An unusual case: bilateral orbital varices.

PURPOSE: To present a rare case of bilateral orbital varices. METHODS: An 18-year-old man showing bilateral orbital masses on magnetic resonance (MR) imaging was examined with color Doppler ultrasonography (US), computed tomography (CT) and digital subtraction venography. RESULTS: The presenting symptoms of the patient were pain and fullness in both orbits induced by bending forward. Ocular examination was normal with the exception of a two millimeter proptosis of both eyes during Valsalva maneuver. MR imaging demonstrated bilateral retrobulbar masses, but was not diagnostic. The comparison of CT images obtained before and after Valsalva maneuver revealed the diagnosis of orbital varices. Color Doppler US and orbital venography demonstrated a large venous connection between the lesions and systemic circulation. CONCLUSION: Clinical presentation of orbital varices is unusual. Different radiological methods may be necessary for the confirmation of the diagnosis and demonstration of the anatomic and the dynamic features of the lesions.     

Role of magnetic resonance imaging in the evaluation of the hydroxyapatite orbital implant.

The role of magnetic resonance imaging (MRI) in the assessment of fibrovascular ingrowth in the integrated hydroxyapatite orbital implant is evaluated. Fifteen patients who underwent enucleation and placement of a hydroxyapatite orbital implant were evaluated for degree of implant vascularity with gadolinium-DPTA-enhanced MRI with surface coil before drilling the implant. On T1-weighted images, the hydroxyapatite sphere appeared with intermediate signal. After gadolinium-DPTA administration, all patients showed an enhancement in the implant consistent with the presence of fibrovascular ingrowth. The enhancement was most notable in the peripheral portions of the sphere and was seen as early as 5 months after implantation. Comparison of gadolinium-DPTA-enhanced MRI with contrast-enhanced computed tomography, ultrasonography, and color Doppler imaging suggests that these latter techniques are not as helpful in the detection of the fibrovascular tissue in the orbital implant. Bone scan, a technique used by many surgeons, demonstrates fibrovascular ingrowth, but it is limited by its one-dimensional low-resolution image. Because of its three-dimensional capability and its highest resolution, contrast-enhanced MRI with surface coil appears to be the best imaging method for evaluating the hydroxyapatite orbital implant and its fibrovascular ingrowth.     

Neuroimaging in neuro-ophthalmology

Computed tomographic scanning is an excellent modality for evaluation of most orbital and intracranial tumors and strokes. However, MR scanning is definitely superior to CT when evaluating for multiple sclerosis, posterior fossa lesions (evaluation of gaze palsies, internuclear ophthalmoplegia, and downbeat nystagmus), or when assessing an area where sagittal scanning is important (chiasmal lesions). Magnetic resonance has increased specificity when the CT is equivocal. Although MR and CT may be complementary in the information they provide, many clinical studies have shown MR to be superior to CT in evaluating cerebral infarctions, hematomas, the intracanalicular optic nerve, optic chiasm, sella turcica, and the cavernous sinus. Magnetic resonance generally has replaced metrizamide CT cisternography as the procedure of choice for evaluating the suprasellar cistern and posterior fossa. Computed tomography is still preferable for major trauma, especially involving acute fractures and hematomas, although MR is more sensitive to the more subtle intracerebral lesions, such as shear injuries and subdural hematomas, that may provide prognostic information. Computed tomography also is preferred in situations where detecting small amounts of calcification is important for the differential diagnosis. As the development of MR imaging continues with faster scan times, finer spatial resolution, the use of paramagnetic contrast agents, and with increased availability and decreased cost, MR imaging may become preferable to CT as the imaging modality of choice for the CNS and orbit.     

Neuroimaging contrast agents in ophthalmology

Magnetic resonance (MR) imaging and computed tomography (CT) are routinely performed with the use of contrast materials in the diagnosis of neuro-ophthalmologic disease. Iodinated agents are commonly used in CT scanning and femoral contrast arteriography, and gadolinium is used in MR imaging. While contrast materials contribute greatly to diagnostic accuracy, they may also be responsible for adverse effects, ranging in severity from mild discomfort to death. The most frequent and severe side effects are associated with ionic iodinated contrast agents, while the rate of adverse reactions is less with use of nonionic iodinated contrast agents. Side effects and adverse reactions to gadolinium are uncommon, but they do occur. In neuro-ophthalmologic diagnosis, MR imaging is generally preferred over CT scanning, partly because of its greater ability to delineate soft tissue intracranial structures, but also because of the relative safety of gadolinium as a contrast agent. Properties of contrast agents are discussed in the context of specific imaging techniques and tissues investigated. Types and severity of adverse effects as well as risk factors for incurring such effects are summarized.     

Imaging in orbital trauma

Orbital trauma is one of the most common reasons for ophthalmology specialty consultation in the emergency department setting. We survey the literature from 1990 to present to describe the role of computed tomography (CT), magnetic resonance imaging (MRI) and their associated angiography in some of the most commonly encountered orbital trauma conditions. CT orbit can often detect certain types of foreign bodies, lens dislocation, ruptured globe, choroidal or retinal detachments, or cavernous sinus thrombosis and thus complement a bedside ophthalmic exam that can sometimes be limited in the setting of trauma. CT remains the workhorse for acute orbital trauma owing to its rapidity and ability to delineate bony abnormalities; however MRI remains an important modality in special circumstances such as soft tissue assessment or with organic foreign bodies.     

Update on imaging techniques in oculoplastics

Imaging is a beneficial aid to the oculoplastic surgeon especially in orbital and lacrimal disorders when the pathology is not visible from outside. It is a powerful tool that may be benefited in not only diagnosis but also management and follow-up. The most common imaging modalities required are CT and MRI, with CT being more frequently ordered by oculoplastic surgeons. Improvements in technology enabled the acquisition times to shorten incredibly. Radiologists can now obtain images with superb resolution, and isolate the site and tissue of interest from other structures with special techniques. Better contrast agents and 3D imaging capabilities make complicated cases easier to identify. Color Doppler imaging is becoming more popular both for research and clinical purposes. Magnetic resonance angiography (MRA) added so much to the vascular system imaging recently. Although angiography is still the gold standard, new software and techniques rendered MRA as valuable as angiography in most circumstances. Stereotactic navigation, although in use for a long time, recently became the focus of interest for the oculoplastic surgeon especially in orbital decompressions. Improvements in radiology and nuclear medicine techniques of lacrimal drainage system imaging provided more detailed analysis of the system.     

Orbital diagnosis and imaging

A myriad of imaging modalities now exists to aid in the diagnosis of orbital disease. Most of the recent advances in orbital diagnosis are based on refinements of established techniques, although several represent the application of new technology. Invasive techniques, such as orbital arteriography and venography, have been supplanted with computed tomography, which has become the mainstay of orbital diagnosis. The use of magnetic resonance imaging in the assessment of orbital pathology has also increased. Color Doppler, a recent development in ultrasonography, has now been applied to the eye and orbit.     

Radiologic findings in infected and noninfected scleral buckles

PURPOSE: To present the radiologic findings in scleral buckle infections and in the early postoperative period after scleral buckling. METHODS: Retrospective multicenter orbital computed tomography (CT) study of 14 patients and brain magnetic resonance (MR) in one patient with scleral buckle infections, some with the referring diagnosis of endophthalmitis, proliferative vitreoretinopathy, orbital cellulitis, or unilateral headache. The control population consisted of early postoperative prospective CT study of 38 consecutive patients with scleral buckle without clinical infection. RESULTS: Diffuse scleral thickening and preseptal soft tissue swelling were noted in acute scleral buckle infections. Scleral thickening decreased radiologically following prompt antibiotic therapy in five patients with acute infections. Silicone sponge had low attenuation without infection and high attenuation with infection. In chronically infected scleral buckle, the sclera was thickened around the buckle, with scleral melt under the buckle. MR showed increased signal intensity in the preseptal region in one patient with chronic fungal infection. In the controls, two had thickening of the sclera without soft tissue swelling. CONCLUSIONS: CT or MR can assist in the early diagnosis and management of scleral buckle infections.     

Orbital solitary fibrous tumor: A report of two cases

Solitary fibrous tumor (SFT) is a rare spindle-cell neoplasm that can be found in the orbit. Here, we report two cases affected by orbital SFT. Both patients were female, aged 52 years and 59 years, respectively, and had experienced a painless unilateral orbital lesion. Computed tomography (CT) imaging revealed a well-circumscribed and contrast-enhanced soft tissue mass simultaneously. The tumors were located in the laterotemporal extraconal space of the right orbit and the inferior portion of the left orbit, respectively. Both patients underwent complete resection of their tumors. The histological findings showed alternating hypercellular and hypocellular areas composed of bland spindle cells with a fibrous stroma. The strong immunoreactivity for CD34 supported the diagnosis of orbital SFT. There was no recurrence at the 2-year and 3-year follow-up visits, respectively. SFTs should be considered in the differential diagnosis of an orbital tumor. The combination of a CT scan, histologic findings, and immunohistochemical staining will provide an accurate diagnosis. En bloc excision of the tumor is the mainstay of treatment in order to avoid recurrence.     

Correlation of orbital computed tomographic findings with office probing and irrigation in 17 patients after successful and failed dacryocystorhinostomy

PURPOSE: To investigate the role of orbital computed tomography (CT) in the evaluation of patients after dacryocystorhinostomy (DCR). METHODS: Computed tomography scans of patients who underwent both successful and failed DCR were examined to determine the relationship of the soft-tissue changes to the surgical ostium, and the findings were correlated with postoperative results of office probing and irrigation. RESULTS: After a successful DCR (n = 7), a patent fistulous tract was confirmed by office probing and irrigation. A characteristic "Y-on-its-side" configuration of the soft tissue was noted on a CT scan. Total occlusion of the osteotomy by soft tissue on probing and irrigation corresponded to a mucocelelike soft-tissue density with a central lucency and soft-tissue obstruction (n = 2). Total occlusion of the osteotomy by inadequate excision of bone and adjacent soft tissue, visualized by CT imaging, was confirmed by palpation of bone by office probing (n = 1). Partial obstruction on probing and irrigation was associated on a CT scan with an increased soft-tissue density (n = 4) and bone in the region of the osteotomy (n = 3). CONCLUSIONS: Computed tomography allows visualization of a patent fistula after successful DCR as well as soft-tissue or bone obstruction of the surgically created fistula after failed DCR. When combined with probing and irrigation, CT helps to formulate a surgical plan after failed DCR.     

Cavernous hemangioma with rapidly developing proptosis

Purpose: To report an unusual case of cavernous hemangioma with rapidly developing proptosis. Methods: Case report. The clinical features, imaging findings and orbital surgery were presented. Results: A 54-year-old man presented with rapidly developing proptosis and a mass in the lower eyelid of his left eye for 8 h. The left eye had 5 mm of proptosis. Color Doppler ultrasonography and computed tomography disclosed a well-defined soft tissue mass in the left anterior orbit, which extended along the floor of the orbit and sized 1.7 × 2.2 cm without bone destruction. An anterior orbitotomy was performed. At surgery a red-purple, well-defined and cone-shaped mass and a hematoma, which was found on the lateral part of the mass, were removed. The histopathological evaluation of the mass revealed cavernous hemangioma. Conclusions: Patient with a rapidly developing proptosis might have the possibility of orbital cavernous hemangioma. The paper was sponsored by the Natural Science Foundation of Guangdong Province, China (036651).     

Colour Doppler imaging in the demonstration of an orbital varix.

Colour Doppler imaging (CDI) is a recent development in ultrasonography. It allows simultaneous two-dimensional structural imaging and Doppler evaluation of blood flow. Quantitative information on flow velocity is obtained by pulsed Doppler spectral analysis, the colour information being used to choose the vessel of interest. Using this technique the authors examined a patient with an orbital varix previously diagnosed by clinical findings and computed tomography. Dynamic evaluation with real-time direct imaging of flow facilitated the diagnosis of this orbital disorder without the need for any contrast material. This technique may prove to be a useful adjunct to computed tomography for the evaluation of suspected vascular lesions of the orbit.     

Orbital giant cell fibroblastoma

BACKGROUND: This report describes the clinical and morphologic (light and electron microscopic and immunohistochemical) features of orbital giant cell fibroblastoma which, to the best of our knowledge, has not been reported before in the ophthalmological literature. METHODS: Clinical symptoms, computed tomography (CT), and magnetic resonance (MR) features, light and electron microscopic and immunohistochemical findings were reviewed in a 65-year-old woman who developed an orbital giant cell fibroblastoma. RESULTS: The patient presented with a large, infiltrating, intra- and periorbital mass, causing severe proptosis, ocular displacement, and visual loss on the left side. CT and MR imaging demonstrated a large, irregular tissue density in the orbit leading to displacement of the globe anteriorly and inferolaterally. With T(1)-weighted MR images, the lesion was isointense to the gray matter of the brain and revealed marked enhancement with Gd-DTPA. Histopathologically, the tumor consisted of a mixture of spindle and multinucleated giant cells scattered within a myxomatous stroma. CONCLUSION: Giant cell fibroblastoma, a benign mesenchymal tumor of infancy, is rarely encountered within the orbital region. This lesion is considered to be a distinct, non-metastasizing tumor, but its clinical management may be very difficult, as in our case, because of its invasive nature and potential for recurrence.     

Orbital giant cell fibroblastoma

BACKGROUND This report describes the clinical and morphologic (light and electron microscopic and immunohistochemical) features of orbital giant cell fibroblastoma which, to the best of our knowledge, has not been reported before in the ophthalmological literature. METHODS Clinical symptoms, computed tomography (CT), and magnetic resonance (MR) features, light and electron microscopic and immunohistochemical findings were reviewed in a 65-year-old woman who developed an orbital giant cell fibroblastoma. RESULTS The patient presented with a large, infiltrating, intra- and periorbital mass, causing severe proptosis, ocular displacement, and visual loss on the left side. CT and MR imaging demonstrated a large, irregular tissue density in the orbit leading to displacement of the globe anteriorly and inferolaterally. With T 1 -weighted MR images, the lesion was isointense to the gray matter of the brain and revealed marked enhancement with Gd-DTPA. Histopathologically, the tumor consisted of a mixture of spindle and multinucleated giant cells scattered within a myxomatous stroma. CONCLUSION Giant cell fibroblastoma, a benign mesenchymal tumor of infancy, is rarely encountered within the orbital region. This lesion is considered to be a distinct, non-metastasizing tumor, but its clinical management may be very difficult, as in our case, because of its invasive nature and potential for recurrence.     

Diagnosis of magnetic resonance imaging (MRI) for blowout fracture--three advantages of MRI

INTRODUCTION: Magnetic resonance imaging (MRI) gives a much more detailed picture of the soft tissue than computerized tomography (CT). In blowout fracture cases, it is very easy to observe the incarcerated orbital tissue. SUBJECTS: We performed MRI in 19 blowout fracture cases. RESULTS: After evaluating the images, we found three advantages of MRI. The first is that even small herniation of the orbital contents can easily be detected because the orbital fatty tissue contrasts well around the other tissues in MRI. The second is that the incarcerated tissues can be clearly differentiated because a clear contrast between the orbital fatty tissue and the extraocular muscle can be seen in MRI. The third is that the running images of the incarcerated muscle belly can be observed because any necessary directional slies can be taken in MRI. CONCLUSION: These advantages are very important in the diagnosis of blowout fractures. MRI should be employed in blowout fracture cases in addition to CT.     

Intraorbital wood. Detection by magnetic resonance imaging

The authors present two cases in which intraorbital wooden foreign bodies remained undetected after initial ophthalmologic examination and radiologic investigation which included plain orbital x-rays, orbital computed tomography (CT) scans, and, in one case, orbital ultrasound. In each case, subsequent magnetic resonance imaging (MRI) showed a well-delineated low-intensity lesion suggestive of a retained foreign body. Investigation of a case of suspected wooden foreign body in the orbit should include an MRI scan if there is no contraindication, and no foreign body has been defined on CT scan, ultrasound, or plain orbital films.     

11例眼眶朗格尔汉斯细胞组织细胞增多症的临床分析

目的探讨眼眶朗格尔汉斯细胞组织细胞增多症（LCH）的临床表现、影像学特征、诊断方法及治疗原则。方法对11例眼眶LCH患者的临床症状、眼部体征、影像学检查、治疗方法及随访情况等临床资料进行回顾性分析,其中嗜酸细胞肉芽肿患者7例,汉-许-克综合征患者4例。结果嗜酸细胞肉芽肿好发于青少年,多单发于眶内。汉-许-克综合征多见于5岁以下的男性患儿,以多灶性组织细胞增生为特征,典型患者具有三联征（眼球突出、尿崩症及多灶性颅骨缺失）。患者多以眼球突出、眶区发现肿块就诊。颅部x线片示颅骨多灶性缺失,B超及彩色多普勒超声检查示眶内软组织肿物,CT检查可同时显示眶骨缺失和软组织肿块,MRI检查可示眶内肿瘤及颅内受累情况。结论特征性的影像学表现有助于LCH的诊断。治疗宜采用综合疗法,即在手术治疗的基础上配合局部放疗及化疗。预后与分型有关,嗜酸细胞肉芽肿预后最好,婴儿型LCH预后最差。（中华跟科杂志．2006,42：892-895）     

眼眶神经鞘瘤的影像学研究

目的 探讨眼眶神经鞘瘤的CT和MRI的影像学表现及诊断价值。方法 42例眼眶神经鞘瘤均经手术及病理证实。结果 42例中CT显示（1）球后视神经上方20例，视神经外侧9例（2例位于眶尖），视神经下方11例和内侧2例。（2）椭圆形和类圆形27例，分叶状或S形9例，哑铃形6例（其中5例经眶上裂向颅内蔓延）。（3）平扫显示肿瘤内均质高密度28例，不均质14例，其中5例肿瘤内有较大片状低密度区（囊变区）。37例MRI扫描中等T1、长T24例；等T1、短等长T2混杂信号29例；等T1等T24例。在37例MRI检查中35例行Gd-DTPA增强，3l例呈不均匀增强；4例均匀增强。显示肿瘤颅内蔓延5例。结论 CT和MRI能显示肿瘤的位置、形状和病变内部特征，可明确诊断，为手术治疗提供重要依据；而MRI在肿瘤的定性和定位诊断方面明显优于CT。     

Magnetic resonance imaging of the orbit

Magnetic resonance imaging (MRI) employs the nuclear resonance phenomenon to produce images of living tissues. Unlike computed tomography (CT), which relies solely on differences in the propensity of tissues to absorb X-rays to produce various contrasts, MRI offers a wide variety of pulse sequences, each of which exploits differences in the magnetic properties of protons in living tissue to produce contrast resolution. When optimal protocols are used, MRI contrast resolution in the orbital soft tissues is superior to that provided by any other imaging modality. Other advantages of MRI over CT include the ability to select the plane of imaging, and improved safety due to the lack of ionizing radiation.     

Advances in magnetic resonance imaging of orbital disease

Magnetic resonance imaging (MRI) is increasingly used by the orbital surgeon to aid in the diagnosis, surgical planning, and monitoring of orbital disease. MRI provides superior soft tissue detail compared with computed tomography or ultrasound, and advancing techniques enhance its ability to highlight abnormal orbital pathology. Diffusion-weighted imaging is a specialized technique that uses water molecule diffusion patterns in tissue to generate contrast signals and can help distinguish malignant from benign lesions. Steady-state free precession sequences such as Constructive Interference in Steady-State (CISS) and Fast Imaging Employing Steady-state Acquisition (FIESTA) generate highly detailed, 3-dimensional reconstructed images and are particularly useful in distinguishing structures adjacent to cerebral spinal fluid. Magnetic resonance angiography can be used to characterize vascular lesions within the orbit. New developments in magnetic field strength as well as the use of orbital surface coils achieve increasingly improved imaging resolution.