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images in clinical medicineT h e ne w e ngl a nd jou r na l o f m e dic i ne n engl j med 356;1 www.nejm.org january 4, 2007 67A 59-year-old nonobese man presented with a 7-year history of gradually progressive swelling over the left eye. He had no other clinically significant medical history or history of trauma. There was a soft, yellowish mass in the outer temporal subconjunctival region (Panel A). The patient's vision was normal. Among the disorders in the differential diagnosis, orbital lymphoma was a particular concern. Characteristic features of an orbital lymphoma typically include a lesion of salmon color that is firm on palpation, that has a solid appearance on computed tomography (CT), and that follows the contour of the orbit without bony erosion. The mass was reducible on direct pressure, and it enlarged on retropulsion of the globe (Panel B), suggesting the fluid nature of its content and intraorbital extension. CT revealed a density identical to that of intraorbital fat, confirming the clinical impression of subconjunctival prolapse of orbital fat -a benign entity. Surgical intervention may be needed if such a lesion is cosmetically unacceptable or causes discomfort. Clinical recognition of this condition can spare the patient an extensive lymphoma workup, a biopsy, and further follow-up.

IntroductionAbduction deficit in the elderly is commonly caused by sixth cranial nerve palsy due to microvasculopathy. However, not all such cases are of neurogenic origin, as our case report shows.Case presentationWe present the case of a 75-year-old woman who was generally unwell, developed acute diplopia and was found to have a right abduction deficit in a quiet eye with no gross orbital signs and symptoms. A computed tomography scan of the head and orbits revealed a metastatic mass in the right lateral rectus muscle. Systemic evaluation confirmed widespread thoracic and abdominal metastases from an occult systemic malignancy. Lateral rectus metastasis from an occult systemic malignancy was masquerading as abducens palsy.ConclusionOrbital metastasis involving extraocular muscles can present as isolated diplopia with minimal local signs and the absence of a history of systemic malignancy. A detailed history and systemic examination can identify suspicious cases, which should be investigated further. The clinician should avoid presuming that such an abduction deficit in the elderly is a benign neurogenic palsy.

Purpose To evaluate the outcomes of early pars-plana vitrectomy (PPV) in the management of acute onset endophthalmitis after cataract surgery. Study design Retrospective observational study. Patients and methods We collected data from 11 patients who were diagnosed as acute infectious endophthalmitis within 6 weeks after cataract surgery, from January 2015 to December 2020 and had undergone early 23-G PPV and were followed up for 3 months. We analyzed factors that may affect prognosis and final visual outcomes. Results The mean age was 58±5 years, there was male predominance (72.7%). The mean axial length was 24.76±1.58 mm. The baseline best-corrected visual acuity was 2.3 logMAR and was improved to 1.2 logMAR at the third month (P<0.001). Mixed air/fluid intraocular tamponade was used in 63.6% of patients. About half of the cases had positive cultures (54.5%), and the most frequent organism was Staphylococcus aureus (66.7%). Retinal detachment was reported in 36.4% of patients. The preoperative factors correlated with final best-corrected visual acuity were posterior vitreous detachment and intraocular tamponade. Conclusions Early PPV for acute-onset endophthalmitis after cataract surgery aided in improving final visual outcome and preserving structural and functional integrity of the globe, thus preventing late complications that could affect patients’ quality of life. Factors that influence the final visual outcome were intraocular tamponade and posterior vitreous detachment.