1. 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

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

3. 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

4. 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

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

6. 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

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

8. 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

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

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

11. 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

12. 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

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

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

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

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

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

18. CASE 2
fs T1-WI + Gd
Mucosal enhancement

19. 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

20. 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

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

22. REFERENCES
Meltzer, DE. Orbital imaging: a patter-based approach. Radiol Clin N Am. 2015;53: Tailor TD, Gupta D, Dalley RW, Keene CD, Anzai Y. Orbital neoplasms in adults: clinical, radiologic, and pathologic review. Radiographics. 2013;33(6): Choi JW, Kim HJ, Kim ST, Lee HB. CT and MR imaging findings of tumors and tumor-like conditions of the lacrimal sac. EPOS 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.