Glenn Yiu

Gillian Lieberman, MD March 2007

Imaging of the Orbit

Glenn Yiu, HMS-III
Gillian Lieberman, MD
 Glenn Yiu
Gillian Lieberman, MD

Our Patient GB
History:
53 y/o male with type II DM and history of
proptosis, who presents with visual complaints in
the right eye
Exam:
Bilateral proptosis L>R
Visual acuity normal
No relative afferent pupillary defect bilaterally
Optic cup enlargement in R eye
 Glenn Yiu
Gillian Lieberman, MD

Differential Diagnosis
Inflammation/Infection Neoplastic
Orbital pseudotumor Lymphoma
Thyroid ophthalmopathy Dermoid
Sarcoid Metastases
Orbital cellulitis
Abscess Vascular

RULE OUT:
Hemangioma
lid lag Vascular
relative enophthalmos malformations
external swelling
 Glenn Yiu
Gillian Lieberman, MD

Orbit Anatomy
Extraconal fat Eyeball

Zygomatic
bone

Lateral rectus
Intraconal fat
Medial rectus

Optic nerve

Annulus of Zinn
Ethmoid sinus
(Wichmann & Muller-Forell, Eur J Radiol. 2004)
 Glenn Yiu
Gillian Lieberman, MD

Orbit Anatomy
Extraconal fat Eyeball Globe
Zygomatic Intraconal space
bone

Muscle cone
Lateral rectus Extraconal space
Intraconal fat
Medial rectus

Optic nerve

Annulus of Zinn

(Wichmann & Muller-Forell, Eur J Radiol. 2004)

 Glenn Yiu
Gillian Lieberman, MD

Orbit Anatomy
Extraconal fat Eyeball Globe
Zygomatic Intraconal space
bone
Optic nerve glioma
Meningioma
Lateral rectus Varix
Intraconal fat
Muscle cone
Medial rectus
Orbital pseudotumor
Optic nerve
Thyroid ophthalmopathy

Annulus of Zinn Extraconal space

Orbital cellulitis
(Wichmann & Muller-Forell, Eur J Radiol. 2004)
 Glenn Yiu
Gillian Lieberman, MD

Orbital Imaging Techniques

CT
CT
+ most versatile
MRI + bony detail or calcifications
+ temporal / spatial resolution
- radiation-induced cataracts
- beam hardening artifacts from
dental fillings

MRI:
+ better for optic nerve and tumors
+ no radiation
- poor temporal resolution
(Wichmann & Muller-Forell, 2004)
(Wichmann & Muller-Forell, 2004) - must screen for metallic foreign
bodies in orbit before MRI
 Glenn Yiu
Gillian Lieberman, MD

Orbital Imaging Techniques

Ultrasound:
CT
good for lesions within globe or
MRI foreign bodies in orbit
Ultrasound poor penetration

Plainfilm Plain film:

Angiography mainly for screening for metallic
foreign bodies before MRI
useless for soft tissue details

Angiography:
good for vascular malformations
and vascularized tumors
invasive and time-consuming
 Glenn Yiu
Gillian Lieberman, MD

Orbit Anatomy on CT
1. Zygomatic bone
1
3 4 5 2 2. Nasal septum
3. Lacrimal gland
4. Sclera
5. Vitreous body
6. Optic nerve
12 7. Medial rectus
13
8. Lateral rectus
8 9. Superior orbital fissure
6
7 10. Optic canal
10 11. Pituitary gland
9 11
12. Ethmoid sinus
(Wichmann & Muller-Forell, Eur J Radiol., 2004)
13. Sphenoid sinus
 Glenn Yiu
Gillian Lieberman, MD

Orbit Anatomy on CT
12
6 1 2
5 3 1. Optic nerve
4
7 2. Ophthalmic artery
3. Superior rectus
4. Inferior rectus
8 8
5. Medial rectus
6. Lateral rectus
9 9 7. Superior oblique
8. Ethmoid sinus
9. Maxillary sinus
10 11 10. Inferior turbinates
11. Zygomatic bone
(Wichmann & Muller-Forell, Eur J Radiol., 2004) 12. Frontal bone
Glenn Yiu
Gillian Lieberman, MD

Normal MRI of the Orbits

(Wichmann & Muller-Forell, Eur J Radiol., 2004)

Fat-saturation improves ability to visualize

optic nerve due to retro-orbital fat
 Glenn Yiu
Gillian Lieberman, MD

Radiological findings: Our Patient GB

Axial and coronal

non-contrast CT of orbits
 Glenn Yiu
Gillian Lieberman, MD
Patient GBs Findings on Axial CT

Bilateral proptosis
Normal

(Wichmann & Muller-Forell, 2004)

(PACS, BIDMC, 2007)

 Glenn Yiu
Gillian Lieberman, MD
Patient GBs Findings on Coronal CT

Extra-occular muscle enlargement

Bilateral
enlargement of all
extra-occular
muscles, including
* * *
* superior obliques
*
*

(PACS, BIDMC, 2007)

 Glenn Yiu
Gillian Lieberman, MD
Patient GBs Findings on Axial CT

Extra-occular muscle enlargement

Bilateral
enlargement of all
extra-occular
* * muscles, including
superior obliques

Center
enlargement with
no involvement of
tendons
(PACS, BIDMC, 2007)
Glenn Yiu
Gillian Lieberman, MD
Patient GBs Findings on Axial/Coronal CT

Normal fat

*
*

* *

No fat stranding
(PACS, BIDMC, 2007)
Glenn Yiu
Gillian Lieberman, MD
Patient GBs Findings on Axial CT

Graves Ophthalmopathy
Proptosis

Extra-occular muscle
enlargement

Central enlargement with

sparing of tendons

IM SLow (inferior, medial,

superior, & lateral rectus)

(PACS, BIDMC, 2007)

Glenn Yiu
Gillian Lieberman, MD

Graves Ophthalmopathy

(www.uptodate.com)
 Glenn Yiu
Gillian Lieberman, MD

Graves Ophthalmopathy: Pathogenesis

An autoimmune disease of retroorbital tissues that
occurs in 20-25% of patients with Graves disease,
more often in women than in men.

Antibodies activate TSH receptors not only in thyroid

tissue, but also in orbital fibroblasts and adipocytes.

T-cell activation stimulates secretion of glycosamino-

glycans (GAG), mostly hyaluronic acid, resulting in
increased volume of both extraocular muscles and
retroorbital connection/adipose tissues.

Risk factors include genetics, female sex, smoking,

and radioiodine therapy.
 Glenn Yiu
Gillian Lieberman, MD

Graves Ophthalmopathy: Classification

Werner classification (mnemonic: NO SPECS)
Grade 0: No signs or symptoms
Grade 1: Only signs (lid retraction)
Grade 2: Soft tissue involvement (chemosis, etc)
Grade 3: Proptosis (minimum <23, moderate, marked >28)
Grade 4: Extraocular muscle involvement
Grade 5: Corneal involvement
Grade 6: Sight loss
Additional signs of Thyroid eye disease
Dalrymples sign: Lid retraction
von Graefes sign: Upper lid lag on downward gaze
Griffiths sign: Lower lid lag on downward gaze
Bostons sign: Jerky irregular movement of the upper lid on downward gaze
Jellineks sign: Increased pigmentation of the lids
Stellwags sign: Infrequent blinking
Kochers sign: Increased lid retraction with visual fixation
Enroths sign: Puffy swelling of the lids
Rosenbachs sign: Tremor of closed lids
Mobius sign: Weakness of convergence
Ballets sign: Palsy of one or more extraocular muscles
Sukers sign: Weakness of fixation on lateral gaze
Cowens sign: Jerky papillary contraction to consensual light
Knies sign: Unequal dilatation of the pupils
Jeffreys sign: Absence of forehead wrinkling on upward gaze
 Glenn Yiu
Gillian Lieberman, MD
Patient GBs Findings on Axial CT

Graves Ophthalmopathy: Treatment

Glucocorticoid therapy Patient GB was s/p
External orbital radiation orbital decompression
Orbital decompression surgery

(PACS, BIDMC, 2007)

 Glenn Yiu
Gillian Lieberman, MD

Differential Diagnosis
Inflammation/Infection
Orbital pseudotumor
Thyroid ophthalmopathy
Sarcoid
Orbital cellulitis
Abscess
Neoplastic
Lymphoma
Dermoid
Metastases
Vascular
Hemangioma
Vascular malformations
 Glenn Yiu
Gillian Lieberman, MD
Companion Patient Findings on Axial/Coronal CT

Orbital Pseudotumor
Inflammation/Infection
Orbital pseudotumor
Thyroid ophthalmopathy
Sarcoid
Orbital cellulitis
Abscess
Neoplastic *
Lymphoma
Dermoid
Metastases Fatstranding
Vascular Tendon not spared

Hemangioma (Courtesy of Fabio Komlos, BIDMC)

Vascular malformations
 Glenn Yiu
Gillian Lieberman, MD
Companion Patient Findings on Axial CT

Preseptal & Postseptal Cellulitis

Inflammation/Infection
Orbital pseudotumor
Thyroid ophthalmopathy
Sarcoid
Orbital cellulitis
Abscess
Neoplastic
Lymphoma
Dermoid
Metastases
Vascular Unilateral
Hemangioma Sinus involvement
Vascular malformations
(Caruso et al., Radiology, 2006)
 Glenn Yiu
Gillian Lieberman, MD
Companion Patient Findings on Axial CT

Orbital Lymphoma
Inflammation/Infection
Orbital pseudotumor
Thyroid ophthalmopathy
Sarcoid
Orbital cellulitis
Abscess
Neoplastic
Lymphoma
Dermoid
Metastases
Radiologically difficult to distinguish
Vascular
from orbital pseudotumor
Hemangioma (http://www.uhrad.com/mriarc/mri049.htm)
Vascular malformations
 Glenn Yiu
Gillian Lieberman, MD
Companion Patient Findings on MRI

Cavernous Hemangioma
Inflammation/Infection
Orbital pseudotumor
Thyroid ophthalmopathy
Sarcoid
Orbital cellulitis
Abscess
Neoplastic
Lymphoma
Dermoid
Metastases
Vascular Well-defined mass
Hemangioma Progressive peripheral to
center enhancement post-gado
Vascular malformations (http://mni.mcgill.ca/neuroimage/nov2001/nov2001_p6.htm)
 Glenn Yiu
Gillian Lieberman, MD

References
Agarwal A. Handbook of Ophthalmology. 2006.
Aviv RI, Casselman J. Orbital imaging: Part 1. Normal anatomy. Clin Radiol. 2005
Mar;60(3):279-87.
Aviv RI, Miszkiel K. Orbital imaging: Part 2. Intraorbital pathology. Clin Radiol. 2005
Mar;60(3):288-307.
Belden CJ, Zinreich SJ. Orbital imaging techniques. Semin Ultrasound CT MR. 1997
Dec;18(6):413-22.
Braffman BH, Naidich TP, Chaneles M. Imaging anatomy of the normal orbit. Semin
Ultrasound CT MR. 1997 Dec;18(6):403-12.
Caruso PA, Watkins LM, Suwansaard P, Yamamoto M, Durand ML, Romo LV,
Rincon SP, Curtin HD. Odontogenic orbital inflammation: clinical and CT findings--
initial observations. Radiology. 2006 Apr;239(1):187-94.
Davies TF. Pathogenesis and clinical features of Graves ophthalmopathy
(orbitopathy). www.uptodate.com.
Davies TF. Treatment of Graves ophthalmopathy (orbitopathy). www.uptodate.com.
Wichmann W, Muller-Forell W. Anatomy of the visual system. Eur J Radiol. 2004
Jan;49(1):8-30.
 Glenn Yiu
Gillian Lieberman, MD

Acknowledgements
Fabio Komlos, MD
Michael Geary, MD
Gillian Lieberman, MD

Pamela Lepkowski
Larry Barbaras