Metastatic pancreatic carcinoma to the orbital apex presenting as a superior divisional third cranial nerve palsy

Paula E Pecen,¹ Nicholas A Ramey,¹ Michael J Richard,¹ M Tariq Bhatti<sup>1,2

1</sup>Department of Ophthalmology, Duke University Eye Center, Durham, NC, USA; ²Department of Medicine (Division of Neurology), Duke University Medical Center, Durham, NC, USA

Abstract: Metastatic tumors to the orbit are rare, especially from a primary pancreatic carcinoma. A 59-year-old man presented with 4 weeks of right eye pain and eyelid swelling. There was right upper eyelid ptosis associated with a right supraduction deficit consistent with a superior divisional third cranial nerve (CN III) palsy. Magnetic resonance imaging revealed a right orbital apex lesion. A right orbital exenteration was performed for intractable and severe pain. Surgical pathology demonstrated a poorly differentiated carcinoma that was ultimately felt to be derived from the pancreas. In this report, we describe the clinical and neurological imaging findings of a superior divisional CN III palsy as the presenting manifestation of a presumed metastatic pancreatic carcinoma to the orbital apex, and review the neuroanatomy of CN III with particular emphasis on the anatomical bifurcation of the nerve into a superior and inferior division.

Keywords: orbital tumor, orbital metastasis, superior division, third cranial nerve palsy