symptoms. Clinicians must be thorough when assessing and investigating this clinical entity. A comprehensive eye exam, systemic evaluation, orbit imaging, biopsy and immunohistochemistry analysis are essential to promptly diagnose orbital metastases and plan the appropriate treatment.