Multiple bilateral extraocular muscle metastases as the initial manifestation of breast cancer.

A 75-year-old woman had gradually progressive binocular diplopia and 2 months later had breast cancer diagnosed. Examination showed bilateral external ophthalmoplegia with lid retraction and lag and no pupillary abnormalities. Orbital magnetic resonance imaging showed enlargement and enhancement of all extraocular muscles bilaterally. A right orbital biopsy was consistent with metastatic breast carcinoma. Positron emission tomography, bone scan, and computed tomography of the chest, abdomen, and pelvis failed to disclose other evidence of breast cancer metastases. It is unusual to encounter metastatic breast cancer affecting every extraocular muscle before the diagnosis of the primary carcinoma.

Isolated subconjunctival hemorrhages in nonaccidental trauma.

PURPOSE: To establish child abuse as part of the differential diagnosis of isolated bilateral subconjunctival hemorrhages in infants. METHODS: To review three cases of nonaccident trauma initially presenting with isolated bilateral subconjunctival hemorrhages as the only significant clinical finding. RESULTS: Ophthalmic examination in cases 1 and 2 were entirely normal except for the large bilateral subconjunctival hemorrhages. Hematological parameters were normal in all three infants. Initial radiological findings were normal in case 1 but multiple healing rib fractures were identified when the chest X-ray was repeated 3 weeks later. Case 2 had skin and skeletal X-ray findings compatible with abuse at time of presentation to the ophthalmologist. Case 3 was admitted to hospital for multiple unexplained limb fractures but had been seen 2 weeks prior for poorly explained bilateral isolated subconjunctival hemorrhages and facial petechiae. CONCLUSION: Nonaccidental trauma should be considered in the differential diagnosis of bilateral isolated subconjunctival hemorrhages in infants especially if associated with facial petechiae. These isolated subconjunctival hemorrhages may be part of the traumatic asphyxia syndrome caused by severe, prolonged compression of the child's chest and upper abdomen. Appropriate assessment includes a complete ophthalmic and pediatric examination as well as hematological testing and imaging studies. If the coagulation profile and initial imaging studies are normal yet there remains a high suspicion of abuse, an immediate nuclear scan or a repeat skeletal survey or chest film 2 weeks later is indicated.