Imaging of Orbit

Dr. Faisal M. Shembesh.

Computed X-ray Tomography XIndications:

CT remains the technique of choice for investigation of suspected orbital disease. Cost. Accessibility. Speed. High tissue contrast within the orbit. Pain. Deformity. Proptosis. Swelling. restriction of eye movements. visual loss. CT of the eye is generally less sensitive than either sonography or MRI. However, it is the examination of choice for demonstrating possibly intraocular foreign bodies when plainplain-film localisation is inadequate & orbital trauma .

Magnetic Resonance Imaging

Indications
Although MRI has the obvious advantages in this context of not using ionising radiation and of being able to generate images in any plane, it should be regarded as a complement to CT. plane, The insensitivity of MRI to calcification, which may vitiate diagnosis of drusen, choroidal osteoma, senile scleral plaques or even optic nerve sheath meningioma Chemical shift artefacts, which can simulate a capsule or calcification. must be borne in mind. Nevertheless, there are a number of well-defined wellsituations in which MRI can usefully complement CT.

The general contraindications to MRI, such as Metallic foreign bodies. intracranial

aneurysm clips, pacemakers, nerve stimulators, and magnetic ocular prostheses,

Magnetic Resonance Imaging

Indications

Distinction of lesions arising from the optic nerve or its sheath from those which about the optic nerve, when this is not evident on CT, is of major importance, since the former are rarely an indication for surgery, whereas in the latter group surgery can be curative. The coronal plane is usually the most informative in this context. context.

Magnetic Resonance Imaging

Indications

Demonstration of signal change within a morphologically normal optic nerve may be of largely academic interest, since it should rarely affect treatment. However, in inflammatory disease, the ability to show that the process involves the nerve sheath (as in, say, sarcoidosis) rather than the nerve itself (as in demyelinating retrobulbar neuritis), may orientate management.

Magnetic Resonance Imaging

Indications

Demonstration of intracranial changes indicative of a more widespread central nervous system disease. Perhaps the most obvious example is when plaques of demyelination are shown in a patient with an optic neuropathy of unknown cause. Meningeal infiltration, suggestive of granulomatous disease or neoplasia, may also orientate the diagnostic process.

Magnetic Resonance Imaging

Technique

Thin sections are usually required. Axial and coronal images are usually most helpful. The latter are preferred for assessment of the optic nerve and its sheath. Fat suppression is helpful; STIR, FLAIR or fatfatsuppressed spin-echo sequences may be obtained. Fat spinsuppression is essential when contrast-enhanced contrastimages are obtained.

Orbital Anatomy
Each orbital recess contains the globe, globe, nerves (II, III, IV, V, and VI), muscles, blood muscles, vessels, vessels, connective tissue, and most of the tissue, lacrimal apparatus. The bony orbit is apparatus. bordered by the periosteum

Seven bones comprise the orbit

Frontal, Maxillary, Ethmoid, Sphenoid, Lacrimal, Palatine, and Zygoma bones.

Tenon's capsule (fascia bulbi)

is a fibroelastic membrane that envelops the eyeball from the optic nerve to the ciliary muscle. The inner surface of Tenon's capsule is separated from the outer surface of the sclera by a potential space - the episcleral or Tenon's space. space.

Four orbital spaces:

useful for surgical planning and for differential diagnosis.

(1) intraconal (central orbital). (2) extraconal (peripheral orbital). (3) Tenon's. (4) subperiosteal. potential spaces . subperiosteal.

separated from the other spaces by the rectus muscles

IntraIntra-orbital fatty reticulum is divided into

(1) peripheral orbital fat
outside the muscle cone, and its intermuscular membranes

(2) the central orbital fat

which is within the muscle cone Retro-orbital fat

Orbital Imaging Anatomy

Orbital Pathology

Developmental Orbital Cysts

The most frequent developmental orbital cysts are the dermoid and epidermoid cysts. cysts. Both result from the inclusion of ectodermal elements during closure of the neural tube.
Dermoid and epidermoid cysts favor the upper portion and in particular superior temporal quadrant rather than the lower quadrants of the orbit for their growth.

On CT. Dermoid cysts which contain fat (well(well-differentiated teratomas) show fat density, fluid-fluid levels, and fluidinfrequently, calcification.

On (MRI). These cysts show long T1 T1 and long T2 characteristics The fat T2 component of dermoids show, short T1 and T2 characteristics . T2

Inflammatory Diseases of the Orbit

Orbital infections account for about 60% of primary 60% orbital disease processes. The process may be acute, subacute or chronic the majority of acute inflammatory disorders are of sinus origin.
The classification of orbital infection includes five categories or stages of orbital involvement from sinusitis: (1) inflammatory edema. (2) subperiosteal phlegmon and abscess. (3) orbital cellulitis. (4) orbital abscess. (5) ophthalmic vein and cavernous sinus thrombosis .

MRI remains the study of choice for intracranial complications of inflammatory conditions of the orbit and sinonasal cavity

Acute, Subacute and Chronic Idiopathic Orbital Inflammatory Disorders

Idiopathic inflammatory orbital syndromes are usually referred to as orbital "pseudotumors", a clinically and histologically confusing category of lesions.
Pseudotumors may be classified as: (1) acute and subacute anterior idiopathic orbital inflammations. (2) acute and subacute idiopathic diffuse orbital inflammations. (3) acute and subacute idiopathic myositic orbital inflammations. (4) acute and subacute idiopathic apical orbital inflammations. (5) idiopathic dacryoadenitis. (6) idiopathic optic perineuritis. (7) posterior scleritis and tenon fasciitis.

CT and MRI findings include moderate to marked contrast enhancement of an infiltrative process involving the retrobulbar fat, muscles, optic nerve, lacrimal gland, and tenon's capsule.

Painful Ophthalmoplegia
Painful external ophthalmoplegia, or Tolosa-Hunt Tolosasyndrome, is now considered to be an idiopathic inflammatory disease and a regional variant of orbital pseudotumors.
It is important to exclude the possibility of neoplastic, inflammatory (particularly mycotic infection such as invasive aspergillosis), and vasculogenic (e.g. aneurysm) lesions.

Thyroid Ophthalmopathy
Thyroid ophthalmopathy, also called Grave's myositis, occurs most commonly in middle-aged women. This is middleconsidered to be an autoimmune disorder, involving Extraocular muscles (EOM) and the Orbital fatty reticulum.
The involvement may be unilateral or frequently bilateral. EOM enlargement in thyroid ophthalmopathy and associated compressive neuropathy, if any, can be visualized by CT and MRI. Typically, enlargement involves the muscle belly, sparing its tendinous portion .

Orbital Lymphoma
Lymphomas are solid tumors of the immune system. Most are composed of monoclonal B cells. Lymphoid tumors account for 10%-15% of 10% 15% orbital masses.

The CT and MRI findings of orbital lymphoma are nonnonspecific and at times can be impossible to differentiate from orbital pseudotumors, lacrimal gland tumors, optic nerve tumors, primary orbital tumors, or orbital cellulitis.

Lymphomas are more often seen in anterior portions of the orbit, retrobulbar areas, or the superior orbital compartment. Generally the lesions mold themselves to pre-existing structures without preeroding them.

Both pseudotumor and lymphoma may have intermediate or hypointense signal on T1-W.I. T1 and P.D. MR images, and appear isointense or hyperintense to fat on T2-weighted MR images, T2 with mild to intermediate contrast enhancement.

Vasculogenic Lesions of the Orbit

Capillary hemangiomas are tumors that occur primarily in infants during the first year of life. The tumor often increases in size for 6-10 months and then gradually involutes.
Most of these lesions are extraconal. On CT, these capillary hemangiomas show an intense homogeneous enhancement. MR features of capillary hemangiomas are characteristic of long T1 and long T2 lesions. There T1 T2 will be marked contrast enhancement .

Lymphangiomas
Lymphangiomas are vascular anomalies and are considered to be venous lymphatic malformations. These lesions present abruptly due to hemorrhage and can also enlarge concomitant with upper respiratory infections

Both CT and MRI show the multicompartmental nature of these vascular malformations. At times fluid-fluid fluidlevel is present due to bleeding .

Cavernous Hemangiomas
Cavernous hemangioma (CH) of the orbit is the most common orbital vascular tumor in adults. The tumor possesses a distinct fibrous pseudocapsule, and therefore, appears as a well-defined wellmass. CH may be located anywhere in the orbit but frequently (83%) occurs within the retrobular muscle cone. 83%)
CH appears on CT as a well-defined, smoothly marginated, homogeneous, wellmarginated, rounded, ovoid, or lobulated soft tissue mass of increased density with variable degrees of contrast enhancement

The MRI features include lesion with long T1 and T2 characteristics with mild to moderate or marked enhancement (delayed enhancement)

Cavernous hemangiomas should be differentiated from

1-Hemangiopericytoma. 2-Fibrous histiocytoma. 3-Schwannoma. 4-Neurofibroma. 5-Meningioma. 6-Rhabdomyosarcoma. 7-Orbital varix. 8-Metastasis. Metastasis.

Optic Nerve Sheath Meningioma

Optic nerve sheath meningioma (ONSM) arises from either the arachnoid cells covering the optic nerve or extension into the orbit from an intracranial meningioma.
Optic nerve sheath meningioma is usually seen in middle-aged women middleand seen as localized eccentric expansion, often at the orbital apex .

Optic Nerve Sheath Meningioma

CT is an informative study to evaluate optic nerve sheath meningioma. postMRI with contrast to include post-contrast fat suppression pulse sequences is the study of choice for the evaluation of optic nerve sheath meningioma. Optic nerve sarcoidosis may be confused on CT and MRI with optic nerve sheath meningioma.

Optic Nerve Glioma

Optic nerve glioma (ONG), also called juvenile pilocytic astrocytoma, is usually a tumor of childhood (2-8 years). It can be present at birth and (2 is rare in the adult years.Optic nerve glioma in slowchildren is a benign, well differentiated, and slowgrowing tumor. Bilateral optic nerve gliomas are characteristic of Type I neurofibromatosis (NF1). (NF1

Optic Nerve Glioma cont

Malignant optic glioma (glioblastoma multiformis) is primarily seen in adults. Optic nerve glioma is seen as fusiform enlargement of the optic nerve. Diffuse, tortuous enlargement of the optic nerve with kinking and buckling appearance is a characteristic feature of the childhood form of optic nerve glioma and It shows homogeneous or heterogeneous enhancement on enhanced CT and MRI scans.

Orbital Rhabdomyosarcoma
Rhabdomyosarcoma is the most common orbital malignancy in children. Clinically, its occurrence involves the differential diagnosis of acute and subacute proptosis of childhood. Rapidly progressing unilateral proptosis is the hallmark of orbital rhabdomyosarcoma.
The differential diagnosis of orbital rhabdomyosarcoma Orbital cellulitis. Capillary hemangioma. Lymphangioma. Plexiform neurofibroma. Teratoma. Dermoid cyst. Langerhans histiocytosis. Juvenile xanthogranuloma. Leukemic deposit. Metastatic neuroblastoma. Granulomatous diseases.

Orbital Rhabdomyosarcoma

cont.

The MRI features of orbital rhabdomyosarcoma are of long T1 and T2 lesions. There will be moderate to marked T2 enhancement following IV. Contrast. IV.

Lacrimal Gland and Fossa Lesions

Epithelial tumors (50% benign & 50% malignant) (50% 50% represent about 50% of masses involving the 50% lacrimal gland. The remaining 50% of lacrimal gland 50% masses are the lymphoid-inflammatory type. lymphoidadenoid cystic (adenocystic) carcinoma. mucoepidermoid carcinoma. Adenocarcinoma. squamous cell carcinoma. undifferentiated (anaplastic) carcinoma.

Lacrimal Gland and Fossa Lesions

cont.

Calcification is more common in malignant tumors of the lacrimal gland. The MRI features of benign and malignant epithelial tumors of the lacrimal gland are charactertistic of long T1 and T2 lesions. These T1 T2 tumors demonstrate moderate to marked enhancement following IV. Contrast.

Cholesterol crystals and clefts, which are pathognomonic, with minor chronic inflammatory infiltrate. infiltrate.

Orbital trauma

Intraorbital air Intraocular haemorrhage

Corneal and lens injury

Rupture of globe

Miscellaneous

Mesenchymal Chondrosarcoma

Cross sectional imaging of globe

Malignant uveal melanoma. melanoma.

Choroidal melanoma, metastasis, hemangioma, lymphoma, granuloma, retinal hemangioma

THE END