1. Imaging of extraocular orbital pathology
BY : Ali Hekmatnia M.D

2. Imaging indications
Ophthalmologist suspects pathology symptomatically or by sonography not exactly delineated
In cases of trauma (e.g. foreign body, fractures)
Posttreatment

3. Imaging modalities US
CT – MDCT often working horse
MRI

4. Imaging techniques CT
MDCT, axial, -/+ CM (depending on pathology), coronal/sagittal reconstructions, soft tissue/bone window level
MRI
Headcoil/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 sections
Coronal sections from the lateral
orbital rim to the posterior aspect of the
optic canals
(anterior clinoid or dorsum sellae)

6. Coronal images : - Extraocular muscles , optic nerve
sheath , nasal complex ,vessels
and globes , Spread of processes
from surrounding structures
Windowing : soft tissue as well as
bone-oriented window

7. MRI : - Multiplanar capability , without ionizing radiation and
bony artifact(especially in the orbital apex,optic canal
and parasellar regions ) .Best soft tissue contrast.
- Protocol of MRI :
coronal and axial T1 and T2W images , coronal T1W
with fat saturation(before and after contrast injection )

8. Anatomy of the Orbit Compartimental anatomy
Extraconal
Conal
Intraconal
Globe
Lacrimal gland

9. Orbital Anatomy : - Bony cavity , the globe, muscle cone,optic
nerve-sheath complex,lacrimal apparatus,orbital
fat,vascular and nerve structures,orbital septum
and 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

11. Optic nerve sheath complex :
- Optic nerve , subarachnoid space , fluid
between dura and nerve , diameter of
complex (4-6mm)

12. Anatomy of the Orbit
Intraorbital
ExtraconalConal
Intraconal
Globe

13. Anatomy of the Orbit Compartimental anatomy
Intraorbital
Extraconal
Conal
Intraconal
Globe
Lacrimal gland

14. Supraorbital fissure
Supraorbital fissure
Infraorbital fissure and pterygopalatine fossa

15. Close relationship to PNS
Variant

16. Anatomy of the orbit
Muscles

17. Anatomy of the orbit
Muscles

18. Orbita may be easily affected!!!
Close relationship to vascular/nerval structures!!!
Orbita may be easily affected!!!

19. Anatomic regions Fossa pterygopalatina
Close relation Orbit-PNS-Oropharynx
Nerves III, IV, V, VI, VII
Parasellarregion
Maxillary nerve Greater petrosal nerve

20. Cave metallic foreign bodies
Pathology
Inflammation orbital-extraorbital
Blastoma orbital-extraorbital benign-malignant
Trauma
Foreign bodies
Cave metallic foreign bodies
NO MRI !!!

21. Inflammation
Inflammation of lid
CT (Abscess)
MRI (Phlegmone)

22. Subperiostal abscess CT
Harnsberger R:
Head and Neck 2004
Spread of infection from
ethmoid cells
Compression of optic nerve
Thrombosis

23. Subperiostal abscess MRI -Spread of infection from ethmoid cells
Harnsberger R:
Head and Neck 2004
Subperiostal
abscess MRI
-Spread of infection from ethmoid cells
-Compression of optic nerve!!
-Thrombosis!!

24. Dacryoadenitis

25. Subperiosteal abscess
Orbital cellulitis in a 13-year-old boy with extensive right ethmoid sinus disease
Subperiosteal abscess
in a 4-year-old girl with chronic right ethmoid sinusitis
The inflammation involved the medial extraconal portions of the right orbit
The inflammation involved the preseptal and
extraconal 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 subperiosteal
abscess
Axial CT scan shows lateral displacement
of the medial rectus muscle and infiltration ofthe extraconal fat (arrows)

26. Orbital pseudotumor
Gross 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 proptosis
Diffuse enlargement of the lacrimal gland is seen with preservation of its shape
There is diffuse thickening of the bilateral medial and lateral rectus muscles including their tendinous insertion (arrows) which is typically spared in thyroid ophthalmopathy

28. Optic nerve neuritis (MS)

29. Pseudo-inflammation 3T
Orbital pseudotumor
No diffuse infiltration

30. Endocrine orbitopathy CT
Graves disease / M. Basedow

31. Endocrine orbitopathy MR
Graves disease / M. Basedow

32. Endocrine orbitopathy
3T MR
Thickening and hyperintensity of medial and inferior rectus muscle

33. Small capillary
hemangioma

34. 3T MR
Large capillary
hemangioma

35. Hemangiomatosis

36. 3T MR
Large lymphatic-venous
malformation

37. in a patient who experienced sudden proptosis and discoloration
Lymphangioma in a 4-year-old boy with sudden supraorbital fullness of the right eye
Lymphangioma
in a patient who experienced sudden proptosis and discoloration
about his right eye
Axial 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 orbit
MRI 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-like
Fibrous dysplasia, Metastasis Adenoma, Dermoid, pleomorphic Adenoma, Lymphoma Grave`s, Hemangioma, Lymphoma, Schwannoma, Pseudotu (Melanoma, Retinoblastoma) Glioma, Meningeoma
Bone
Lacrimal gland
Conus
(Globe)
Nerve
P. Som Head and Neck Imaging 4th ed. 2003

40. Orbital pathology Pathology bony orbit
Fibrous dysplasia orbit

41. Blastoma
Melanoma lower lid

42. Fat
Dermoid

43. 3T MR
Pleomorphic adenoma

44. Pleomorphic carcinoma with papilla infiltration (II)
Pleomorphic adenoma
parotid gland

45. MALT-lymphoma lacrimal gland

46. Orbital lymphoma diffuse infiltration

47. Rhabdomyosarcoma

48. 3T MR
Rhabdomyosarcoma
M. rectus superior

49. Rhabdomyosarcoma

50. Cavernous
hemangioma

51. Orbital varix
Axial 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 in
venous pressure (Valsalva ` maneuver)

72. Orbital Varix
Axial 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 eyelid
Axial 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 hemangioma
Axial 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 hemangioma
A 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

77. Tram-track
Optic nerve
meningeoma

78. Glioma II

79. 3T MR
Glioma II

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 neurofibroma
Left orbital plexiform neurofibroma in a 10-month-old boy
Optic nerve gliomas
in a teenage girl with neurofibromatosis
Axial Ti-weighted (a) and T2-weighted (b) MR images show diffuse bilateral enlargement ofthe optic nerves by gliomas (arrows)

81. NF-1
Axial 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 neurofibroma
Radiograph 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 meningiomas
Axial 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 neurofibromatosis
Optic nerve glioma
in a young boy without neurofibromatosis
Axial CT scan reveals bilateral calcified meningiomas ofthe optic sheath
Axial CT scan shows diffuse involvement of the right optic nerve by a glioma. Pediatric optic nerve gliomas are frequently associated with neurofibromatosis

84. Extraorbital pathology
Schwannoma III

85. Schwannoma V2 with elevation
of rectus inf. muscle

86. Angiofibroma with
orbital infiltration

87. SCC

88. Trauma CT
Le Fort II

89. Orbital floor-fx with
herniation of fat

90. Hematoma

91. Orbital floor fracture,
Motility disturbance

92. Foreign bodies No MRI metallic !!!
Foreign bodies extraconal intraorbital

93. Foreign bodies
Foreign body sclera

94. Foreign bodies
Perforating
intraocular fb

95. Take home points Remind anatomic situation
Imaging technique and characteristics and localisation of pathology (intraorbital compartments)
Involvement of adjacent structures
Careful analysis DIAGNOSIS

96. Intraocular disorders

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 retinoblastomas
The increased signal intensity of the right globe is likely secondary to hemorrhage
The calcifications so prominent on the CT scan are poorly visualized on the MR image

99. Trilateral retinoblastoma
Axial CECT shows bilateral intraocular masses with calcification
with a separate intensely enhancing mass in the pineal location

100. Medulloepithelioma

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 eye
Coronal T2/W MR image better depicts this abnormality. The increased signal intensity in the right globe is due to hemorrhage

102. PHPV
Transverse 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 leukokoria
Sclerosing endophthalmitis
Axial 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 disease
Color doppler USG shows a large retinal detachment with hypoechoic subretinal exudates
CT 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 remodelled
Axial 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 swelling
and involvement the left orbit, diffuse
scleral thickening with enhancement, and a
poorly defined intraconal mass that envelops
the optic nerve. There is resultant proptosis.

109. Neuroblastoma in a 14-year-old boy
Midline granuloma
Axial 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 Lichtenstein
Bone or bone marrow lesions ( Overall incidence 23% )
Most commonly in frontal bone ( superior or superolateral wall
of orbit )

112. CT and MRI findings : - An osteolytic lesion or multiple lesions
- Well defined or diffuse soft tissue mass , encroaching
lacrimal gland , lateral rectus or even the globe

113. Differential diagnosis :
- Rhabdomyosarcoma
- Juvenile fibrosarcoma
- Aggressive fibromatosis
- Lacrimal gland tumor
- Leukemic infiltration
- Metastasis ( Neuroblastoma , Wilm's , Ewing's)

120. Bilateral Anophthalmia

121. Microphthalmos in a 13-year-old boy
Posterior optic coloboma
in a 2-year-old girl with seizures
CT scan shows the small right globe
The presence of the radiopaque lens differentiates microphthalmos from an orbital cyst
Sagittal 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 coloboma
Axial 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

123. Duplication cyst

124. Congenital cystic eye
Axial 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 present
Sagittal 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 brain
abnormalities
Absence of the septum pellucidum and pituitary -
hypothalamic endocrine dysfunction and hypoplasia of the
optic 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 syndrome
Axial CT scan demonstrates the proptosis and shallow orbits

129. Orbital encephalocele in a newborn
Axial CT scan demonstrates an encephalocele protruding through
the left orbit. A left globe was not seen, although retinal remnants were found within the encephalocele at
autopsy
Coronal CT scan demonstrates a prominent encephalocele that has
ballooned 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 areas
of thickening of the globe to large destructive lesion