Orbit, 27:293–295, 2008 Copyright  c 2008 Informa Healthcare USA, Inc. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.1080/01676830802222878 CASE REPORT Bilateral Infiltrative Disease of the Extraocular Muscles: A Rare Clinical Presentation of Early Stage Chronic Lymphocytic Leukemia Yashin D. Ramkissoon Moorfields Eye Hospital, London, United Kingdom Richard W. J. Lee Department of Clinical Sciences South Bristol, University of Bristol, and Bristol Eye Hospital, Bristol, United Kingdom Rizwan Malik Moorfields Eye Hospital, London, United Kingdom James D. Hsuan Department of Ophthalmology, Walton Hospital, Liverpool, United Kingdom Mike J. Potts Bristol Eye Hospital, United Kingdom ABSTRACT Orbital involvement in chronic lymphocytic leukemia (CLL) is highly unusual and most commonly involves hemorrhage or soft tissue infil- tration in advanced disease. We report a case of rapid onset bilateral orbital muscle infiltration as the presenting feature of early stage CLL. In addition, we demonstrate clinico-pathological correlation with an identical chronic B-cell lymphocytic infiltrate in both orbit and bone marrow, with good response of the orbital disease to local radiotherapy. KEYWORDS Leukemia; lymphocytic; chrome; B-cell; leukemic infiltration; neoplasm; staging; orbit; radiotherapy Chronic lymphocytic leukemia (CLL) accounts for a quarter of all cases of leukemia in the Western world. Although acute leukemia is well documented to manifest in the eye and orbit, any ocular involvement by CLL is extremely unusual, and a primary leukemic infiltrate of the orbit in CLL is especially rare (Buchan et al., 2003; Kincaid & Green, 1983; McKelvie et al., 2001). Here we de- scribe a case of early, clinical stage, chronic B-cell lymphocytic leukemia present- ing with rapid onset bilateral, simultaneous infiltration of the orbit, and extraoc- ular muscles. Magnetic resonance imaging (MRI) and definitive histopatholog- ical studies demonstrated direct infiltration of all extraocular muscles by an otherwise low-grade CLL. CASE REPORT A 72-year-old man presented with a 5-day history of progressive bilateral retro- orbital pain associated with conjunctival chemosis, lid edema, and restricted eye movements (Fig. 1A). His left eye was known to be densely amblyopic, with a long-standing left exotropia, but there was no other past ocular or medical his- tory of note. Best corrected visual acuities were 6/9 right and hand movements left. There was no relative afferent pupillary defect, and his color vision was full in the right eye. He had mild bilateral axial proptosis (Hertel’s exophthal- mometer readings were 22 mm for both eyes), and ocular motility was markedly Received 16 July 2007; Accepted 3 March 2008. Address correspondence to Dr. Richard Lee, Bristol Eye Hospital, Lower Maudlin Street, Bristol, BS1 2LX, UK. E-mail: richard.lee@bristol.ac.uk 293