Strabismus surgery complicated by "pulled in two syndrome" in a case of breast carcinoma metastatic to the medial rectus muscle

Metastatic carcinoma to the extraocular muscles is extremely rare; it is re ported to occur from breast, lung, and gastric carcinoma as well as skin me lanoma.(1-3) Overall, intraocular metastases occur much more frequently tha n orbital metastases.(4) The most common primary tumors causing orbital met astases are breast and lung carcinomas.' Strabismus due to orbital metastas es from breast carcinoma usually results from fibrosis of the muscle, which often causes painful ophthalmoplegia and enophthalmos.(6,7) We report a ca se of presumed metastatic carcinoma to the medial rectus muscle causing res trictive strabismus in which surgery was complicated by the "pulled in two syndrome," or PITS.