C. Douglas Phillips MD FACR

Director of Head and Neck Imaging

Weill Cornell Medical College/NewYork-Presbyterian Hospital

Disclosures

Neither I nor any family members have

any pertinent financial relations of note

regarding material in this presentation

Special thanks to Dr. Deborah

Shatzkes for case material and ideas

The Orbit

Brief Anatomy

Orbital Trauma

Orbital Infectious/Inflammatory Disease

IOIS (orbital pseudotumor)

Orbital cellulitis

Vascular Lesions of the Orbit

CCF

Venous or lymphatic malformations

Differential diagnoses of orbital disease

Bony Orbit and Foramina

Major Anatomic Compartments

Globe

Optic nerve and sheath

Extraocular Muscles

Lacrimal Gland

Intraconal vs. Extraconal Compartment

Preseptal vs. Postseptal Compartment

Globe and Optic Nerve

Globe

Divided into anterior and posterior segments by lens

Optic nerve and sheath

Orbital (tortuous)

Intracanalicular

Intracranial or intracisternal

Intraconal Compartment

4 rectus muscles and

fibrous septa make up

muscle cone

Extraocular muscles

originate from

common tendinous

ring (annulus of Zinn)

in orbital apex

Contains optic nerve,

vessels, CN III, IV and

VI and retrobulbar fat

Extraconal Compartment

Outside muscle

cone

Between bony orbit

and rectus muscles

Contains lacrimal

gland and fat

Lateral rectus

Medial rectus

Optic nerve

Ophthalmic artery

Anterior clinoid Carotid artery

Globe

Anterior clinoid process

Optic nerves

Superior orbital fissure

Sphenoid sinus (air filled)

Orbital Apex

Lacrimal Sac

Nasolacrimal apparatus has close relationship with ethmoid air-cells

Nasolacrimal duct

Drains into inferior meatus

Protected by bony canal

Normally may be opacified with fluid or contain air

Orbital Trauma

Fractures involving orbit are common

and can be urgent

Thin section CT with MPR is necessary

to depict and detail these fractures

Soft tissue injuries are often overlooked

but can be more serious

Retinal versus Choroidal

Detachment

Choroidal Retinal

Retinal versus Choroidal

Detachment

Retinal Choroidal

S/P assault w/ blunt and sharp instruments, multiple stab

wounds: ruptured globe, retinal detachment

Fall w/ eye injury: choroidal detachment + hemorrhage,

vitreal hemorrhage, dislocated cataract lens

Orbital Fracture with Orbital

Hematoma

Must review soft tissue windows

Orbital Infectious/Inflammatory

Diseases

Infections of orbit

60% of primary orbital disease

Often complication of sinusitis

Superficial tissues most commonly

Extraconal and preseptal

Can extend and involve intraconal soft tissues and/or CNS

Immunocompromised hosts – remember fungal disease

Orbital Inflammatory Disease

Wide range of immunologic conditions

may affect orbit

Remember orbital involvement with

systemic immunologic diseases

Cross-reactivity of many immune

complexes with orbital structures

Stages of Orbital Cellulitis

Inflammatory edema/pre-septal cellulitis

Post-septal disease

Subperiosteal phlegmon/abscess

Orbital cellulitis

Orbital abscess

Ophthalmic vein and cavernous sinus

thrombosis

Pre-septal Orbital Cellulitis

Erythema, pain, conjunctivitis, blurred vision

80% <10 years of age

Staph/Strep are common organisms

Imaging: CT with contrast

indicated in patients with unreliable physical exam due to age or signs of post-septal involvement

MR if accessible

Orbital Cellulitis

Extension from periorbital structures or pre-septal infection

Mortality/morbidity very low Pre-ATBX: 17% mortality, 20% blind in affected

eye

Now estimated <1%

Complications arise from progressive disease Subperiosteal/orbital abscess (7-9%)

Ophthalmic vein/cavernous sinus thrombosis (50% mortality)

Intracranial abscess

Pre-septal Orbital Cellulitis

Post-septal Orbital Cellulitis

Pre- and Post-Septal

Orbital Cellulitis

Invasive Fungal Sinusitis –

Orbital Abscess

Invasive Fungal Sinusitis –

Orbital Abscess

Orbital Inflammatory Conditions

Primary considerations

Idiopathic orbital inflammatory disease

(IOID), or orbital pseudotumor

Thyroid orbitopathy

Mixed, collagen-vascular diseases, and

other orbital inflammatory conditions

○ Sjogren’s, sarcoid, etc.

○ Granulomatosis with polyangiitis (Wegener’s)

Orbital Pseudotumor

Most common intraorbital mass lesion in adults

Inflammation of ANY orbital structure of unknown cause Fat - 76%

Muscles - 57%

Optic nerve - 38%

Uvea/sclera - 33%

Lacrimal gland - 5%

Two types: Tumefactive (diffuse) and myositic

Tends towards transcompartment involvement

IOID or Orbital Pseudotumor

“Tumefactive” pseudotumor

Over 2/3rds of cases

Infiltrating more common than focal disease

75% retrobulbar, with or without muscle

cone involvement

Myositic pseudotumor

Second most common pattern

Unilateral involvement

Involves tendinous insertions

IOID or Orbital Pseudotumor

Imaging Distinguish tumefactive type from neoplasia

Distinguish pseudotumor from thyroid orbitopathy

CT

○ Intense enhancement of conal/intraconal lesions

○ Involvement of muscle tendons

MRI

○ Lesions are hypo- to isointense to fat on T2 (other neoplasia often hyperintense to fat on T2)

○ Intense enhancement

NB: Can look like ANYTHING!

IOID or Orbital Pseudotumor

IOID or Orbital Pseudotumor

IOID or Orbital Pseudotumor

IOID or Orbital Pseudotumor

Myositic IOID

Orbital Pseudotumor Following Steroids

Orbital Pseudotumor – same

diagnosis, different species…

Granulomatosis with Polyangiitis (Wegener’s)

Note sinus disease!

Optic Neuritis

Optic nerve inflammation due to:

Demyelination (MS)

Infections: Lyme disease, TB, syphilis

Viral: HIV, HBV, herpes, CMV

50% of patients diagnosed with MS

Long term severe vision loss in 20%

Triad of symptoms: loss of vision, eye

pain, dyschromatopsia; 70% unilateral

Optic Neuritis

Optic Neuritis

Intracranial WM Lesions

Orbital Vascular Lesions

Cavernous hemangioma (orbital venous

malformation) is most common orbital

mass in adults

Emergent presentation may be seen

with a limited number of orbital vascular

lesions

Orbital Venous Malformation

(Cavernous Hemangioma) Most common orbital vascular lesion in adult

Classic imaging appearance in most cases 80% intraconal - usually retrobulbar

CT Homogeneous, slightly hyperdense

(microcalcifications)

Usually marked homogeneous enhancement

MR Isointense to muscle on T1

Hyperintense on T2

Patchy enhancement that may progressively opacify

Cavernous Hemangioma

Immediate Post Contrast

One hour Post Contrast

Cavernous Hemangioma

Carotid Cavernous Fistula

Communication between ICA and cavernous sinus

Indirect CCF AV shunting via multiple dural arteries

○ Usually spontaneous

○ Most often in middle-aged women

Rare secondary to vascular tumor

Direct CCF Post-traumatic (arterial laceration)

Rupture of cavernous carotid aneurysm

Carotid Cavernous Fistula

Pulsatile exophthalmos, chemosis, bruit

Imaging findings

Dilatation of SOV

Exophthalmos with enlargement of EOM

Abnormal contour (bulging) of CS

CT and MR typically diagnostic

CTA/MRA superior in depiction

Catheter angiography for morphology and treatment

Observations

“Bulging” wall of

cavernous sinus

Too many flow voids

in cavernous sinus

Dilated ipsilateral

SOV

Catheter Angiography

Indirect CCF

Direct CCF

Post-Traumatic

Supine

Hanging Head

Orbital Varices

Lymphatic Malformations

Lymphocytes may proliferate during viral

infections and cause worsening

proptosis

Hemorrhage, either spontaneous or

secondary to minor trauma, is common

Results in “chocolate cysts”

Sudden proptosis, rare optic nerve

compression

Orbital Lymphatic Malformation

Orbital Lymphatic Malformation

Orbital Lymphatic Malformation

Orbital Disease: Patterns

Lesion of bony orbit that involves orbit

Enlargement of the extraocular muscles

Retrobulbar mass

Retrobulbar infiltrate

Lesion of Bony Orbit

Child Adult

Mets

(neuroblastoma,

sarcomas)

Leukemia/lymphoma

Rhabdomyosarcoma

Histiocytosis

Fibro-osseous lesion

Expansile PNS

process

Mets (lung, breast,

melanoma, renal)

Multiple myeloma

Meningioma

Leukemia/lymphoma

Fibro-osseous lesion

Expansile PNS

process

Enlargement of Extraocular

Muscles

EOM Enlargement

Thyroid orbitopathy

Idiopathic Orbital Inflammatory

Syndrome (pseudotumor)

Metastatic disease

Infection

Lymphoproliferative disease

Vascular lesions

Retrobulbar Mass

Retrobulbar Masses

Hemangioma

Lymphangioma

Met

Lymphoproliferative

disease

Hematoma

Schwannoma/neurof

ibroma

Rhabdomyosarcoma

Chloroma

Hemangiopericytoma

Meningioma

Optic n. lesions

Epidermoid/dermoid/

Teratoma

Retrobulbar Infiltrate

Orbital Infiltrative Processes

Infection

Hemorrhage

Lymphoproliferative disease

Pseudotumor

Sarcoid

Wegeners

Metastatic Disease

CCF/SOV thrombosis

Thyroid orbitopathy

Narrowing Your DDx

Know clinical setting

Know patient’s age