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October 11, 2022; 99 (15) Resident & Fellow Section

Teaching NeuroImage: Horizontal Diplopia Due to Extraocular Muscle Metastasis

Merve Atik, David Nathan Abarbanel, Ugur Sener
First published August 19, 2022, DOI: https://doi.org/10.1212/WNL.0000000000201061
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An 80-year-old woman with previously resected melanoma of the right thigh presented with acute binocular diplopia. Neurologic examination demonstrated inability to abduct the left eye with normal right eye adduction. Examination was otherwise normal. This presentation of left lateral rectus palsy can occur due to ischemic, inflammatory, autoimmune, compressive, or neoplastic etiologies. MRI orbits identified an enhancing left lateral rectus lesion consistent with extraocular muscle metastasis. MRI of the brain revealed multiple subcentimeter-enhancing lesions (Figure).1 Subsequent lymph node biopsy confirmed metastatic melanoma. Despite radiotherapy and BFRAF-targeted systemic therapy, rapid progression occurred, and the patient died 5 months after initial evaluation.2

Figure
Figure MRI of the Brain and Orbits

(A) Postcontrast T1-weighted MRI axial demonstrating subcentimeter right frontal and right occipital enhancing lesions consistent with metastasis (arrows). (B) T2-weighted fluid-attenuated inversion recovery MRI demonstrating left lateral rectus lesion (arrow). (C) Postcontrast T1-weighted MRI of the orbits demonstrating enhancing lesion involving left lateral rectus (arrow) in axial view. (D) Postcontrast T1-weighted MRI of the orbits demonstrating enhancing lesion involving left lateral rectus (arrow) in coronal view.

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No targeted funding reported.

Disclosure

The authors report no relevant disclosures. Go to Neurology.org/N for full disclosures.

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Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Submitted and externally peer reviewed. The handling editor was Roy Strowd III, MD, MEd, MS.

  • Teaching slides links.lww.com/WNL/C261

  • Received January 10, 2022.
  • Accepted in final form June 17, 2022.

References

  1. 1.↵
    1. Leung V,
    2. Wei M,
    3. Roberts TV
    . Metastasis to the extraocular muscles: a case report, literature review and pooled data analysis. Clin Exp Ophthalmol. 2018;46(6):687-694. doi:10.1111/ceo.13162.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Dummer R,
    2. Ascierto PA,
    3. Gogas HJ, et al
    . Encorafenib plus binimetinib versus vemurafenib or encorafenib in patients with BRAF-mutant melanoma (COLUMBUS): a multicentre, open-label, randomised phase 3 trial. Lancet Oncol. 2018;19(5):603-615. doi:10.1016/S1470-2045(18)30142-6.
    OpenUrlCrossRefPubMed

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