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2 CASES OF EYE ASYMMETRY N. De Vos1,2 Prof. Dr. F. M. Vanhoenacker1,2,3 Prof. Dr. M. Mespreuve1,2 Dr. J. Van Haesendonck4 1. Department of Radiology, UZ Gent 2. Department of Radiology, AZ Sint-Maarten, Duffel-Mechelen 3. Department of Radiology, UZ Antwerpen 4. Department of otorhinolaryngology, AZ Sint-Maarten, Duffel-Mechelen THEORETICAL CONSIDERATIONS ORBITAL ANATOMY Tailor TD et al. Radiographics, 2013. THEORETICAL CONSIDERATIONS APPROACH TO DDx CLASSICAL APPROACH • Etiology: inflammation – infection – neoplasm – trauma • Comprehensive DDx: not clinically helpful LOCATION-BASED APPROACH • Anatomy: conal – intraconal – extraconal – intraocular • Concise DDx: helpful for clinician THEORETICAL CONSIDERATIONS APPROACH TO DDx CLINICAL FINDINGS • Age, duration, pain, uni- or bilateral • Crucial for further narrowing DDx MIMICKERS • Metastases, lymphoproliferative diseases, sarcoidosis, idiopathic orbital inflammation • Variety of imaging presentations • May involve several orbital structures CASE 1 CASE 1 • • • • • 70 year-old female Painless left-sided exophthalmos Since 3 months Medical history: / Fundoscopy: normal CASE 1 CECT Extraconal mass, inferomedial side of left orbit Extension to inferior nasal meatus Uniform contrast enhancement CASE 1 CECT Bone remodeling with dilation of nasolacrimal duct CASE 1 T1-WI T2-WI Low to intermediate signal intensity CASE 1 fs T1-WI + Gd Uniform enhancement Absence of necrosis CASE 1 DWI ADC Restricted diffusion CASE 1 DIFFERENTIAL DIAGNOSIS CRUCIAL FINDINGS • 70 year-old female • Rapid onset of painless exophthalmos • Extraconal orbital mass • MRI: low SI, diffusion restriction: high nuclear-cytoplasmic ratio DIFFERENTIAL DIAGNOSIS • Lacrimal sac tumor • Lymphoproliferative disease CASE 1 DIAGNOSIS AND TREATMENT BIOPSY: LYMPHOMA • B-cell non-Hodgkin lymphoma • 24% of all space-occupying orbital tumors in patients older than 60 years • 30% of patients will develop systemic lymphoma within next 10 years TREATMENT: CHEMOTHERAPY • Bendamustine + Rituximab CASE 2 CASE 2 • • • • 50-year old male Right-sided enophthalmos Longstanding Sensation of eye displacement when blowing nose • Medical history: / CASE 2 CT Right-sided enophthalmos No intra-orbital abnormalities CASE 2 CT Heterogeneous opacification of maxillary sinus Volume loss, inferior displacement of orbital floor CASE 2 CT CECT Thin-walled sinus, no erosions, small calcifications Minimal enhancement CASE 2 T1-WI T2-WI T1-WI: low SI T2-WI: high SI Fat proliferation in infratemporal fossa CASE 2 fs T1-WI + Gd Mucosal enhancement CASE 1 DIFFERENTIAL DIAGNOSIS CRUCIAL FINDINGS • 50 year-old male • Longstanding right-sided enophthalmos • Right-sided maxillary sinus • Complete opacification • Volume loss • Thin osseous walls CASE 2 DIAGNOSIS SILENT SINUS SYNDROME Case courtesy of Prof Frank Gaillard, Radiopaedia.org, rID: 9447 TAKE HOME MESSAGES ORBITAL IMAGING • Location-based: globe – muscle cone – extraconal – intraconal • Clinical findings • Mimickers: lymphoproliferative diseases, metastases, sarcoidosis, idiopathic orbital inflammation • Paranasal sinuses REFERENCES Meltzer, DE. Orbital imaging: a patter-based approach. Radiol Clin N Am. 2015;53:37-80. Tailor TD, Gupta D, Dalley RW, Keene CD, Anzai Y. Orbital neoplasms in adults: clinical, radiologic, and pathologic review. Radiographics. 2013;33(6):1739-58. Choi JW, Kim HJ, Kim ST, Lee HB. CT and MR imaging findings of tumors and tumor-like conditions of the lacrimal sac. EPOS. 2011. http://dx.doi.org/10.1594/ecr2011/C-1926 Illner A, Davidson HC, Harnsberger HR, Hoffman J. The silent sinus syndrome: clinical and radiographic findings. AJR Am J Roentgenol. 2002;178(2):503-6.
