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Middle-aged Woman With Atypical Upper Eyelid Retraction

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 42-year-old woman with history of a functional pituitary adenoma, breast cancer in remission for which she was undergoing tamoxifen therapy, and prior bilateral laser in situ keratomileusis surgery was referred for evaluation of right lagophthalmos. She reported 2 months of increasing right-sided blurry vision and a sensation of eye dryness. She was found to have incomplete eyelid closure by her primary care physician, who initiated artificial tear lubrication and bedtime eyelid taping with partial symptom improvement.

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Cicatricial upper eyelid retraction from metastatic breast carcinoma

D. Magnetic resonance imaging of the orbit

While upper eyelid retraction is most commonly seen in thyroid eye disease (choice A), coinciding globe proptosis, rather than enophthalmos, would be anticipated. Additionally, while a finding of slowed upper eyelid depression with downward globe rotation can be seen in thyroid disease (ie, Von Graefe sign), a static eyelid lag is more suggestive of levator muscle tethering or dysgenesis, such as in congenital ptosis or cicatricial disease.1 A facial (cranial nerve VII) palsy commonly presents with upper eyelid retraction from unopposed eyelid elevating forces and incomplete eyelid closure that could be addressed by gold weight implantation (choice B). Suspected idiopathic Bell palsy can be treated with systemic steroid and antiviral therapy when other etiologies are not suspected (choice C). However, ipsilateral orbicularis weakness should be present in cranial nerve VII palsy, and findings of globe enophthalmos and upper eyelid lag are not characteristic.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Natalie A. Homer, MD, UC Davis Health Eye Center, Division of Ophthalmic Plastic and Orbital Surgery, Department of Ophthalmology, University of California, Davis, 4860 Y St, Ste 2400, Sacramento, CA 95817 (natalie.a.homer@gmail.com).

Published Online: June 16, 2022. doi:10.1001/jamaophthalmol.2022.1532

Conflict of Interest Disclosures: Dr Homer reported personal fees as a consultant from Pulse Biosciences outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Harvey  JT , Anderson  RL .  Lid lag and lagophthalmos.   Ophthalmic Surg. 1981;12(5):338-340. doi:10.3928/1542-8877-19810501-08PubMedGoogle ScholarCrossref
2.
Shields  JA , Shields  CL , Brotman  HK , Carvalho  C , Perez  N , Eagle  RC  Jr .  Cancer metastatic to the orbit.   Ophthalmic Plast Reconstr Surg. 2001;17(5):346-354. doi:10.1097/00002341-200109000-00009PubMedGoogle ScholarCrossref
3.
Goldberg  RA , Rootman  J , Cline  RA .  Tumors metastatic to the orbit.   Surv Ophthalmol. 1990;35(1):1-24. doi:10.1016/0039-6257(90)90045-WPubMedGoogle ScholarCrossref
4.
Ben Simon  GJ , Yoon  MK , Atul  J , Nakra  T , McCann  JD , Goldberg  RA .  Clinical manifestations of orbital mass lesions at the Jules Stein Eye Institute, 1999-2003.   Ophthalmic Surg Lasers Imaging. 2006;37(1):25-32. doi:10.3928/1542-8877-20060101-06PubMedGoogle ScholarCrossref
5.
Reifler  DM .  Orbital metastasis with enophthalmos.   Henry Ford Hosp Med J. 1985;33(4):171-179.PubMedGoogle Scholar
6.
Lawson  A .  Secondary contracting scirrhus of orbit.   Trans Ophthalmol Soc U K. 1910;30:236.Google Scholar
7.
Sacks  JG , O’Grady  RB .  Painful ophthalmoplegia and enophthalmos due to metastatic carcinoma.   Trans Am Acad Ophthalmol Otolaryngol. 1971;75(2):351-354.PubMedGoogle Scholar
8.
Uddin  JM , Rose  GE .  Downgaze “hang-up” of the upper eyelid in patients with adult-onset ptosis.   Ophthalmology. 2003;110(7):1433-1436. doi:10.1016/S0161-6420(03)00457-3PubMedGoogle ScholarCrossref
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