2 CASES OF EYE ASYMMETRY N. De Vos1,2 Prof. Dr. F. M. Vanhoenacker1,2,3 Prof. Dr. M. Mespreuve1,2 Dr. J. Van Haesendonck4 1. Department of Radiology, UZ Gent 2. Department of Radiology, AZ Sint-Maarten, Duffel-Mechelen 3. Department of Radiology, UZ Antwerpen 4. Department of otorhinolaryngology, AZ Sint-Maarten, Duffel-Mechelen

Tailor TD et al. Radiographics, 2013. THEORETICAL CONSIDERATIONS ORBITAL ANATOMY Conal compartment: extraocular muscles Tailor TD et al. Radiographics, 2013.

APPROACH TO DDx CLASSICAL APPROACH LOCATION-BASED APPROACH THEORETICAL CONSIDERATIONS APPROACH TO DDx CLASSICAL APPROACH Etiology: inflammation – infection – neoplasm – trauma Comprehensive DDx: not clinically helpful LOCATION-BASED APPROACH Anatomy: conal – intraconal – extraconal – intraocular Concise DDx: helpful for clinician

APPROACH TO DDx CLINICAL FINDINGS MIMICKERS THEORETICAL CONSIDERATIONS APPROACH TO DDx CLINICAL FINDINGS Age, duration, pain, uni- or bilateral Crucial for further narrowing DDx MIMICKERS Metastases, lymphoproliferative diseases, sarcoidosis, idiopathic orbital inflammation Variety of imaging presentations May involve several orbital structures

CASE 1 70 year-old female Painless left-sided exophthalmos Since 3 months Medical history: / Fundoscopy: normal

CECT Extraconal mass, inferomedial side of left orbit CASE 1 CECT Extraconal mass, inferomedial side of left orbit Extension to inferior nasal meatus Uniform contrast enhancement

Bone remodeling with dilation of nasolacrimal duct CASE 1 CECT Bone remodeling with dilation of nasolacrimal duct

Low to intermediate signal intensity CASE 1 T1-WI T2-WI T2 WI: intermediate to low SI due to high cellular nuclear/cytoplasmic ratio Low to intermediate signal intensity

CASE 1 fs T1-WI + Gd Uniform enhancement Absence of necrosis

DWI ADC Restricted diffusion CASE 1 Restricted diffusion: high cellularity  water moves less freely Restricted diffusion

DIFFERENTIAL DIAGNOSIS CASE 1 DIFFERENTIAL DIAGNOSIS CRUCIAL FINDINGS 70 year-old female Rapid onset of painless exophthalmos Extraconal orbital mass MRI: low SI, diffusion restriction: high nuclear-cytoplasmic ratio DIFFERENTIAL DIAGNOSIS Lacrimal sac tumor Lymphoproliferative disease

DIAGNOSIS AND TREATMENT CASE 1 DIAGNOSIS AND TREATMENT BIOPSY: LYMPHOMA B-cell non-Hodgkin lymphoma 24% of all space-occupying orbital tumors in patients older than 60 years 30% of patients will develop systemic lymphoma within next 10 years TREATMENT: CHEMOTHERAPY Bendamustine + Rituximab

CASE 2 50-year old male Right-sided enophthalmos Longstanding Sensation of eye displacement when blowing nose Medical history: /

CASE 2 CT Right-sided enophthalmos No intra-orbital abnormalities

CT Heterogeneous opacification of maxillary sinus CASE 2 CT Heterogeneous opacification of maxillary sinus Volume loss, inferior displacement of orbital floor

Thin-walled sinus, no erosions, small calcifications CASE 2 CT CECT Thin-walled sinus, no erosions, small calcifications Minimal enhancement

Fat proliferation in infratemporal fossa CASE 2 T1-WI T2-WI T1-WI: low SI T2-WI: high SI Fat proliferation in infratemporal fossa

CASE 2 fs T1-WI + Gd Mucosal enhancement

DIFFERENTIAL DIAGNOSIS CASE 1 DIFFERENTIAL DIAGNOSIS CRUCIAL FINDINGS 50 year-old male Longstanding right-sided enophthalmos Right-sided maxillary sinus Complete opacification Volume loss Thin osseous walls

Case courtesy of Prof Frank Gaillard, Radiopaedia.org, rID: 9447 DIAGNOSIS SILENT SINUS SYNDROME Maxillary sinus obstruction due to occlusion of infundibulum Accumulation of mucus, which leads to chronic low-grade inflammatory response Osteolysis of mucosal walls with volume loss due to negative pressure Case courtesy of Prof Frank Gaillard, Radiopaedia.org, rID: 9447

TAKE HOME MESSAGES ORBITAL IMAGING Location-based: globe – muscle cone – extraconal – intraconal Clinical findings Mimickers: lymphoproliferative diseases, metastases, sarcoidosis, idiopathic orbital inflammation Paranasal sinuses

REFERENCES Meltzer, DE. Orbital imaging: a patter-based approach. Radiol Clin N Am. 2015;53:37-80. Tailor TD, Gupta D, Dalley RW, Keene CD, Anzai Y. Orbital neoplasms in adults: clinical, radiologic, and pathologic review. Radiographics. 2013;33(6):1739-58. Choi JW, Kim HJ, Kim ST, Lee HB. CT and MR imaging findings of tumors and tumor-like conditions of the lacrimal sac. EPOS. 2011. http://dx.doi.org/10.1594/ecr2011/C-1926 Illner A, Davidson HC, Harnsberger HR, Hoffman J. The silent sinus syndrome: clinical and radiographic findings. AJR Am J Roentgenol. 2002;178(2):503-6.