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Last Month’s Blink

Basal Cell Carcinoma Complicated by Orbital Myiasis

Written by Kasturi Bhattacharjee, MD, MBBS; Obaidur Rehman, MBBS, MS; Deepak Soni, MBBS, MS; and Vatsalya Venkatraman, MD. Photos by Mukesh Das. All are at Sri Sankaradeva Nethralaya in Guwahati, Assam, India.

A 60-year-old man presented with pain, a crawling sensation, and a foul smell emanating from a large periorbital wound in the area of the right eye (Fig. 1). An exophytic fungating mass involving the entire lower eyelid and 75% of the upper eyelid with ulcerated, necrotic margins was noted. It contained a deep cavity filled with greasy, black ne­crotic material, and live crawling maggots (Fig. 2). Ocular examination of the right eye was not possible, while the left eye was essentially normal.

CT revealed heterogeneous periorbital soft tissue swelling with orbital infiltration, pushing the right globe superomedially (Fig. 3). The orbital apex, orbital walls, and paranasal sinuses were spared, and no intracranial extension was observed.

Orbital exploration with turpentine oil lavage was performed, and live maggots were extracted. Punch biopsy from the eyelid revealed atypical cells with peripheral palisading, indicating basal cell carcinoma. Oral antibiotics, analgesics, and ivermectin (200 μg/kg/day) were prescribed. Entomological evaluation confirmed Cochliomyia hominivorax species, which predominates at high altitudes and has a specific predilection for causing myiasis in exposed skin malignancies.

A total orbital exenteration was performed with a pedicled temporalis muscle flap rotated into the orbital cavity and covered with split-thickness skin graft (Fig. 4).

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