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A 73-year-old man with congestion and mild proptosis of the left eye
Digital Journal of Ophthalmology 2016
Volume 22, Number 2
April 25, 2016
DOI: 10.5693/djo.03.2014.05.001
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Amanda Mohanan Earatt, MS | Department of Ophthalmology, Amala Institute of Medical Sciences, Thrissur, Kerala, India
Lathika Vasu Kamaladevi, MS, DO, FRCS Glasgow | Department of Ophthalmology, Amala Institute of Medical Sciences, Thrissur, Kerala, India
Charles K. Skariah, MS, DO | Department of Ophthalmology, Amala Institute of Medical Sciences, Thrissur, Kerala, India
Diagnosis and Discussion
The patient was diagnosed with left orbital metastasis from adenocarcinoma of the prostate with intracranial extension. About 2%-9% of all orbital neoplasms are metastatic lesions.(1) Breast, lung, lymphomas, and leukemia are among the most common primary neoplasms known to metastasize to the orbit.(2,3) The average age of onset of orbital metastasis from prostate carcinoma is later, compared to orbital metastasis from other malignancies (70.1 vs 53.6 years).(4,5)

Another differentiating feature is that prostate metastases usually present as osteoblastic lesions in contrast to other orbital metastases which present as osteolytic lesions.(4,5) However, in the terminal stages of the disease, osteolytic and mixed osteoblatic-osteolytic lesions are seen.(6) A characteristic feature suggestive of prostatic origin is a hyperostotic and spiculated lesion on CT scan.(7) Soft tissue involvement is rare and the PSA level is elevated in 99% cases of metastatic disease.(8,9) In contrast to the aforementioned typical features, the present case was unusual because the patient presented with osteolytic metastasis to the orbit with significant soft tissue involvement and low PSA values, necessitating a biopsy to confirm the diagnosis.

Tumor metastasis to the orbit from prostate cancer may occur through the general hematogenous route of the carotid/ophthalmic artery or through Batsons venous plexus, which transports tumor emboli from the prostate to the cerebral venous sinuses/ophthalmic vein.(10-12) Patients usually present with one or more clinical features, such as decreased visual acuity, ocular pain, proptosis, retinal detachment, presence of a mass, secondary glaucoma, and osteoblastic lesions of the orbital wall.(12) The treatment of prostatic metastases to the orbit is palliative (androgen ablation or local radiotherapy) and does not alter survival.(5)

Prostate cancer is the second most common cancer in men and the fifth most common cause of death from cancer in men worldwide.(13) Hence, clinicians should maintain a high index of suspicion of metastasis from prostate cancer in any elderly male who presents with even a mild conjunctival chemosis. This is especially relevant in patients with comorbid conditions that can lead to a similar clinical presentation. The present case highlights the fact that neither the osteolytic nature of the orbital lesion nor normal PSA levels can conclusively rule out orbital lesions secondary to prostate carcinoma and that early and accurate diagnosis may only be possible with a biopsy.

Literature Review
Pubmed, MEDLINE, Google Scholar, were all searched, without language restriction, on February 3, 2016, using the following terms: prostate carcinoma, orbital metastasis in prostate carcinoma, proptosis in orbital metastasis, PSA levels, vertebral veins AND prostate carcinoma.