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HistoryA 73-year-old man presented to the Department of Ophthalmology, Amala Institute of Medical Sciences, Kerala, with mild congestion of left eye. He believed that his symptoms began after accidental exposure of his eyes to medicated oil used during a massage session, as part of traditional medical treatment he was taking. He was diagnosed with toxic conjunctivitis and treated with loteprednol eyedrops. At his follow-up visit on the third day, he complained that his left eye had not improved and that it was starting to "bulge out."The patient denied vision loss, double vision, headache, or other systemic symptoms. He had undergone bilateral orchidectomy and radiotherapy for prostate carcinoma 3 years earlier and was now on hormone therapy with bicalutamide. He had undergone thyroidectomy for hyperthyroidism 15 years previously and was now onlevothyroxine. Ocular history was remarkable for uneventful cataract extraction in both eyes with IOL placement 20 years previously. ExaminationOn initial examination, best-corrected visual acuity was 20/20 in each eye. Color vision was normal in both eyes. There was periorbital fullness and partial ptosis of the left eye. Palpation revealed apainless, firm swelling along the lateral one-third of superior orbital margin. It was found to displace the globe inferiorly ( Figure 1A). Hertel exophthalmometry measured 16 mm in the right eye and 22 mm in the left eye ( Figure 1B). Ocular motility was full on the right side; the left eye showed generalized restriction and complete loss of elevation ( Figure 1C).Slit-lamp examination of the anterior and posterior segments was entirely normal except for temporal bulbar conjunctival congestion with chemosis in left eye. Pupils were reactive, with no afferent pupillary defect.General examination did not reveal any abnormal cervical lymph nodes. Cranial nerve evaluation was within normal limits. Ancillary TestingRoutine blood testing, thyroid function tests, and prostate specific antigen (PSA; 0.1 ng/ml) were within normal limits. Computed tomography (CT) of brain and orbit demonstrated an enhancing lytic lesion, with a significant soft tissue component and calcification. It measured 22 × 35 × 34 mm and involved the left frontal bone encroaching on the lateral wall of orbit. The lesion was found to indent the globe on its superior aspect. Both the superior rectus and superior oblique muscles appeared to be involved. The left optic nerve was free. These findings were suggestive of left orbital metastasis with intracranial extension (Figure 2).