Download Imaging Proptosis

Carolyn Kloek HMSIV
Gillian Lieberman, MD
November 2001
Imaging Proptosis
Carolyn Kloek, Harvard Medical School Year IV
Gillian Lieberman, MD
Carolyn Kloek HMSIV
Gillian Lieberman, MD
AGENDA
• Introduce our patient
• Define and review Ddx of proptosis
• Review the anatomy of the eye and orbit
• Discuss different radiologic studies available
for imaging the orbit
• Show examples of how these imaging
modalities can be used distinguish between
different causes of proptosis
• Return to our patient
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Student Name
Gillian Lieberman, MD
The Patient
•50 year old man riding bicycle hit by automobile
•Hit head on pavement
•Taken to the ED for evaluation
•Clinical exam notable for left proptosis; patient states
that he has had this “forever”
•Head CT without contrast ordered to r/o intracranial
bleed
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Definition and Ddx of Proptosis
PROPTOSIS: protrusion of the eye with a difference of > 3mm
between the two eyes.
DIFFERENTIAL DIAGNOSIS OF PROPTOSIS:
I. DISORDERS OF EXTRAOCULAR MUSCLES
dysthyroid eye disease, rhabdomyosarcoma
II. INFECTIVE DISORDERS
orbital cellulitis, preseptal cellulitis
III. INFLAMMATORY DISEASE
orbital pseudotumor
IV. VASCULAR ABNORMALITIES
carotico-cavernous fistula, AVM, orbital varix
V. ORBITAL TUMORS
optic nerve gliomas/meningiomas, lymphoma, mets,
cavernous hemangioma
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Review of the anatomy of the eye
From Robbins Pathologic Basis of Disease.
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Review of the anatomy of the
orbit
From James, Chew, and Bron. Lecture Notes on Ophthalmology, 8th ed.
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Menu of Imaging Modalities for
the Orbit
1. Plain film
radiography
2. Ultrasound
3. CT
4. MRI
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Normal Radiograph
CALDWELL
PROJECTION
WATERS PROJECTION
Frontal sinus
Orbital
roof
Superior
orbital
fissure
Frontal sinus
Inferior orbital rim
Maxillary sinus
From Casper, Chi, Trokel.
Orbital Disease, Imaging and Analysis, 1993.
Orbital floor
From Casper, Chi, Trokel.
Orbital Disease, Imaging and Analysis, 1993.
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Pros/Cons of Radiography
PROS
CONS
¾Cost-efficient
¾Limited ability to
detect changes in
tissue density
¾Good for initial
evaluation of
orbital trauma, esp
fractures
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Choose radiograph when:
• you want to evaluate bony structure,
ex. orbital fracture
•You want to evaluate sinus pathology
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Orbital Cellulitis
•Infection of orbital soft
tissue
From Spalton, Hitchings, Hunter, Atlas of Clinical Ophthalmology, 2nd ed.
•Often secondary to acute
or chronic sinusitis
• needs immediate
treatment given risk of
spread to CNS
Air-fluid level in
the left frontal sinus
From Spalton, Hitchings, Hunter, Atlas of Clinical Ophthalmology, 2nd ed.
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
November 2001
Normal Ocular Ultrasound
Posterior
Anterior
Retina
Lens
Anterior
Chamber
Posterior
Chamber
Optic
Nerve
From Vander, Gault. Ophthalmology Secrets, 1998.
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Pros/Cons of Orbital Ultrasound
PROS
CONS
¾safe/inexpensive
¾examiner dependent
¾Can detect calcifications
¾good for detection of
intraocular foreign bodies,
ocular tumors, retinal
detachment, vitreous
hemorrahge
From Newton, Bilaniuk. Radiology of the Eye and Orbit, 1990.
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Choose ultrasound to image the
orbit when:
• you want to assess the presence or size
of an ocular tumor
• you want to look for clues to characterize
tumor tissue (ex. calcifications)
• a patient presents with an orbital
process and you want to evaluate the orbit
• locate intraocular foreign bodies
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Cavernous Hemangioma
•
Right Proptosis
Most common benign orbital tumor
• Vasular orbital tumor, usually intraconal
• Affects middle-aged women
From Orbit, Eyeballs, and the Lacrimal System,
American Academy of Ophthalmology, 1999-2000.
• Presents as slowly progressive axial
proptosis
Anterior
Posterior
Well circumscribed retrobulbar mass
with homogeneous irregular echo
From Newton, Bilaniuk. Radiology of the Eye and Orbit, 1990.
structure
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Right Orbital Ultrasound
Carolyn Kloek HMSIV
Gillian Lieberman, MD
Carotico-cavernous fistula
•Arteriovenous communication
between the carotid arterial system
and the cavernous sinus
• Can be high flow or low flow
From Orbit, Eyeballs, and the Lacrimal System,
American Academy of Ophthalmology, 1999-2000.
• Secondary to trauma or spontaneous
dilated superior
ophthalmic vein
From Frazier Byrne, Green. Ultrasound of the Eye and Orbit, 1992.
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Normal CT
Globe
50%
50%
Lateral
rectus
Optic
Nerve
From Casper, Chi, Trokel. Orbital Disease, Imaging and Analysis, 1993.
Medial
rectus
Orbital apex
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Pros/Cons of CT for orbital
imaging
PROS
CONS
¾Good for bony
pathology/
calcifications
¾Lower cost than MRI
¾Poor for imaging the soft
tissues at the orbital apex
¾Always used before MRI
in cases of trauma
Young woman s/p trauma with proptosis.
Intra-ocular metallic
From Casper, Chi, Trokel. Orbital Disease,
Foreign body
Imaging and Analysis, 1993.
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Choose CT to image the orbit
when:
• you want to evaluate bony pathology
• you want to visualize calcifications
• the patient is s/p trauma
• there is a contra-indication to MRI
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Thyroid Eye Disease
From Spalton, Hitchings, Hunter,
Atlas of Clinical Ophthalmology, 2nd ed.
80%
20%
From Casper, Chi, Trokel. Orbital Disease,
Imaging and Analysis, 1993.
•Can occur with hyper OR
hypo thyroidism
• Lymphocytic infiltration of
EOM Æ enlarged EOM Æ
impaired gaze/proptosis
• Can be unilateral or bilateral
Enlarged medial/lateral
rectus muscles
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Normal MRI
T1 (better anatomic detail)
T2 (better for detecting
pathologic change)
LENS
GLOBE
OPTIC N.
ORBITAL
FAT
From Casper, Chi, Trokel. Orbital Disease, Imaging and Analysis, 1993.
EOM
From Casper, Chi, Trokel. Orbital Disease,
Imaging and Analysis, 1993.
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Pros/Cons of MRI for orbital
imaging
PROS
CONS
¾good soft tissue contrast
¾cost
¾better for vascular and
hemorrhagic lesions
¾Difficult to differentiate illdefined lesion
¾Good for work-up of wellcircumscribed lesions
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Choose MRI to image the orbit
when:
• you suspect an intraocular process involving
the optic nerve (meningioma, glioma, etc)
• a patient presents with acute onset proptosis
and you are unsure of the cause
• there is an intraocular tumor and you want to
assess whether there has been extraocular
extension
• there is a contra-indication to CT
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Optic Nerve Glioma
•Most often present in children and young adults with unilateral
proptosis and decreased visual acuity
•usually benign
•rarely spreads along optic nerve and invade chiasm
•25-50% associated with neurofibromatosis
T1
T2
Mass of the
optic nerve
From Casper, Chi, Trokel. Orbital Disease, Imaging and Analysis, 1993.
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Back to our patientAxial CT without contrast
Retrobulbar soft tissue density
throughout which are dispersed
multiple round high-attenuation
foci
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Back to our patientAxial CT without contrast
Left middle cerebral artery
Large curvilinear region of
high attenuation
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Our Patient
MRI-Saggital View
Dilated veins
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Our Patient
MRI- Axial View
multiple dilated flow voids
within the left sylvian fissure
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Our Patient’s Diagnosis: AVM
ƒcongenital or acquired vascular lesion
ƒMost common form of intracranial hamartoma
ƒUsually presents as an ill-defined mass
ƒ70% of AVMs symptomatic by second or third decade of life
ƒ usually present with intracranial bleeds or seizures depending
on size
ƒEndovascular or surgical treatment according to the
location/type of lesion
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Carolyn Kloek HMSIV
Gillian Lieberman, MD
Our Patient
Our patient refused treatment for this AVM.
There was no significant acute trauma related abnormalities.
The patient left AMA.
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Student Name
Gillian Lieberman, MD
References
•
•
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•
•
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Casper, Chi, Trokel. Orbital Disease, Imaging and Analysis. Thieme Medical Publishers, 1993.
Frazier Byrne, Green. Ultrasound of the Eye and Orbit. Mosby-Year Book, Inc: 1992.
James, Chew, Bron. Lecture Notes on Ophthalmology, 8th edition. Blackwell Science, 1977.
Newton, Bilaniuk. Radiology of the Eye and Orbit. Clavadel Press:1990.
Spalton, Hitchings, Hunter. Atlas of Clinical Ophthalmology. Gower Medical Publishing, 1984.
Vander, Gault. Ophthalmology Secrets. Hanley&Belfus, 1998.
Robbins Pathologic Basis of Disease.
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Student Name
Gillian Lieberman, MD
Acknowledgements
•
•
•
•
•
•
Larry Barbaras
Jim Busch, MD
Cara Lyn D’amour
Ian Dunn
Pamela Lepkowski
Gillian Lieberman, MD
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THANK YOU!
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