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[Eye Reports 2012; 2:e4] [page 13]

Orbital metastasis from 
cutaneous melanoma
Loukia Tsierkezou, Peter Cikatricis,
Parveen Abdullah, Samer Elsherbiny
Birmingham Midland Eye Centre, City
Hospital, Birmingham, UK

Abstract

We report a case of a metastatic cutaneous
melanoma to the orbit. A 60-year-old
Caucasian male presented with a 2-day history
of left-sided ocular pain, lid swelling and
chemosis. Initially, this was treated as con-
junctivitis with no signs of improvement. Four
days later, the patient developed left proptosis,
mechanical ptosis, left esotropia and diplopia.
Computed tomography scan of the orbit
demonstrated marked thickening of the lateral
rectus muscle. The patient was treated as
pseudotumor. Subsequent biopsy revealed
malignant cutaneous melanoma. The patient
had a history of cutaneous melanoma excised
15 years previously. Further imaging showed
advanced metastatic disease in the brain, the
lung and the liver. The patient passed away
five months after initial presentation.
Cutaneous melanoma metastasizing to the
orbit has poor prognosis. Patients often have
advanced disease at the time of presentation
and orbital metastases may be the initial sign.
A detailed history is paramount in making
timely diagnosis.  

Introduction

Metastatic cutaneous melanoma to the eye
and the orbit is very rare.1-4 In autopsy series of
metastatic cutaneous melanoma patients, the
numbers of orbital metastases are reported
ranging from 1-33%.5 Orbital metastases from
cutaneous melanoma account for 5.3-15% from
all metastatic tumors to the orbit.6 The most
common primary source of metastatic tumors
to the orbit is breast cancer (42%), followed by
lung cancer (11%).3,5,7,8 Cutaneous malignant
melanoma is reported to be the fourth most
common.4 The predominant site of orbital
metastases in breast cancer and melanoma
tends to be the orbital fat and extra-ocular
muscles, whereas in the case of lung cancer it
is the bony orbit.9 Frequently, the orbital
involvement presents long after the primary
disease and sometimes it represents the first
sign of a metastatic disease before the primary
tumor is found. Therefore, a thorough history
and physical examination (by the appropriate

specialist) is very important.10

Orbital melanomas derive from melanocytes
of the uveal tissues or characterize distant
metastasis of cutaneous melanomas to the
orbit. They can be classified into primary and
secondary orbital melanomas. Primary orbital
melanomas are extremely rare whereas sec-
ondary orbital melanomas are more common.
Orbital melanomas usually represent massive
extra-scleral extensions of uveal melanomas.11

Case Report

A 60-year-old Caucasian male presented
with a 2-day history of unilateral, left-sided
ocular pain, lid swelling and chemosis. At first,
this was treated as conjunctivitis with topical
antibiotics by his general practitioner with no
signs of improvement. Left eyelid swelling,
chemosis and limited ocular movements on
abduction and adduction were noted. The
visual acuity in the right eye was 6/6 and in
the left was 6/9. Intraocular pressures were 13
mmHg in the right eye and 19 mmHg in the
left eye. Fundal examination was normal.
Optic nerve function was preserved with nor-
mal color vision and pupils equal and reactive
to light without afferent pupillary defect. The
first impression of the casualty officer was
allergic reaction and the patient was dis-
charged home with oral antihistamines and
steroid eye drops. Four days later the patient
was reviewed. On examination, there was
marked left proptosis, mechanical ptosis, left
esotropia and diplopia. 

The patient was otherwise systemically well
with a history of atopy. A computed tomography
(CT) scan of the orbit demonstrated markedly
thickened belly of the left lateral rectus muscle
with musculo-tendon junction involvement in
keeping with pseudotumor (Figure 1A). A CT
scan of the head revealed 2¥2 cm low attenua-
tion area in the left parietal area, which
required further imaging. Blood tests showed
raised C-reactive protein (CRP) (160 mg/L),
erythrocyte sedimentation rate (ESR) (83
mm/hr) and slightly deranged liver function
tests. Thyroid function was normal. The patient
was initially treated as a pseudotumor with
suspected myositis. Oral prednisolone, oral
ibuprofen and topical treatment with pred-
nisolone eye drops were prescribed, again, with
no signs of improvement. The patient subse-
quently gave a history of previously excised
skin melanoma 15 years ago.

A biopsy of the left orbital and lateral rectus
muscle mass subsequently revealed malignant
melanoma. Sections of the biopsy from the left
orbital mass showed fibrovascular tissue,
which was infiltrated by lymphocytes, plasma
cells and macrophages. There were scattered
groups and clusters of atypical cells with hyper-

chromatic and pleomorphic nuclei. The nuclei
were oval, round to elongated and there was
melanin pigment in the background.
Immunohistochemistry was performed and the
cells were positive for S100, Melan-A and
HMB45. CD68 was positive in the background
macrophages but the tumor cells were nega-
tive for it (Figure 2). A diagnosis of metastatic
orbital melanoma was made based on patient’s
history of cutaneous melanoma. Further inves-
tigations including a whole body CT-scan
revealed metastases in the lungs, the liver with
possible peritoneal and serosal deposits
(Figure 1B and C). Magnetic resonance imag-
ing of the brain and orbit showed metastases
in the brain and left lateral rectus (Figure 3).
The patient was referred to the oncologists for
further management. Exenteration of the orbit
was not recommended in the first instance due
to poor life expectancy. Two months later B-
scan ultrasonographic examination revealed
an intraconal mass of 14 mm in diameter.
Repeat CT demonstrated increased number of
metastases in the lungs and the liver with new
pelvic and peritoneal lesions. The oncologists
recommended evisceration and a month later
debulking of the orbit. Removal of the orbital
and brain masses was carried out by the neu-
rosurgeons. The patient passed away shortly
afterwards, five months after orbital presenta-
tion.

Eye Reports 2012; volume 2:e4

Correspondence: Loukia Tsierkezou, 
Birmingham Midland Eye Centre, City Hospital,
Dudley road, B18 7QH, Birmingham, UK. 
Tel. +44 121 5076799. 
E-mail: ltsier@hotmail.com

Key words: cutaneous melanoma, metastases, orbit.

Contributions: LT, data collection, analysis and
interpretation, manuscript preparing, revising and
editing of the final version submitted for publica-
tion; PC, images, histopathology report and slides
selection and editing, manuscript critical review
and final approval; PA, histopathology report and
slides providing; SE-S, clinical data providing,
manuscript critical review and approval of the final
version submitted for publication. 

Conflict of interests: the authors declare no
potential conflict of interests.

Received for publication: 9 March 2012.
Revision received: 11 June 2012.
Accepted for publication: 15 June 2012.

This work is licensed under a Creative Commons
Attribution NonCommercial 3.0 License (CC BY-
NC 3.0).

©Copyright L. Tsierkezou et al., 2012
Licensee PAGEPress, Italy
Eye Reports 2012; 2:e4
doi:10.4081/eye.2012.e4

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[page 14] [Eye Reports 2012; 2:e4]

Discussion

Differentiation between primary and sec-
ondary orbital melanomas is difficult. Fine
needle aspiration biopsy can help provide
information about the origin of any orbital
tumor.12 De Bustros et al.1 based their diagno-
sis of metastatic disease in accordance with
the history or presentation of other metastatic
lesions at the time of diagnosis. In their series
they emphasize that the eye can be the initial
site of recurrence of cutaneous melanoma.
Even in cases where there is no known history
of skin lesion excisions and a metastatic
orbital melanoma is suspected, the dermatolo-
gists should search for a cutaneous or mucos-
al melanoma.2 Many patients (like our patient)
may not remember to mention a history of pre-
viously excised skin lesion. Therefore, it is
very important to actively seek information in
every case with intraocular or orbital tumor.1

Ramesh et al.12 reviewed literature regard-
ing intraocular sites of cutaneous melanoma
metastases. In total, 75% involved the uvea. De
Bustros et al.1 in their series of 12 eyes report
the eye as a potential initial site of a clinically
identifiable recurrence of cutaneous malig-
nant melanoma. Valenzuela et al.9 in a chart
review of 80 patients established that the orbit
was the first site of presentation of a metasta-
tic tumor in 15% of the cases. Generally, a
metastatic tumor may present with ophthalmic
symptoms before the diagnosis of the primary
source of tumor has been established.4,5,13

Orbital metastases in some cases occur after
long, disease-free intervals.6,10 In our case ocu-
lar metastases presented 15 years following
the excision of skin melanoma with wide-
spread metastases. The mean survival of
patients with intraocular metastasis of
melanoma is generally poor. Zografos et al.3 in

Case Report

Figure 3. A and B) Magnetic resonance imaging scan of the orbit shows focal and globular swelling of the lateral rectus muscle repre-
senting metastasis. C) A T1 weighted coronal magnetic resonance imaging scan of the brain with contrast enhancement demonstrates
lesion in the parietal region and surrounding oedema (white arrow).

Figure 1. A) An axial computed tomogra-
phy (CT) scan of brain and orbit showing
markedly thickened lateral rectus at the
muscle belly, which is involving the mus-
culo-tendon junction (white arrow). B)
Axial CT scan of the lungs showing mul-
tiple deposits (white arrows). C) Axial CT
scan showing metastasis in the liver
(white arrow).

Figure 2. (A) Histopathology slides showing Melan-A immuno stain for melanoma. (B)
Hematoxylin and eosin stain (see text). 

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[Eye Reports 2012; 2:e4] [page 15]

a retrospective clinical study of 15 eyes have
reached similar figures of mean survival to
those reported in other literature. This corre-
sponds to a mean survival time of patients with
intraocular metastasis between 2.5 and 9.0
months. The mean survival for orbital metasta-
tic melanoma was 19.7 months. Ferry and
Fond7 carried out a clinical-pathological study
of 227 patients with carcinoma metastatic to
the eye or the orbit and the mean survival was
7.4 months from the time of ocular/orbital
involvement. Holland et al.14 reported the mean
survival to be at 14.7 months (Table 1).
Patients who present with ocular metastases
from cutaneous melanoma have usually wide-
spread systemic disease at the time of ocular
manifestation.3,4,15 At presentation, our patient
had widespread systemic metastases and 5
months survival. 

Melanoma in the orbit preferentially
involves extra-ocular muscles.3,5 CT scanning
demonstrates smooth enlargement of the mus-
cle.6 As described previously, the CT of the
orbit in this case revealed a markedly thick-
ened lateral rectus at the muscle belly.
Therefore, diplopia and extraocular muscles
limitations are common presenting signs.6,8,15

Proptosis and pain usually present in the early
clinical course of the disease as well.9 In cer-
tain cases, debulking of the mass may be a pal-
liative measure.3,6,16 Orbital exenteration and
surgical treatment of brain metastasis repre-
sent in some options too aggressive of a man-
agement of patient with poor prognosis and
short life expectancy. Among the various pos-
sible treatment options gamma knife radio-
surgery maybe an effective treatment option
for orbital tumors as well as intracranial
tumors. Kim et al.17 in a study of 15 patients
with orbital tumors (2 of which were metasta-
tic tumors) showed that in the 13 patients
whose vision was preserved preoperatively, 6
patients showed improvement in visual acuity,
4 patients showed no change in vision, and 3
patients showed deterioration. However, three
patients with malignant lesions had to under-

go another operation due to tumor progres-
sion. Circumscribed proton beam radiothera-
py or global photon beam radiotherapy at rela-
tively high irradiation doses, seem to achieve
some favorable results.3

Conclusions

In patients with a known history of cuta-
neous melanoma presenting with ocular
inflammation, a high index of suspicion for
metastatic disease should be maintained.
Orbital metastases of malignant cutaneous
melanoma are very rare but they may be the
first sign of manifestation of advanced
metastatic disease. The diagnosis is based on
a previous history of cancer. Most frequently it
involves the extra-ocular muscles. Imaging is
an important tool in detecting and localising
the tumour, defining its characteristics and
extent within the orbit, as well as in establish-
ing the systemic spread of the disease. The life
expectancy is short. Thus, in the majority of
cases any treatment may only be palliative. The
diagnosis of orbital metastases is very impor-
tant as it can lead to early diagnosis and it can
establish the extent of the primary disease, in
order to improve the patient’s quality of life
with palliative management.

References

1. De Bustros S, Augsburger JJ, Shields JA, et
al. Intraocular metastases from cutaneous
malignant melanoma. Arch Ophthalmol
1985;103:937-40.

2. Fujii K, Komurasaki Y, Kanno Y, Ohgou N.
Unilateral exophthalmos due to orbital
metastasis from a contralateral intraocular
melanoma. Eur J Dermatol 1998;8:343-6.

3. Zografos L, Ducrey N, Beati D, et al.
Metastatic melanoma in the eye and orbit.

Ophthalmology 2003;110:2245-56. 
4. Ullah T, Gurwood AS, Myers MD. Ocular

metastasis of cutaneous malignant
melanoma. Optometry 2009;80:572-8.

5. Rosenberg C, Finger PT. Cutaneous malig-
nant melanoma metastatic to the eye, lids
and orbit. Surv Ophthalmol 2008;53:187-
202.

6. Ahmad SM, Esmaeli B. Metastatic tumors of
the orbit and ocular adnexa. Curr Opin
Ophthalmol 2007;18:405-13. 

7. Ferry AP, Fond RL. Metastatic carcinoma to
eye and orbit. Arch Ophthalmol 1974;92:
276-86. 

8. Pedroli GL, Hamedani M, Barraco P, et al.
Orbital metastasis in malignant melano ma.
J Fr Ophthalmol 2001;24 286-90.

9. Valenzuela AA, Archibald CW, Fleming B, et
al. Orbital metastasis: clinical feaures, man-
agement and outcome. Orbit 2009;28: 153-9.

10. Bond JB, Wesley RE, Reynolds VH, et al.
Orbital metastasis from cutaneous
melanoma. South Med J 1985;79:1439-42.

11. Liarikos S, Rapidis AD, Roumeliotis A,
Angelopoulos AP. Secondary orbital
melanomas: analysis of 15 cases. J
Craniomaxillofac Surg 2000;28:148-52.

12. Ramesh K, Marshall JWV, Wharton SB,
Dhillon B. Intraocular metastases of cuta-
neous melanoma: a case report and review
of the literature. Eye 1999;13:247-50.

13. Char DH, Miller T, Kroll S. Orbital metas-
tases: diagnosis and course. Br J
Ophthalmol 1997;81:386-90.

14. Holland D, Maune S, Kovács G, Behrendt S.
Metastatic tumors of the orbit: A retrospec-
tive study. Orbit 2003;22:15-24.

15. Drummond SR, Fenton S, Pantilidis EP, et al.
A case of cutaneous melanoma metastatic
to the right eye and left orbit. Eye
2003;17:420-2.

16. Orcutt JC, Char DH. Melanoma metastatic
to the orbit. Ophthalmology 1988;95:1033-7.

17. Kim MS, Park K, Kim JH, et al. Gamma knife
radiosurgery for orbital tumors. Clin Neurol
Neurosurg 2008;110:1003-7.

Case Report

Table 1. Relative incidence of cutaneous melanoma metastatic to the orbit and mean survival.

Authors and Type of No. of Orbital  Metastatic orbital Mean timing of Mean survival
references study patients metastasisfrom cutaneous ocular 

all causes melanoma presentation

Ferry & Fond7 Clinical 227 28 1 7.4 months
Bond et al.10 Case reports 2 2 2 7.5 years 8 months
De Bustros et al.1 Clinical 12 0 0 3.25 years 2.4 months
Char et al.13 Clinical 31 31 5 16 months
Liarikos et al.11 Clinical 15 15 1 16.6 months
Zografos et al.3 Clinical 20 7 5 5.5 years 19.7 months
Holland et al.14 Clinical 20 20 0 5.3 years 14.7 months
Rosenberg and Review 93 29 29 5.5 years 7.5 months
Finger5 patients in 

case reports
Ullah et al.4 Case report 1 1 1 6 months
Valenzuela et al.9 Clinical 80 80 16 3.6 years 18 months

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