Sixth nerve palsy or not? (Image)

Here in we present a case of a 72-yearold Caucasian female with remote history of breast cancer who presented with diplopia in the right gaze over the past several months. There had been no improvement after a 5-day course of steroids by an outside ophthalmologist. On neuro-ophthalmic examination, the right eye did not abduct beyond midline, In addition, there was subtle limitation in adduction, elevation and depression. CT of the orbits revealed soft tissue thickening along the right lateral rectus muscle, containing multiple hypoattenuating foci. The differential diagnosis at that point included infectious process, metastatic foci or less likely a pseudotumor. She was ultimately found to have widespread metastatic disease. This case emphasizes the importance of thorough history taking, examination and targeted imaging studies which all lead to timely and accurate management. See related video: https://collections.lib.utah.edu/details?id=2389754