This document discusses the use of ultrasound in evaluating orbital pathologies. It outlines the advantages and disadvantages of ultrasound for orbital imaging. Key advantages include rapidity, accessibility, lack of radiation, ability to follow lesions over time, and lower cost compared to CT or MRI. Common orbital conditions seen in both children and adults are described, along with characteristic ultrasound findings for each condition. These include dermoid cysts, rhabdomyosarcoma, optic nerve glioma, thyroid ophthalmopathy, and others. Imaging features useful in diagnosis, such as lesion shape, borders, internal reflectivity, and Doppler flow, are emphasized. A variety of orbital masses, inflammatory conditions, and structural abnormalities are shown through ultrasound images.

2. ADVANTAGES
 Rapidity
 Accessibility
 No radiation
 Follow up of lesions

3.  Cost effective
 Patient friendly
 Real time display
 Better than CT in subtle lesion of sclera and optic
nerve

4. DISADVANTAGES
 Less resolution than CT and MR
 Less magnification
 No coronal view
 No view of adjacent structures

5. METHOD
 Contact method
 5-10 MHz frequency
 Horizontal plane preferred
 Vertical plane useful in upper anterior orbit and
inf. Rectus examination.

6. ORBITAL PATHOLOGIES
CHILDREN
 Orbital cellulitis
 Rhabdomyosarcoma
 Dermoid and epidermoid cysts
 Capillary hemangioma and lymphangioma
 Optic nerve glioma

7.  Histiocytosis X
 Leukemia
 Orbital pseudotumor
 Neurofibroma
 Metastatic neuroblastoma

8. ADULTS
 Thyroid ophthalmopathy
 Orbital pseudotumor
 Cavernous hemangioma
 Lymphoproliferative disorders
 Meningioma

9. ORBITAL CELLULITIS

10.  Vision and life threatening
 Causes
 Trauma
 Extension of infection like sinusitis

11. superior orbit showing fluid-filled pockets (white arrows)

12. Posterior scleral thickening on B-ultrasound scan

13. RHABDOMYOSARCOMA
 Commonest malignant orbital tumor of childhood
 Around 7 yrs age
 Rapidly progressive proptosis
 Usually in superio-nasal quadrant
 Low reflective irregular mass with good
penetration of sound beam

14.  A cone-shaped rhabdomyosarcoma (arrowheads) is seen in the
orbit behind the eyeball. The optic nerve (black arrow) is partially
encased by the tumor. Note the retinal detachment (white arrow)
in the eye. The patient was a five-year-old child.

16. DERMOID CYST

17.  most common orbital cystic lesion.
 They are lined with keratinizing epidermis and
filled with dermal appendages.
 Epidermoid cysts are lined by only epidermis and
are usually filled with keratin.
 smooth, painless, oval mass that slowly enlarges.
 In 75% of cases, the lesion is located in the
lateral brow adjacent to the zygomatic frontal
suture.

18.  Dermoid. (A) An 18-month-old child with an eyelid mass. (B) High-resolution
ultrasound of the temporal aspect of the upper eyelid
demonstrates an oval anechoic lesion with smooth borders. A blood
vessel (arrow) is demonstrated by this color Doppler examination only
around the lesion, with no evidence of blood vessels entering it.

19. CAPILLARY HEMANGIOMA

20.  most common vascular tumor of childhood,
 manifest primarily in the first year of life.
 involutional phase in 75% over 4 to 7 years.
 Presentation is usually at birth in the upper eyelid
or superior orbit, which is strawberry in color
(superficial) or bluish (deeper).

21.  They may cause ptosis, strabismus,
anisometropia, and occlusion amblyopia
 Less reflective than cavernous type due to small
vascular channels and scant stroma.
 Prominent arterial supply gives a positive doppler
phenomenon

22.  Superficial orbital hemagioma. (A) A 2-month-old child with a right upper
mass. (B) High-resolution ultrasound of the temporal aspect of the upper
eyelid demonstrates a smooth lesion with regular borders and multiple
intercalating networks of blood vessels within (arrow).

23.  Deep orbital hemagioma. (A) A 3-month-old child with a right upper nasal
mass. (B) High-resolution color Doppler ultrasound of the nasal aspect of
the orbit demonstrates an intraorbital hypoechoic lesion with blood
vessels within (arrow).

24. OPTIC NERVE GLIOMA
 Benign congenital hamartoma
 Usually 4-8 yrs age
 Manifest as visual loss and proptosis
 Ultrasound shows fusiform or irregular
expansion of optic nerve
 Low reflective with poor acoustic transmission

26. THYROID OPHTHALMOPATHY

27.  Graves' disease is the most common cause of
bilateral proptosis.
 Seventy percent of cases are bilateral and
symmetrical.
 There is a four-to-one female preponderance.
 The disease is characterized by symmetrical
swelling of the extra ocular muscles.
 The medial and inferior rectus muscles are most
often involved.

28.  The muscle enlargement characteristically
involves the body of the muscle, sparing the
tendinous attachment to the globe.
 On ultrasound muscle have medium to high
reflectivity due to separation of muscle
fibres by edema and inflammatory cells
 Severity assessed by medial rectus width by
electronic calliper. Upper normal limit is 4mm
 Other features are increased orbital fat and
orbital edema seen as fluid with in tenon’s
capsule and encysted spaces with in orbital fat

29. Enlarged belly of inferior rectus. Vertical scan

32. PSEUDOTUMOR
 non-specific inflammation of orbital tissues.
 unilateral and accounts for 25% of all cases of
unilateral exophthalmos.
 Acute onset
 Middle aged patients
 Includes myositis, dacryoadenitis, periscleritis,
perineuritis and diffuse condition.

33.  Ultrasound shows low reflective lesion
 Smooth or irregularly shaped
 In diffuse form, orbital fat gives mottled
appearance
 Myositis is seen as enlargement of whole of extra
ocular muscle
 T sign… edema in tenon’s capsule along optic
nerve sheath

34.  Scleral thickening, T sign, choroidal
effusion

35. T sign….. arrows

36. CAVERNOUS HEMANGIOMA
 Commonest benign orbital tumor in adults
 2nd to 5th decade of life
 Slowly progressive unilateral proptosis
 Ultrasound shows transonic mass with
echoes of medium to strong reflectivity

37.  Poor attenuation of sound beam
 Negative doppler phenomenon
 Calcified phleboliths may be seen

38. 37-year-old man with hemangioma of orbit.

39. 37-year-old man with hemangioma of orbit.

40. ARTERIOVENOUS FISTULA
 Carotid-cavernous fistula and dural-cavernous
arteriovenous malformation
 Develop spontaneously or after trauma
 Pulsatile proptosis
 Diagnosed by color doppler
 Blood flow is reversed in superior ophthalmic
vein

41. Arterialized blood flow in superior ophthalmic vein

42. ORBITAL LYMPHOMA
 Usually non-hodgkin type
 Above 60 yrs age
 Any part of orbit
 Ultrasound shows elongated low reflective
oval mass

45. METASTASIS
 40 % of children with neuroblastoma
 Others from Ewing's sarcoma, wilms tumor,
leukemia
 In adults metastasis usually arise from primaries
in bronchus, breast, prostate, kidney and GIT

46. Orbital mets (arrow) displacing optic nerve

48. NEURILEMMOMA
 Optic nerve tumor
 Usually in superior orbit
 On ultrasound low to medium amplitude echoes
and cystic areas

49. Neurilemomma
a well-defined heterogenous mass with cystic spaces

50. OPTIC NERVE SHEATH MENINGIOMA
 Optic nerve sheath meningioma arise from
arachnoid villi
 Unilateral
 Slowly progressive visual impairment
 Causes optic nerve compression, proptosis.
 Ultrasound shows diffuse/focal broadening
of optic nerve with high reflectivity

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