Presentation on theme: "Imaging of extraocular orbital pathology"— Presentation transcript:
1 Imaging of extraocular orbital pathology BY : Ali Hekmatnia M.D
2 Imaging indicationsOphthalmologist suspects pathology symptomatically or by sonography not exactly delineatedIn cases of trauma (e.g. foreign body, fractures)Posttreatment
3 Imaging modalitiesUSCT – MDCT often working horseMRI
4 Imaging techniquesCTMDCT, axial, -/+ CM (depending on pathology), coronal/sagittal reconstructions, soft tissue/bone window levelMRIHeadcoil/surface coils, axial IR, axial T1wSE -/+ CM, coronal/sagittal T1wSE+CM+ FS, matrix 512x512, FOV ~20cm
5 CT Scan : TECHNIQUE - Axial and coronal images - Axial 3mm sections - Coronal 5mm sectionsCoronal sections from the lateralorbital rim to the posterior aspect of theoptic canals(anterior clinoid or dorsum sellae)
6 Coronal images : - Extraocular muscles , optic nerve sheath , nasal complex ,vesselsand globes , Spread of processesfrom surrounding structuresWindowing : soft tissue as well asbone-oriented window
7 MRI : - Multiplanar capability , without ionizing radiation and bony artifact(especially in the orbital apex,optic canaland parasellar regions ) .Best soft tissue contrast.- Protocol of MRI :coronal and axial T1 and T2W images , coronal T1Wwith fat saturation(before and after contrast injection )
8 Anatomy of the Orbit Compartimental anatomy ExtraconalConalIntraconalGlobeLacrimal gland
9 Orbital Anatomy : - Bony cavity , the globe, muscle cone,optic nerve-sheath complex,lacrimal apparatus,orbitalfat,vascular and nerve structures,orbital septumand lids
10 Muscle Cone : - Superior,medial,lateral and inferior recti,Superior and inferior obliques, Levator palpebrae superioris.- Introconal space : Surgical problems- Extraconal space : Medical management- Globe : Cornea,lens,anterior chamber,vitreous,retinal - scleral complex
21 InflammationInflammation of lidCT (Abscess)MRI (Phlegmone)
22 Subperiostal abscess CT Harnsberger R:Head and Neck 2004Spread of infection fromethmoid cellsCompression of optic nerveThrombosis
23 Subperiostal abscess MRI -Spread of infection from ethmoid cells Harnsberger R:Head and Neck 2004Subperiostalabscess MRI-Spread of infection from ethmoid cells-Compression of optic nerve!!-Thrombosis!!
25 Subperiosteal abscess Orbital cellulitis in a 13-year-old boy with extensive right ethmoid sinus diseaseSubperiosteal abscessin a 4-year-old girl with chronic right ethmoid sinusitisThe inflammation involved the medial extraconal portions of the right orbitThe inflammation involved the preseptal andextraconal portions of the medial right orbit. Axial CT scan shows the slightly displaced and thickened medial rectus muscle and a small focal fluid collection (arrow), which was confirmed as representing a subperiostealabscessAxial CT scan shows lateral displacementof the medial rectus muscle and infiltration ofthe extraconal fat (arrows)
26 Orbital pseudotumorGross mass-like enlargement of the medial rectus muscle, with characteristic hypointense signal on T1W (a) and T2W (b) sequences. Moderate heterogeneous enhancement is seen in the post gadolinium image (c)
27 Orbital pseudotumor (different patients) Axial CECT shows a diffuse infiltrative right orbital mass involving the globe and causing marked proptosisDiffuse enlargement of the lacrimal gland is seen with preservation of its shapeThere is diffuse thickening of the bilateral medial and lateral rectus muscles including their tendinous insertion (arrows) which is typically spared in thyroid ophthalmopathy
37 in a patient who experienced sudden proptosis and discoloration Lymphangioma in a 4-year-old boy with sudden supraorbital fullness of the right eyeLymphangiomain a patient who experienced sudden proptosis and discolorationabout his right eyeAxial CT scan reveals a multilocular intraconal lymphangioma in the right orbit.Axial T2/W MR image demonstrates hemorrhage into a multilocular lymphangioma.The high-signal-intensity methemoglobin is layering anteriorly in each cyst.
38 Venolymphatic malformation USG reveals a multiseptate cystic mass in the orbitMRI reveals a heterogeneous intraconal mass in the right orbit displacing the optic nerve.Lesion is heterogeneous in signal intensity with a hyperintense area on T1W image (a)which shows blood-fluid level on T2W sequence (arrows) (b).There is only mild enhancement following contrast administration (c)
39 Blastoma/Tumor-likeFibrous dysplasia, Metastasis Adenoma, Dermoid, pleomorphic Adenoma, Lymphoma Grave`s, Hemangioma, Lymphoma, Schwannoma, Pseudotu (Melanoma, Retinoblastoma) Glioma, MeningeomaBoneLacrimal glandConus(Globe)NerveP. Som Head and Neck Imaging 4th ed. 2003
40 Orbital pathology Pathology bony orbit Fibrous dysplasia orbit
51 Orbital varixAxial T1W and T2W MRI reveal an elongated lesion around the optic nerve which is hypointense on T1W and hyperintense on T2W sequence. Note the characteristic “club like” configuration of the lesion in the sagittal T2W
52 Orbit Varix : Large , tortuous vein or a mass like confluence of small veins may markedly enlarge with changes invenous pressure (Valsalva ` maneuver)
72 Orbital VarixAxial CECT in a child with intermittent proptosis is almost normal. However, during valsalva maneuver the enhancing mass and the associated tortuous venous channels stand out causing significant proptosis
73 Capillary hemangioma in a 5-month-old girl with diffusely dilated capillaries and chemosis of the eyelidAxial and sagittal Ti-weighted MR images demonstrate a capillary hemangioma superficially and preseptally about the left orbit.Several prominent vessels are noted within the mass.
74 Capillary hemangiomaAxial CECT shows an intensely enhancing mass in the eyelid and extraconal space of the left orbit causing displacement of the globe
75 Cavernous hemangioma in a 16-year old boy Sagittal T1/W MR image demonstrates an intraconal cavernous hemangioma posteriorly(arrow).Cavernous hemangiomas may be differentiated from lymphangioma because they enhance greatly after contrast material is administered.
76 Cavernous hemangiomaA homogenous well-defined intraconal mass is seen in the left orbit which is isointense on T1W , hyperintense on T2W sequence and reveals heterogeneous enhancement.Cavernous hemangiomas are not uncommon in children
80 Left orbital plexiform neurofibroma in a 10-month-old boy Axial proton-weighted (a) and coronal Ti-weighted (b) MR images demonstrate extensive involvement of the left eyelid and extraconal region by a plexiform neurofibromaLeft orbital plexiform neurofibroma in a 10-month-old boyOptic nerve gliomasin a teenage girl with neurofibromatosisAxial Ti-weighted (a) and T2-weighted (b) MR images show diffuse bilateral enlargement ofthe optic nerves by gliomas (arrows)
81 NF-1Axial CECT shows the dysplastic left greater wing of sphenoid with anterior herniation of the temporal lobe and an ill-defined infiltrative mass in the temporal fossa invading the orbit suggestive of a plexiform neurofibromaRadiograph of the orbit (a) reveals the characteristic enlarged and “bare” left orbit in a child with NF1
82 Multifocal meningioma in an 18-year-old male adolescent with neurofibromatosis Coronal T1/W MR image demonstrates bilateral isointense intraventricular meningiomasAxial CT scan shows a calcified meningioma of the right optic nerve
83 in a young boy without neurofibromatosis Bilateral optic nerve meningiomas in a 15-year-old girl with no other findings of neurofibromatosisOptic nerve gliomain a young boy without neurofibromatosisAxial CT scan reveals bilateral calcified meningiomas ofthe optic sheathAxial CT scan shows diffuse involvement of the right optic nerve by a glioma. Pediatric optic nerve gliomas are frequently associated with neurofibromatosis
95 Take home points Remind anatomic situation Imaging technique and characteristics and localisation of pathology (intraorbital compartments)Involvement of adjacent structuresCareful analysis DIAGNOSIS
97 Calcified retinoblastoma Axial CT scan demonstrates a calcified mass in the left globe, accompanied by some increased attenuation of the vitreous.
98 Bilateral retinoblastoma Coronal CT scan and T1-w axial MR image demonstrate bilateral calcified retinoblastomasThe increased signal intensity of the right globe is likely secondary to hemorrhageThe calcifications so prominent on the CT scan are poorly visualized on the MR image
99 Trilateral retinoblastoma Axial CECT shows bilateral intraocular masses with calcificationwith a separate intensely enhancing mass in the pineal location
101 Persistent hyperplastic primary vitreous ( PHPV ) in a 3-year-old boy Axial contrast material-enhanced CT scan shows a coneshaped, noncalcified, central retrolental area of increased attenuation in the right eyeCoronal T2/W MR image better depicts this abnormality. The increased signal intensity in the right globe is due to hemorrhage
102 PHPVTransverse color Doppler USG shows an echogenic retrolental structure with a vascular channel within, suggestive of PHPV
103 Sclerosing endophthalmitis Retrolental fibroplasia with bilateral medial retinal detachments in an 1 1-month-old girl with bilateral leukokoriaSclerosing endophthalmitisAxial CT scan shows a uniform increased attenuation throughout the right globe. The linear area of high attenuation seen in the middle to lateral aspects of the globe is a detached retina. A classic nematode infection was confirmed at the histopathologic analysis. The lack of a focal mass and of calcification helps differentiate sclerosing endophthalmitis from retinoblastoma.The infant, born prematurely, had received oxygen therapy for respiratory distress syndrome. Axial CT scan clearly shows the high-attenuation detached retinas (arrows).
104 Coat’s diseaseColor doppler USG shows a large retinal detachment with hypoechoic subretinal exudatesCT shows diffuse increase in the intraocular density
105 Orbital rhabdomyosarcoma in a young child A large superior right orbital mass compressed and displaced the globe anteriorly and inferiorly. The mass is hypointense on the coronal T1/W image and hyperintense on the T2/W image
106 Orbital rhabdomyosarcoma Axial CECT show a homogeneous multicompartmental soft tissue density mass causing orbital expansion and destruction of the medial orbital wall
107 Dermoid and Epidermoid cyst (different patients) Axial CECT : The large well-circumscribed cystic lesion at the inner canthus is suggestive of an epidermoid cyst.The adjacent bone is remodelledAxial CECT : A well-defined fat-containing lesion is seen near the outer canthus
108 Leukemic involvement of the orbit in a 6-month-old boy with acute lymphocytic leukemia Axial CT scan shows preseptal swellingand involvement the left orbit, diffusescleral thickening with enhancement, and apoorly defined intraconal mass that envelopsthe optic nerve. There is resultant proptosis.
109 Neuroblastoma in a 14-year-old boy Midline granulomaAxial CT scan reveals diffuse sclerotic bone involvement from metastatic neuroblastoma. In addition, there is extraconal involvement about the right orbit with resultant proptosis.Coronal CT scan demonstrates a midline mass with encroachment into the left orbit.
110 Langerhan’s cell histiocytosis Axial CECT shows destruction of lateral orbital walls and the greater wing of the sphenoid bone on both sides with associated complex soft tissue mass encroaching on the orbits.The skull radiograph in the same patient reveals multiple well-defined lytic lesions in the cranial vault with typical bevelled edges
111 Langerhans ‘cell Histiocytosis ( Orbital LCH )1953 LichtensteinBone or bone marrow lesions ( Overall incidence 23% )Most commonly in frontal bone ( superior or superolateral wallof orbit )
112 CT and MRI findings : - An osteolytic lesion or multiple lesions - Well defined or diffuse soft tissue mass , encroachinglacrimal gland , lateral rectus or even the globe
121 Microphthalmos in a 13-year-old boy Posterior optic colobomain a 2-year-old girl with seizuresCT scan shows the small right globeThe presence of the radiopaque lens differentiates microphthalmos from an orbital cystSagittal T1/W MR image reveals a small cyst adjacent to the insertion of the optic nerve (arrow)Microphthalmos and persistent hyperplastic primary vitreous (PHPV) are also present
122 Bilateral colobomaAxial CECT shows defect of the right globe at the optic nerve head via which the vitreous projects posteriorly (arrow). The left globe is small, with a retrobulbar (colobomatous) cyst (arrow) and dystrophic calcification at the site of coloboma
124 Congenital cystic eyeAxial CECT shows a large right orbital cyst with absence of the globe.Also note the microphthalmia with coloboma and dysplastic lens on the left side
125 Septo-optic dysplasia in a 22-month-old deaf, mute, and blind boy Axial T1/W MR image shows bilaterally small globes (left larger than the right), with hemorrhage in the left globe. Since no trauma had occurred, the presence of hemorrhage may indicate PHPV is presentSagittal midline T1/W MR image demonstrates agenesis of the corpus callosum and a prominent anterior inferior recess ofthe third ventricle (arrow).
126 Septo - optic dysplasia : - A part of a spectrum of developmental and congenital brainabnormalitiesAbsence of the septum pellucidum and pituitary -hypothalamic endocrine dysfunction and hypoplasia of theoptic nerves
127 Trigonocephaly secondary to metopic suture synostosis Axial CT scan obtained at the level of the orbit roofs demonstrates a marked frontal and rbital asymmetry secondary to cranial synostosis
128 Apert syndrome in a 3-week-old boy Anterior radiograph of the skull demonstrates the typical features ofApert syndromeAxial CT scan demonstrates the proptosis and shallow orbits
129 Orbital encephalocele in a newborn Axial CT scan demonstrates an encephalocele protruding throughthe left orbit. A left globe was not seen, although retinal remnants were found within the encephalocele atautopsyCoronal CT scan demonstrates a prominent encephalocele that hasballooned inferiorly into the nasal cavity and medially into both orbits (arrows).
130 Metastatic disease : Most common primary tumor is breast , then lung - In any part of the orbit , bone or soft tissue- Findings may be subtle , with small focal areasof thickening of the globe to large destructive lesion