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JAMA Ophthalmology Clinical Challenge
December 20, 2018

Progressive Proptosis and Worsening Vision

Author Affiliations
  • 1School of Medicine and Public Health, University of Wisconsin, Madison
  • 2Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison
  • 3Oculoplastic, Facial Cosmetic & Orbital Surgery, Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison
JAMA Ophthalmol. 2019;137(3):312-313. doi:10.1001/jamaophthalmol.2018.5024

A woman in her mid-60s with a history of breast cancer (status post lumpectomy 7 years earlier [N0, M0]) and benign thyroid nodules presented for evaluation of right-sided proptosis. Bulging of the right eye was first noted 6 months earlier elsewhere when she reported progressive proptosis, worsening vision, and tearing in the right eye. She did not report any pain or diplopia.

Visual acuity was 20/150 OD (no improvement with pinhole) and 20/20 OS. Pupillary reaction and confrontational visual fields were normal. External examination was notable for proptosis of 7 mm, hypoglobus, and resistance to retropulsion. A firm, nontender mass was palpable in the right superotemporal orbit. The palpebral lobe of the right lacrimal gland was erythematous and prominent compared with the normal-appearing left lacrimal gland. Ocular motility showed −2 abduction deficit, right eye. Slitlamp examination revealed pseudophakia and posterior capsular opacification (right > left), but was otherwise normal. Sensation was normal in the V1, V2 distribution, and there was no preauricular, submandibular, or anterior cervical lymphadenopathy. Computed tomographic scan of the orbits without contrast from an outside facility revealed a spherical mass of unclear cause in the area of the right lacrimal gland. No lytic bone changes or bone remodeling could be seen (Figure 1).

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