Shifting Extraocular Motility in a Patient With Burkitt Lymphoma

A 48-year-old male with known acquired immunodeficiency syndrome and stage IV Burkitt lymphoma presented with right inferonasal periorbital pain and binocular vertical diplopia. Exam was notable for right proptosis, hypertropia worse in left gaze, and abduction deficit more than supraduction and infraduction (Fig. 1A). Coronal MRI short tau inversion recovery sequence (Fig. 2A) and axial T1 fluid-attenuated inversion recovery (Fig. 2B) demonstrated enlarged right medial and inferior recti, concerning for orbital spread of his lymphoma. The patient had previously received chemotherapy with rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin, so his regimen was adjusted to intravenous dexamethasone and intravenous plus intrathecal chemotherapy with ifosfamide, carboplatin, and etoposide. Nineteen days after the presentation, he had full abduction, worsening right hypertropia, and a new exotropia and adduction deficit. He missed his second cycle of chemotherapy and then 2 months after his initial presentation, he re-presented with marked worsening of his proptosis, extensive chemosis, and near-complete extraocular movement palsy (Fig. 1B). Coronal MRI T2 fluid-attenuated inversion recovery (Fig. 2C) and axial T1 fluid-attenuated inversion recovery (Fig. 2D) demonstrated enlarging and new right intraconal and extraconal masses, and tumor encasement of the anterior right orbital optic nerve with preserved 20/20 vision and no afferent pupillary defect. His chemotherapy regimen was restarted, and 4 months after his initial presentation he experienced symptom improvement and motility recovery (Fig. 1C). These shifting motility deficits on repeat examinations appeared to indicate evolving infiltration of the orbit, medial rectus, and inferior rectus muscles. Orbital lymphomatous infiltration can result in proptosis, diplopia, and varied ocular motility deficits. These signs and symptoms can improve with tumor response to treatment.FIG. 1.FIG. 2.