Prevalence and Predictors of Hering's Response in Müller's Muscle-conjunctival Resection.

PURPOSE: Determine the prevalence and predictors of Hering's response following Muller's muscle-conjunctival resection (MMCR). METHODS: Seventy-five consecutive patients undergoing unilateral MMCR were recruited in this prospective, multicenter, cohort study. Margin-reflex distance-1 (MRD1) of both eyelids was recorded preoperatively and postoperatively. One hundred forty-three variables were investigated as potential predictors of a late postoperative (≥3 months) Hering's response using regression analyses. Main outcome measures were Hering's response (≥0.5 mm descent of the unoperated eyelid from baseline), and a clinically relevant Hering's response (descent of the unoperated from baseline to a MRD1 ≤ 2.0 mm, or descent from baseline such that the MRD1 of the unoperated eyelid became >1 mm lower than the operated eyelid). RESULTS: Twenty-four (32.0%) patients had a late postoperative Hering's response, but only 6 (8.0%) responses were clinically relevant. A Hering's response at the immediate (OR 16.24, p = 0.02) and 1-week postoperative (OR 8.94, p = 0.04) timepoints predicted a late postoperative response. However, the presence (OR 7.84, p = 0.07) and amplitude (OR 8.13, p = 0.06) of a preoperative phenylephrine Hering's response did not predict a late postoperative response. Of the 10 patients with a clinically relevant phenylephrine Hering's response, only 1 demonstrated a clinically relevant response late postoperatively. CONCLUSION: Unilateral MMCR induces a clinically relevant Hering's response in 8% of patients. A preoperative phenylephrine Hering's response does not predict a late postoperative Hering's response. Therefore, when unilateral phenylephrine testing unmasks contralateral blepharoptosis, only the side with blepharoptosis at baseline should be operated.

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.