Sir,

The following case describes an unusual site of metastasis within the eye.

Case report

A 47-year-old female presented with photopsia in her right eye. She had a previous diagnosis of grade 2-invasive ductal carcinoma (not otherwise specified) of the right breast in 2007 with no evidence of metastasis. The carcinoma was positive for oestrogen and progesterone receptor and negative for HER2. Treatment included wide local excision, axillary node clearance, and adjuvant radiotherapy. Her visual acuity in both eyes was normal. We identified a peripheral non-rhegmatogenous superior retinal detachment in her right eye associated with a mass in the ciliary body area measuring 18 mm by 4 mm on ultrasonic bio-microscopy (Figure 1a).

Figure 1
figure 1

(a) Ultrasonic bio-microscopy examination showing the lenticular-shaped ciliary body mass (white arrow). (b) Haematoxylin and eosin-stained section showing the breast carcinoma metastasis morphology. The holes in the tissue represent glandular differentiation. (c) The breast metastasis shows immunohistochemical positivity for pan-cytokeratin marker AE1 AE3 (brown=positive). The unstained cellular tissue between the tumour deposits is a desmoplastic myofibroblastic response triggered by the tumours present in the supraciliary space. It is not the normal ciliary body muscle. (d) Immunohistochemical positivity for cytokeratin-7 (brown=positive). (e) Focal immunohistochemical positivity for GCDFP-15. (f) The tumour shows nuclear immunohistochemical positivity for oestrogen receptor (brown=positive).

Full size image

An open flap biopsy of the right eye was performed. An amelanotic gelatinous mass was found, which was distinct and freely mobile from the overlying sclera and underlying pigmented ciliary body, confirming the supraciliary location of the lesion. Histology showed fragments of a carcinoma with glandular differentiation, strongly positive for pan-cytokeratin marker AE1 AE3, cytokeratin 7, focally positive for gross cystic disease fluid protein-15 (GCDFP15) and almost every nucleus positive for oestrogen receptor (Figures 1b–d). The tumour was HER2 negative (not shown). The features were those of metastatic breast adenocarcinoma within the supraciliary space. Treatment was aimed at controlling the disease, with commencement of tamoxifen. The patient has subsequently developed disseminated metastases.

Comment

To the best of our knowledge, this is the first demonstration of a malignant tumour metastasizing to the supraciliary space. Tumours previously described within the supraciliary space include benign primary mesectodermal leiomyomas1 and one case of direct local spread of a conjunctival mucoepidermoid carcinoma to the supraciliary space.2 Why the supraciliary space was the site of metastasis in this case remains speculative. The distribution of breast metastases to the eye includes the choroid (81%), iris (9%), ciliary body (2%), optic disc (5%), and retina (rare).3 Symptoms are dependent on the site affected, with blurring of vision being common to all. However, patients are often asymptomatic.4 To conclude, we must add the supraciliary space to the list of potential sites of metastases to the eye and also be aware that lesions within this space can present with non-rhegmatogenous retinal detachments.