Imaging Modalities which are clinically used for the management various orbital diseases: Types, Methods, Indications and Contraindications, Advantages and Disadvantages, Identifying Points

1. Chairman
Dr. Syed Nabil Bin Maruf
FCPS - II Course Student
NIO&H
Moderator
Dr. Zinat
Nasrin
Assistant Professor
Department of Radiology
NIO&H
Dr. Shafiul
Mostafiz
Assistant Professor
Fellow - Department of Oculoplasty
NIO&H
Imaging inOrbital
Diseases

2. • Pair of Confined Spaces in the Skull
• Volume : 30 cc
• Direct Link with Cranial Vault
• Contains the Eyeballs along with other important
structures
Orbits

3. Imaging Modalities
 Radiography
 Ultrasonography
 Computed Tomography
 Magnetic Resonance Imaging

4. Anatomical Considerations
• Size, Shape & Relations
• 4 Walls, Base, Apex & Passages of Orbit
• Fascial Compartments / Surgical Spaces
• Contents & their Anatomy
• Paranasal Sinuses

5. Orbital Diseases
• Congenital Malformations
• Inflammatory & Infective
• Vascular Lesions
• Cystic Lesions & Tumours
• Ocular Diseases
• Orbital Trauma

6. Orbital Diseases
Surgical Spaces
• Extraorbital Space
 Bony Lesions & Sinus Lesions
• Subperiosteal Space
 Subperiosteal haematoma, abscess
 Inflammatory & Neoplastic lesions of PNS

7. Orbital Diseases
• Extraconal lesions
 Capillary Haemangioma
 Dermoids & Epidermoids
 Lacrimal Gland Lesions
 Sarcoidosis
• Tenon’s Space
 Extraocular extension of Choroidal Melanoma
 Rhabdomyosarcoma
 Lymphangioma
 Pseudotumor

8. Orbital Diseases
• Intraconal lesions
 Cavernous Hemangioma
 Optic Nerve Meningioma,
Glioma, Neuritis
 Lymphoma
 Lymphangioma
 Pseudotumor & TED
 Varix
 CCF
 Metastatic Seeds
 Orbital Cellulitis

9. Orbital Imaging
CT & MRI are the standard imaging
CT ideal for Bony & Traumatic Manifestations
MRI ideal for Soft Tissue Manifestations
X-Rays can be used in limited cases
B-Scan for Intra-Ocular diseases

10. • Most versatile, informative
• Bony detail or calcification
• Detect metallic foreign body
• Inability to distinguish between pathological soft
tissue masses which are radiologically isodense
• Exposure to radiation - Cataract
Computed Tomography

13. Computed Tomography
Major Considerations
• Slice thickness
• Imaging plane – Axial / Coronal / Sagittal
• Tissue window – Soft or Brain / Bone
• Contrast enhancement – Iohexol (46% Iodine)
• Modification of CT procedure
• Orbit with Brain CT

19. • Better for soft tissue
• Not ideal to visualise Bony manifestations
• Better resolution of Optic Nerve & Orbital Apex
• No radiation
• Must screen for metallic foreign bodies in orbit
Magnetic Resonance Imaging

20. Magnetic Resonance Imaging
Basic Image Sequences
T1- weighted (T1W)
• Fat appear brighter than water/vitreous/CSF
T2- weighted (T2W)
• Water/vitreous/CSF appear brighter than tissues
like blood products

21. Magnetic Resonance Imaging
Fluid attenuation inversion recovery (FLAIR)
• Signal from fluid suppressed
• Useful in demyelinating conditions as white matter
hyperintensities on T2W images are better
appreciated with adjacent CSF bright signals nulled

22. Magnetic Resonance Imaging
Post contrast images
• Gadolinium-T1W
Fat-suppressed images
• Bright signal from intraorbital fat can mask the signal
and enhancement of pathology

23. Magnetic Resonance Imaging

27. Orbital
Diseases
CT-Scan & MRI

28. Thyroid Associated
Orbitopathy

29. Idiopathic Orbital
Inflammatory Disease
Enlargement of Muscle including tendon

30. Hilal & Trokel

31. Orbital Abscess

32. Optic Nerve Glioma
Isodense lobulated fusiform intraconal
mass along the left optic nerve

33. Optic Nerve Glioma
Hyperintense
Hypointense

34. Optic Nerve Sheath
Meningioma
Globular Configuration of Optic
Nerve Sheath Meningioma with
“Tram Track Sign”
Fat-suppressed T1 axial (A) coronal (B) MRI, with Gadolinium

35. Optic Nerve Sheath
Meningioma
Hyperdense mass surrounding the
left optic nerve with slightly
lobulated contour and nerve
compression

36. Orbital Schwannoma

37. Orbital Neurofibroma

38. Lacrimal Gland Tumour
Pleomorphic Adenoma
showing rounded well-
defined lacrimal gland
lesion
Bilateral Benign
Lymphoid Hyperplasia
showing oblong
diffuse enlargement of
the lacrimal gland

39. Rhabdomyosarcoma

40. Retinoblastoma

41. Cavernous Haemangioma
Thrombosis

42. Capillary Haemangioma

43. Dermoid

44. Optic Neuritis
Axial T1W Axial T1W-FLAIR Axial T1W

45. Angiography & Venograpy
MRA / MRV & CTA / CTV
• Indicated for assessing vascular lesions:
 Arteriovenous Malformation
 Haemangioma
 Lymphangioma
 Venous Malformation
 Varix
 Arterial Aneurysm

46. Radiography
Plain X-Ray of the Orbit
• Very limited role
• Indications:
 Traumatic Injuries
 Foreign Bodies

47. Radiography
X-Ray Views
• Waters View
• Caldwell’s View
• Lateral View
• Submentovertex View
• Rhese View

48. Water’s View
a - Frontal sinus
b - Medial Orbital Wall
c - Innominate Line
d - Inferior Orbital Rim
e - Orbital Floor
f - Maxillary Antrum
g - Superior Orbital Fissure
h - Zygomaticofrontal Suture
i - Zygomatic Arch

49. Caldwell’s View
a - Frontal sinus
b - Innominate line
c - Inferior orbital rim
d - Posterior orbital floor
e - Superior orbital
fissure
f - Greater wing of
sphenoid
g - Ethmoid air sinus
h - Medial orbital wall
i - Petrous ridge
j - Zygomaticofrontal
suture
k - Foramen rotundum

50. Lateral View
Orbital Roof
Ethmoid Sinus
Anterior Clinoid
Process
Sella Turcica
Planum
Sphenoidale
Frontal Sinus
Maxillary Sinus

51. Submentovertex View
a - Zygomatic arch
b - Orbit
c - Lateral orbital wall
d - Posterior wall of maxillary
sinus
e - Pterygoid plate
f - Sphenoid sinus

52. Rhese View
a - Right Optic Canal
b - Optic Strut
c - Superior Orbital Fissure
d - Ethmoid Sinus
e - Planum Sphenoidale
f - Greater Wing of Sphenoid

54. Orbital Fat
Herniation
Orbital
Emphysema
Orbital Fracture
Water’s View

55. Radiography
X-Ray Requisition for
Intraorbital / Intraocular Foreign Body
• X-Ray (A/P) of Orbits
• If Intraocular Foreign Body noted -
 Lateral View of Respective Side with Eyes
looking Up & Down

56. Orbital Foreign Body

57. Ultrasonography
• A- & B-Scan can play an important role in differential
diagnoses of orbital masses
• Site, morphology and structure of the lesion (B-scan)
and on the acoustic structure, internal reflectivity,
vascularization and margins of the lesion (A-scan)
• Poor transmission is characteristic in any Solid,
Infiltrative or Inflammatory mass of the orbit
• Real-Time & Dynamic

58. Acoustically Abnormal Orbit
Mass Lesion
Foreign Body
Inflammatory Lesion
• Cellulitis
• Abscess
• Pseudotumour
Rounded
 Hyper-reflective
• Meningioma, Glioma
• Neurofibroma
Hyporeflective
• Mucocele
• Dermoid Cyst
• Cavernous Haemangioma
Irregular
 Hyper-reflective
• Lymphoma
• Metastatic Cancer
Hyporeflective
• Haemangioma
• Lymphangioma
Ultrasonography

59. Cornea
Orbital Lymphoma
Lens Retina
Vitreous
Optic Nerve
Hyper-reflective retrobulbar round
solid mass

60. Cavernous Haemangioma
• 10-MHz A & B-scan
• Well encapsulated
lesion
• Typical hemangioma

61. Advanced Modalities
MRI-DWI (Diffusion Weighted Imaging)
MR Spectroscopy
Perfusion Studies
Positron Emission Tomography (PET) – CT / MRI
• Can characterize lesions at molecular level
• Distinguish malignant from benign
• Metastatic evaluation

62. Conclusion
• CT-Scan is the Imaging of Choice
• MRI in case of Orbital Apex, Optic Canal or
Intracranial extension of Orbital Neoplasm
• Coordinate with the Radiologist for best outcome
• Diagnose on the basis of Clinical Correlation

63. Thank You