The Orbit and Visual Pathways

Wade Wong DO FACR FAOCR

Emeritus Professor of Radiology

University of California, San Diego

ImagingNormal Anatomy

• Ethmoid

• Frontal

• Zygomatic

• Maxillary

• Sphenoid

Preseptal Lesions

• Preseptal Cellulitis

• PreseptalNeoplasms

Preseptal to Postseptal Mass

Basal Cell Carcinoma

Ocular Lesions

Leukokoria

• Retinoblastoma

• PHPV

• Retinopathy of Prematurity

• Coats Disease

• Toxocara

• Cataract

Pediatric Ocular Lesions

• Retinoblastoma

• PHPV

• Coats Disease

• Toxocaris

Retinoblastoma

Ocular Calcifications

Choroidal osteoma

Drusen

Scleral calcifications

Retinoblastoma• M/C Ocular

neoplasm ofchildhood

• 60% unilateral

• 90% ca++

Trilateral= Bilat Retinoblastomas+ Pinealblastoma

PHPV

• PersistentHyperplasticPrimary Vitreus

• Small eye

• Cloquet canal/hyaloid artery

PHPV Toxocara

• Dog round worm

• Uveitis,enopthalmitis

• Post Larval death

• Dense Vitreus,posterior mass

• NO Ca++

Toxocarais

Harnsberger 2nd ed

Immunologic Rxn to roundworm larval death

DDX: Retinoblastoma, Coats, PHPV

Coats Disease

• Multipletelangiectasias ofretina

• Serous &lipoproteinaceousexudates

• Retinal detachment• Normal eye size;

no ca++

Harnsberger 2nd ed

Adult Ocular Lesions

• Melanoma

• Mets

• ChoroidalHemangioma

• Lymphoma

Uveal Melanoma

Uveal Melanoma

• Primary or metastaic

• Most melanotic

• Paramagnetic effect ofmelanin

Metastatic Prostate Cancer to the Choroid

Metastatic Renal Cell Cancer to the choroid

Choroidal Hemangioma Optic Nerve Drusen

Coloboma

• Congenital oracquired

• Cone shaped defect@ posterior globe

• Possibly associatedw/ encephalocele, CCagenesis, Iris defect,olfactory hypoplasia,cardiac anomalies,midline defects

Herpes Simplex Retinitis

Post Traumatic Ocular Lesions

Hyphema

Ocular Hemorrhage

Von Hipple Lindau

Pthysis Bulbi Subretinal Hematoma/Detachment

Scleral Banding Intraconal Lesions

• Optic Nerve

• Optic N. Sheath

• Vascular

• Orbital ApexLesions

• Other

Optic Nerve Lesions

• PediatricOptic N. GilomaSepto optic dys

• AdultNeuritisPseudotumorIncr. ICP/ Sys

Disease

Optic Nerve Glioma

Optic Nerve Gioma

• Low gradeAstrocytoma (JPA)

• NF-1

• Anywhere alongoptic pathways

7y/o F c/o poor vision since birth

Septo Optic Dysplasia

Optic Neuritis Non Hodgkins Lymphoma

Leukemia of Optic N. & Sheath Orbital Trauma

Contused Optic Nerve

Orbital Pseudotumor Orbital Pseudotumor

) Tends to be unilateral) 25% of all cases of unilateral

exophthalmos) Diffuse infiltration of orbital tissues) Remitting or chronic and progressive) May regress spontaneously or

responds to steroids) Similar to lymphoma clinically,

radiographically & pathologically

Optic Nerve Sheath Lesions

• Meningioma

• Leukemia

• Granulomatous Ds.

• Other

Optic Nerve Sheath Meningioma

? Optic Nerve or Sheath

Oblique Coronal

? Intracranial Extention

Sarcoid

History: 10 y/o boy with proptosis

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Dx: Lymphangioma

Orbital Lymphatic Malformation

Venolymphatic Malformation(Prev. called Lymphangioma)

Lymphatic +venous componentsLobulatedFluid-Fluid LevelsBlood ProductsCysts

Other Intra orbital Vascular Lesions

• CavernousHemangioma

• CC fistula

• Orbital Varix

• Opthalmic V.thrombosis

• Other

Cavernous Hemangioma

• M/C orbital tumor

• 20-40 y/o

• WellCircumscribed,rounded

• Spares orbitalApex

Cavernous Hemangioma

• Slowly growning vascmass

• Proptosis

• Not a trueHemangioma

• CavernousMalformation

Types of Orbital Vascular Malformations1. Lymphatic: no flow2. Venous: slow flow (eg varix)3. Arterial: Hi flow (eg Cav Malf, AVM)

Orbital Cavernous Hemangioma

• Coarse punctatecalcifications &Phleboliths

• May suggest Dx

Orbital Cavernous Hemangioma

40 y/o F c/o proptosis OD Orbital Varix

Valsalva

Relaxed vs ValsalvaOcular Ultrasound

Varix

55 y/o F c/o bulging red eye Spontaneously

CC Fistula: Aneurysm rupture

78 y/o F c/o red bulging eyeNo Trauma

Dural CC Fistula

Endovascular Rx: Embolized L ECA & Sup Opth V

25 y/o M c/o red bulging eye

SOV Thrombosis

Orbital Apex (Intraconal) Lesions

• Mets

• Meningioma

• Optic N. Glioma

• Lymphoma

• Other

Metastatic Lung Ca

Conal Lesions

• Graves Disease

• Pseudo Tumor

• Lymphoma

• Other

30 y/o F: Proptosis Graves Ds: Thyroid Opthalmopathy

• Swelling of musclebellies; Sparing oftendons

• Intraconal changespossible

• Hyper or euthyroid

• I’M SLow

Orbital Pseudotumor

• InvolvementMuscle & Tendon

• Similar histologicalfeatures tolymphoma

Non Hodgkins Lymphoma

Extraconal Lesions

• PediatricRhabdomyosar

• AdultsMets

• Trauma

• Infection

• Lacrimal Lesions

Rhabdomyosarcoma

• M/C pediatricSarcoma

• H&N 2nd M/C site

• Arises frompleuripotential cellsextraconal theninvades musclecone

9 mo later

62 y/o F c/o proptosis & Pain OD

Breast Ca

62 y/o F c/o proptosis, diplopia

Meningioma

64 y/o M c/o opthalmoplegia

Mucoepidermoid Ca w/ extension through inferior orbital fissure

39 y/o F c/o double vision

Adenoidcystic Ca w/extension through orbital floor

45 y/o F c/o opthalmoplegiah/o leukemia

Chloroma (Leukemic Mass)

12 y/ F c/o proptosis OD

Dermoid Dx: Orbital dermoid

History: 57 y/o man with right eye droop

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44 y/o M c/o proptosis, fever, nasal congestion

Sinusits, Orbital Abscess

39 y/o M. HIV + c/o double vision

Sinusitis w/ orbital/ cavernous sinus extension: Mucormycosis

Lacrimal Lesions

• Lacrimal Cysts

• PleomorphicAdenoma

• Salivary GlandMalignancy

• Mets

• Lymphoma

Lacrimal Gland Masses

) 50% - Lymphoid-Inflammatory disease

5 Benign hyperplasia Lymphoma

) 50% - Epithelial tumors

5 1/2 - Pleomorphic adenomas

5 1/2 - Malignant carcinomasAdenocystic, PleomorphicMucoepidermoid, Squamous cellUndifferentiated, Adenocarcinoma

Pleomorphic Carcinoma

OD 107-8

Dacryocystocele

• Dacryocystocele

The Visual Pathways

Chiasmatic Lesions

• Sellar/SuprasellarMasses

• Vascular

Chiasmatic: Bitemporal Hemianopsia

Pituatary Adenoma

77 y/o F: progressive visual loss

Meningioma

18 y/o M: Bitemporal Hemianopsia

Germinoma

47 y/o M: Bitemporal Hemianopsia

ACOM Aneurysm

Optic Tract Lesions

• Optic NerveGlioma

• Other adjacentNeoplasms

• Other

Optic Nerve Glioma along Optic Tracts

Astrocytoma: Mass effect on optic tracts

Optic Radiation Lesions

• Neoplasms

• Vascular

• Inflammatory

47 y/o F c/o defects in vision

AVM

Tumefactive M.S.

Sudden Onset quadrantic visual loss

PCA Infarct

18 y/o M c/o visual loss

Sturge Weber

Affectations of eye movement: Cranial Nerve 3, 4, 6 deficits

• Brainstem Mass

• Vascular

• Inflammatory

• Other

Brainstem Glioma

57 y/o F c/o double vision

Cavernous Sinus Met

E.B.

• 44 y/o M

• Progressive doublevision

Rapidly Worsening 3rd N plasy

Passed BTO & HMPAONext Day

New involvement: L 6 th N• NOW What?

• ?Surgery

• Coiling?

• Stent

• Coils/Stent

Coils

• 7x15 3D firm matr• 6x156 3D std Matr• 5x15 2D matr• 4x10 2D matr• 3x6 hydro• 5x12 hydro• 3x6hydro• 3x4 hydr• 2x6 hydro (2)

• Vortex 6x8,4x6,3x3(2), 3x3

• Heparin drip:ptt 60-80

Pre vs Post

Outcome

• Intense pain day 3

• Neuro intact excfor 3rd & 6 th Npalsies

• MRI/MRA in 3-4weeks

Case Discussions

G.S. 72 y/o F c/o Proptosis OS

DDX?

DDx?

• Pleomorphicadenoma

• Lymphoma

• Adenoid cystic Ca

• Met

E.G.

• 67 y/o F

• H.A. double vision

014-300, 4.5 x 30 NF3 Coils

• 20x30 M 3D• 20x30 M 360• 20x30 M 2D• 18x30 M 360• 18x30 M 360• 14x30 M 360• 14x30 M 2D• 16x20 Hel Hydr• 14x15 “ “• 14x15 “ “

More Coils: 22 total

• 12x15 hel hydr• 10x15 “ “

• 9x15 “ “

• 8x24 complex• 7x21 “• 7x21 “• 6x15 “• 6x15• 6x15• 6x15• 5x12

Final: Uneventful course, discharged next AM

G.C.

• 51 y/o F

• c/o epiphora os

What Next?

Dacryocystogram

Stricture

J.D.

• 47 y/o M

• c/o mucus backinginto R eyewhenever he blowshis nose

• After ESS

Dx: No obstruction.. Findings suggest incompetent valve of Hauser

Other Pathology

SCCA R Max Sinus invading lacrimal duct