Paraneoplastic syndromes with ophthalmic involvement are rare but can signal an underlying malignancy. We describe an 82-year-old African American male with worsening vision and bilateral recurrent compressive optic neuropathies after undergoing successful orbital decompressions for presumed thyroid eye disease. Imaging demonstrated enlargement of all rectus muscles with a tight apex and a left hilar mass. Additional laboratory testing was positive for P/Q Type Voltage Gated Calcium Channel Binding Antibody (VGCC). A biopsy of the lateral rectus muscle confirmed orbital myositis and a biopsy of the apical mass revealed squamous cell carcinoma of the lung. Pembrolizumab was started, and the vision improved to count fingers with resolution of the orbital compartment syndrome and improvement in the orbital inflammation. To our knowledge, this is the first report highlighting the association of a positive paraneoplastic antibody in a case of orbital myositis.

We report a 25-year-old male who underwent en bloc resection of a large NF1-associated high-grade malignant peripheral nerve sheath tumor (MPNST) and oculoplastic reconstruction. Following adjuvant chemo-radiotherapy and 3 years of oncologic surveillance, sequential oculoplastic refinements were performed to address radiation-induced periorbital and facial fibrosis, ptosis, and volume loss. These included brow lift, ptosis repair, blepharoplasty, lateral canthal lengthening, and autologous fat grafting. At one-year follow-up after reconstruction: symmetrical palpebral fissures (30 mm OD, 31 mm OS), bilateral MRD1 of 5 mm, no lagophthalmos, FACE-Q scores improved from 25/100 to 85/100, and MRI confirmed 70% fat graft retention with no tumor recurrence. A structured, stepwise approach to immediate functional stabilization, adjuvant therapy, and surveillance, followed by sequential functional and aesthetic refinements, may help guide reconstructive planning in similarly complex cases.

Pneumosinus dilatans (PSD) is a rare expansile disorder characterized by enlargement of an aerated paranasal sinus beyond its normal anatomic boundaries while preserving bony integrity. We report a 26-year-old man with progressive unilateral proptosis presenting 18 years after severe craniofacial trauma complicated by permanent sixth and seventh cranial nerve palsies. Examination demonstrated 5 mm axial left proptosis with paralytic lagophthalmos, lower eyelid retraction, and exposure keratopathy. Computed tomography revealed marked left frontal sinus enlargement (62.7% volumetric increase) with intact bony walls, consistent with frontal PSD. This case demonstrates the importance of objective exophthalmometry and orbital imaging in distinguishing true space-occupying sinus-related proptosis from smaller anterior globe displacement and periocular changes associated with facial nerve palsy alone. Management consisted of orbital decompression combined with upper and lower eyelid rehabilitation. Hertel asymmetry improved from 5 mm to 1 mm with satisfactory functional and cosmetic outcomes. The case emphasizes that careful imaging is essential when evaluating globe prominence in the setting of facial asymmetry.

Giant cell tumors (GCT) are a rare group of fibrohistiocytic neoplasms that may originate from bone or soft tissue. They are typically found in the extremities or trunk and are rarely reported in the head and neck. While they are benign, they may grow rapidly and be locally destructive. To our knowledge, only three case reports of giant cell tumors of soft tissue involving the orbit have been reported in the literature. We report two cases: one case of giant cell tumor associated with Paget's disease of the bone and one of tenosynovial giant cell tumor.

A 12-year-old girl presented with pain, swelling, and decreased vision in the left eye of 1-month duration. She had a significant history of left Wilms' tumor treated with left radical nephrectomy and chemotherapy at three years of age. Ocular examination revealed massive left proptosis, inferior globe dystopia, visual acuity of 20/160, ptosis, conjunctival chemosis, and corneal exposure changes. Orbital magnetic resonance imaging revealed a well-circumscribed T1-hypo and T2-hyperintense tumor in the superotemporal orbit with marked contrast enhancement. An excisional biopsy was performed, and histopathology was consistent with embryonal rhabdomyosarcoma. Genetic counseling was undertaken in view of multiple malignancies. Whole-exome sequencing identified a likely pathogenic null variant in the TRIP13 (c.998_999delCT, p.Ser333Leufs *30) gene, suggesting a diagnosis of mosaic variegated aneuploidy syndrome 3. Systemic surveillance showed no metastatic lesions. Adjuvant chemoradiotherapy was advised. Mosaic variegated aneuploidy syndrome can be associated with multiple malignancies, including Wilms' tumor and orbital rhabdomyosarcoma.

Nontuberculous mycobacteria may cause indolent postoperative or device-associated infection and can be overlooked in anophthalmic socket inflammation. A 71-year-old woman with a right anophthalmic socket reconstructed with a dermis-fat graft developed progressive inability to retain her prosthesis, followed by purulent discharge. Socket swab was acid-fast smear-positive and subsequently identified as Mycobacterium abscessus species group. Orbital magnetic resonance imaging showed mild curvilinear enhancement along the prosthesis margins without drainable abscess. Management included prolonged susceptibility-guided multidrug antimicrobial therapy in collaboration with the infectious disease team, with staged oculoplastic procedures for concurrent cicatricial contracture. Symptoms improved, a new prosthesis was fitted approximately 3 months after presentation, and the socket remained clinically quiet through approximately 15 months of follow-up. This case highlights atypical mycobacterial infection as a diagnostic consideration in persistent anophthalmic socket inflammation with progressive contracture.

We present two cases of needlefish beak penetration to the orbit and cavernous sinus and a literature review of all 12 published cases involving needlefish orbital injuries. Our first case is a 7‑year‑old boy with a needlefish penetrating orbital injury where the beak was embedded in the orbit and cavernous sinus for 3 months prior to partial surgical removal. The second case is a 20‑year‑old man with a needlefish beak penetrating the orbit and cavernous sinus of his only seeing eye which was completely removed with retention of vision. There are 12 reported cases of needlefish orbital injuries with varying ophthalmic and neurological injury, including death. In three cases, needlefish beak material was left within the orbit to be managed conservatively. Needlefish penetrating orbital injuries are rare and can result in significant morbidity and vision loss. These partly ossified cartilaginous foreign bodies may be conservatively managed, especially if chronic.

Orbital rim repositioning is a pivotal step in lateral orbitotomy. This study aims to introduce a novel mortise-tenon joint fixation (MTF) technique inspired by traditional Chinese woodcraft for lateral orbital rim reconstruction. This retrospective case series analyzed outcomes in patients with thyroid eye disease (TED) undergoing balanced orbital decompression surgery using MTF. The clinical outcomes, the number of surgical implants used, and hospitalization costs were analyzed. Additionally, an orbital model of the same laterality, derived from another patient treated with titanium plate-and-screw fixation (PSF), was selected as the comparator for the three-dimensional finite element analysis. Analysis was conducted with masseter muscle fixation and the application of occlusal force on the masseter muscle. Nine TED patients (12 orbits) undergoing MTF reconstruction were enrolled. A mean proptosis reduction of 5.3 ± 0.9 mm was achieved. No complications such as severe hemorrhage, vision loss, or orbital rim displacement were observed. Finite element analysis showed that maximum stress was lower with MTF than with PSF: 8.59 MPa vs. 91.33 MPa (masseter muscle fixation) and 16.33 MPa vs. 91.20 MPa (force applied). Maximum displacement was also lower for MTF: 0.010 mm vs. 0.014 mm (masseter muscle fixation) and 0.026 mm vs. 0.033 mm (force applied). Implant material expenses in hospitalization costs decreased by $288.43-$412.00, representing an approximate 84.3% reduction compared to PSF. In summary, the MTF technique demonstrates safety, effectiveness, and biomechanical advantages for orbital rim repositioning during lateral orbitotomy. It also reduces patient costs, offering a promising alternative to traditional fixation methods.