Imaging inOrbital Diseases

Dr. Syed Nabil Bin Maruf

FCPS - II Course Student
NIO&H

Chairman Moderator
Dr. Zinat Nasrin Dr. Shafiul Mostafiz
Assistant Professor Assistant Professor
Department of Radiology Fellow - Department of Oculoplasty
NIO&H NIO&H
 Orbits
• Pair of Confined Spaces in the Skull

• Volume : 30 cc

• Direct Link with Cranial Vault

• Contains the Eyeballs along with other important

structures
 Imaging Modalities
 Radiography

 Ultrasonography

 Computed Tomography

 Magnetic Resonance Imaging

 Anatomical Considerations
• Size, Shape & Relations

• 4 Walls, Base, Apex & Passages of Orbit

• Fascial Compartments / Surgical Spaces

• Contents & their Anatomy

• Paranasal Sinuses
 Orbital Diseases

• Congenital Malformations
• Inflammatory & Infective
• Vascular Lesions
• Cystic Lesions & Tumours
• Ocular Diseases
• Orbital Trauma
 Orbital Diseases
Surgical Spaces
• Extraorbital Space
 Bony Lesions & Sinus Lesions
• Subperiosteal Space
 Subperiosteal haematoma, abscess
 Inflammatory & Neoplastic lesions of PNS
 Orbital Diseases
• Extraconal lesions
 Capillary Haemangioma
 Dermoids & Epidermoids  Rhabdomyosarcoma
 Lacrimal Gland Lesions  Lymphangioma
 Sarcoidosis  Pseudotumor
• Tenon’s Space
 Extraocular extension of Choroidal Melanoma
 Orbital Diseases
• Intraconal lesions
 Cavernous Hemangioma 
Pseudotumor & TED
 Optic Nerve Meningioma,  Varix
Glioma, Neuritis  CCF
 Lymphoma  Metastatic Seeds
 Lymphangioma  Orbital Cellulitis
 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

 Computed Tomography
• 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
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
 Magnetic Resonance Imaging
• 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
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

 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

 Magnetic Resonance Imaging
Post contrast images

• Gadolinium-T1W

Fat-suppressed images

• Bright signal from intraorbital fat can mask the signal

and enhancement of pathology

Magnetic Resonance Imaging
Orbital
Diseases
CT-Scan & MRI
Thyroid Associated Orbitopathy
Idiopathic Orbital Inflammatory Disease

Enlargement of Muscle including tendon

Hilal & Trokel
Orbital Abscess
Optic Nerve Glioma

Isodense lobulated fusiform intraconal

mass along the left optic nerve
Optic Nerve Glioma

Hyperintense
Hypointense
Optic Nerve Sheath Meningioma
Fat-suppressed T1 axial (A) coronal (B) MRI, with Gadolinium

Globular Configuration of Optic

Nerve Sheath Meningioma with
“Tram Track Sign”
Optic Nerve Sheath Meningioma

Hyperdense mass surrounding the

left optic nerve with slightly
lobulated contour and nerve
compression
Orbital Schwannoma
Orbital Neurofibroma
 Lacrimal Gland Tumour

Bilateral Benign
Pleomorphic Adenoma
Lymphoid Hyperplasia
showing rounded well-
showing oblong
defined lacrimal gland
diffuse enlargement of
lesion
the lacrimal gland
Rhabdomyosarcoma
Retinoblastoma
Cavernous Haemangioma

Thrombosis
Capillary Haemangioma
Dermoid
 Optic Neuritis

Axial T1W Axial T1W-FLAIR Axial T1W

 Angiography & Venograpy
MRA / MRV & CTA / CTV
• Indicated for assessing vascular lesions:
 Arteriovenous Malformation
 Haemangioma
 Lymphangioma
 Venous Malformation
 Varix
 Arterial Aneurysm
 Radiography
Plain X-Ray of the Orbit
• Very limited role

• Indications:

 Traumatic Injuries

 Foreign Bodies
 Radiography
X-Ray Views
• Waters View

• Caldwell’s View

• Lateral View

• Submentovertex View

• Rhese View
 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
 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
Lateral View
Frontal Sinus
Orbital Roof
Ethmoid Sinus
Anterior Clinoid
Process

Sella Turcica
Planum
Sphenoidale Maxillary Sinus
 Submentovertex View

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

a - Right Optic Canal

b - Optic Strut

c - Superior Orbital Fissure

d - Ethmoid Sinus

e - Planum Sphenoidale

f - Greater Wing of Sphenoid

Orbital Fracture
Orbital
Emphysema

Orbital Fat
Herniation

Water’s View
 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

Orbital Foreign Body
 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
 Ultrasonography
Acoustically Abnormal Orbit
Mass Lesion
Rounded Irregular
 Hyper-reflective Foreign Body  Hyper-reflective
• Meningioma,Inflammatory
Glioma • Lymphoma
Lesion
• Neurofibroma • Metastatic Cancer
Hyporeflective • CellulitisHyporeflective
• Mucocele • Abscess • Haemangioma
• Dermoid Cyst • Lymphangioma
• Pseudotumour
• Cavernous Haemangioma
 Orbital Lymphoma
Lens Retina
Cornea Hyper-reflective retrobulbar round
solid mass

Vitreous

Optic Nerve
 Cavernous Haemangioma

• 10-MHz A & B-scan

• Well encapsulated
lesion
• Typical hemangioma
 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
 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

Thank You