How do you manage a twice-recurrent mucinous adenocarcinoma of the lower eyelid with direct involvement of the lateral rectus muscle and lacrimal duct?  

These are difficult cases. In the past, I have successfully treated a couple of these tumors with neoadjuvant immunotherapy, which allows for reduction in tumor volume to allow for an eye-sparing surgery. Because the orbit is involved, radiation should not be given due to the profound complications ...

Not easy to treat. I usually run a genomic panel to look for potential targets. Once I found EZh2, another time RAS. Both are targetable. Also, carbo/paclitaxel can be useful. Always check for MSI and if positive add PD1 monoclonals.