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OCULARIMAGING
BronwynE.Hamilton,MDProfessorofRadiology
OregonHealth&ScienceUniversity
Outline
• Anatomicreview• Imagingmodalities• Diseasemimics• Pathology
RelevantAnatomy
• Globeisdividedintoanterior&posteriorsegmentsbythelens
• Anteriorsegmentseparatedbytheiris– Anteriorchamber– Posteriorchamber(difficulttoseeonimaging)
• Posteriorsegment(posteriortolens)– Containsvitreous(humororbody)
GlobeAnatomy
NormalAnatomy
• 3layers– Cornea– Sclera– Retina
• Retinacomposedof:– Retina=innersensorylayer
– Uvealtract=Middlevascularlayercontainingchoroid,ciliarybody,&iris
Cornea&scleraaretoughouterlayertoprotectshape&pressure
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SpectrumofOcularAbnormalities
• Abnormalitiesofglobeshape,density&size• Globeinjuries&complications• Treatmentrelatedoculardiseasemimics• Ocularinfections• Ocularinflammatorydisorders• Ocularneoplasms
DisordersofShape&Size:PrimaryOpenAngleGlaucoma
• Oneofleadingpreventablecausesofblindnessintheworld
• MostcommoncauseofblindnessinAfrican-Americans
• Damagesopticnerveovertime;progressioncanbehaltedbutnotreverse
Disordersofshape&size:CongenitalMegalocornea
• Rarehereditarydisorder:– X-linkedrecessive– Notduetoincreasedintraocularpressure
• Clinicallyusuallynormalvision,somedevelopcataractorglaucoma
• Imaging:– Anteriorsegmentenlargement
– Remainderofglobenormal
Buphthalmos(Cow’sEye)
• AssociationwithNF1• Buphthalmosrightglobeduetocongenitalglaucoma– Enlargedglobe
• Pthisisbulbilefteye(chronicshrunkenca++globe)
GlobeRupture• Lossofvolume• Contourdeformity– “Flattire”sign– “Umbrella”sign
• ✓forforeignbodies• +/-intraocularhemorrhage• Asymmetricanteriorchamberdepth
• MostreliableCTfindingsareirregularglobecontour&vitreoushemorrhage
40yFtrippedwhilecarryingavase:Limitedophthalmicexamduetohyphema
Intraocularhemorrhage&glassFBInferiorrectuslacerated,detachedatsurgery
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Facialinjury
Lensdislocation,globecontourabnormality&decreasedvolume
GloberuptureEyeinjury1weekearlier
Nowseverepain,lightperceptiononlyOS
Metallicforeignbody“Disappearinglens”sign:Post-traumaticcataract
37yMwithMarfans:MRI/MRAtor/ovasculardissection
• Leftocularlensposteriordislocation
• Dysmorphicelongatedglobesbilaterally– Bilateralstaphylomas(orcolobomas)
CasecourtesyDPettersson,MD
LensInjuries
• Non-traumaticcausesoflensdislocation:– Marfan’s– Ehler’sDanlos– Homocystinuria
• Dislocationoftenbilateral
ChoroidalDetatchment
• Choroidaldetachmentshaveabiconvexshape• Sphericaloncoronal
• Sparetheposteriorglobe
ChoroidalHemorrhage&RetinalDetachment
IntraocularhemorrhagemayobscuresonographicvisualizationCTcanassessforsecondaryfindings;FB,additionalinjuries
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DISORDERSOFSHAPE:Staphyloma
• Causebyadefectincornea,uveaorsclerallayerwithoutpouching
• Usuallycongenitaloracquired
• Degenerative,post-inflammatory,infectiousortraumatic
• Uncommonlymalignant
Staphylomas
• Axialmyopiaresultsinelongatedglobes– Elongationwithposterioroutpouching
• Peripapillarystaphyloma:Rarecongenitaldefectinfundus– Posteriorglobe&vitreousoutpouching– Extendstoopticnervehead– Ass’dchorioretinalcoloboma
• Raremalignantstaphylomaduetotractionfrommass
Staphylomaduetomass MalignantStaphyloma:ChoroidalMelanoma
Acquiredstaphylomaduetotractionfromassociatedneoplasm
Blindrighteye;visionlossleft Blindleft;visionlossright
ChronicRvisionlossfromretinalangioma;newLretinadetachment&siliconeoiltx(&scleralbuckle)
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VonHippelLindau
• Retinalangiomas(hemangiomas),benign– Causeofvisionloss
• Hemangioblastomasneuraxis• Endolymphaticsactumors– CauseofSNHL
• Renal,pancreatic,testicularcysts• Riskforrenalcellcarcinomas#1causeofdeath
SenileScleralPlaques
• Calcifieddepositsofscleralstroma
• Seenatinsertionofthemedial&lateralrectusmuscleinsertions
• Commoninelderly
CasecourtesyofDrDaliaIbrahim,Radiopaedia.org,rID:29844
CalcifiedTrochlea
• Commonincidentalfinding
• Ca++oftrochleamuscleinsertion
• Morecommoninautoimmunedisease&elevatedALP
RetinalDetachmentTreatment:ScleralBandorBuckle
• Commonimagingfinding• Curvilinearhyper-attenuatingfocialonglateralaspectofglobe(s)– SphericaloncoronalMPRs
• Meanttoreducetractiononretina&allowhealingofretinaldetachments
AhmedGlaucomaDevice• Glaucomaimplant– Manyothervarieties
• Intraocularpressureloweredwhenaqueoushumorfrominsidetheeyethroughthetubeintotheplaterestingonsclera&surroundingcapsule
• Perioculartissuesabsorbaqueoushumorfromthereservoir
RetinalDetachmentTreatment
• Othertreatmentmodalitiesincludegas(pneumaticretinopexy)orsiliconeoiltamponade– Airorsilicone(denseonCT)inposteriorsegment
• SiliconeappearanceonMRI:– Iso-tohyperintenseonT1 – HypointenseonT2
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Ocularinfection:Endophthalmitis
Mass-liketissueposteriorleftglobe(noGadod/tESRD)DWI+c/winfection&abscessbyMRI(fungal)
60yMtypeIDM(glucose514)&Stage5CKDwithrightpreseptalswelling
Diffuseperiscleralthickening&edemaFaintsofttissueabnormalityalonginnerglobe
FloridEndophthalmitis
CasecourtesyDavidPettersson,MD
Unabletogivecontrastd/tESRDDWIthushighlyvaluable
Endophthalmitis• Infectionofinnertissueofeye• Mayprogresstoinvolvethevitreousoranteriorchamber
• Serious,oftenpoorvisualoutcomedespitetx• Imaginghelpswhenclinicalvisualizationislimited(e.g.lensopacity)
• https://www-ncbi-nlm-nih-gov.liboff.ohsu.edu/pmc/articles/PMC4978319/?report=reader
1RadhakrishnanRetal.MRimagingfindingsofendophthalmitis.NeuroradiolJ.2016Apr;29(2):122-9.2RumboldtZetal.DWI,ADC,&FLAIRimaginginendophthalmitis.AJNR2005Aug;26(7):1869-72.
MRI
• FLAIR&DWImosthelpfultoidentifyinvolvement– ExudatesareFLAIRhyperintense– Diffusionrestriction
• UsefulinpatientsunabletoreceiveGBCA
Episcleritis(PosteriorScleritis)
Imaging:MarkedenhancementofscleraEtiologytypicallyinfectiousorinflammatory(autoimmune)
18yFlefteyepainClinicalexam:Opticneuritis?
Dx:IdiopathicScleritis
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Scleritis:Imaging
• Rare,underdiagnosedvision-threateningcondition• Maybeisolatedorassociatedwithotherorbitalabnormalities
• Etiology:Inflammatorynoninfectious>infectious(rare,usuallyimmunesuppressed)
• Idiopathicorduetounderlyingsystemicdisease– Mostoftenautoimmuneetiology(espRA,GPA)
• TreatedwithNSAIDs,steroids,immunesuppression
DiogoMCetal.CTandMRImagingintheDiagnosisofScleritisAJNRAmJNeuroradiol.2016Dec;37(12):2334-2339
ImagingFindings• Imagingfindings:Enhancement,scleralthickening,&focalperiscleralcellulitis
• MRimaging>CTforposteriorscleritis(episcleralcellulitis)
• Anteriorscleritisvisibleclinically• Posteriorscleritisaccountsfor2-12%ofcases– Hardertodiagnose
• Scleritisisclinicallysignificant&mightbevision-saving
Pseudopapilledema
• Pseudopapilledema– Causeisopticdiscelevation,nottruediscedema
– Usuallyduetocongenitalabnormalities
• Drusencanbeautosomaldominant
OpticDiscDrusenPseudopapilledema:18yM
Progressivecentraldensevisionlossinbotheyesoveronemonth,LthenR
PresumedLeber’shereditaryopticneuropathy
DDxincludestoxic&metabolicconditions
17yFwithheadaches:Papilledemaonexam
Ventriclesslit-like?Cisternseffaced?
Idiopathicintracranialhypertension
HighopeningpressureatLPBilateraltransversesinushigh-gradestenoses
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AnteriorIschemicOpticNeuropathy
Mimicspapillitisclinically;usuallynoimagingfindingsMayseesubtleenhancement(orDWI+)atopticdischead
“BrightSpot”Sign
• 15NAION&15GCApatients• 15normalcontrols– AllGCAhadBrightSpot– 7/15NAIONhadBrightSpot
• NoBrightSpotinanycontrol– Mayallowsteroidsinmostappropriatesetting
RemondPetal.TheCentralBrightSpotSign:APotentialNewMRImagingSignfortheEarlyDiagnosisofAnteriorIschemicOpticNeuropathyduetoGiantCellArteritis.AJNR.2017Jul;38(7):1411-1415.
OcularNeoplasms:Children• Retinoblastoma:Mostcommonocularmalignancyinchildren
• Causeof“whitereflex”withDDx:– Coat’sdisease– Retrolentalfibroplasia– Retinopathyofprematurity
• Imaging:– Ca++massonCTin95%– EnhancingmassMRI
Retinoblastoma• CT:Calcifiedmass• OrbitalUSmoresensitive– CTishelpfulifmasscannotbevisualized
• Crosssectionalimagingoftentoassessforinvasivedisease– Opticnerveinvasion(MRI)– Secondarymasses
• Lookfortri-,quadrilateraldz
BilateralRetinoblastoma
• Bilateralin1/3• Visionsparingtreatment:– Chemoradiation>insteadofenucleation
Retinoblastoma
SofttissuesignalonT1,T2,enhancingonT1C+
MayrestrictonDWI
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Retinoblastomawithdetachment
AnyocularmassmaycauseretinaldetachmentRetinoblastomamayalsocausemildasymmetricsmallerglobe
Imaging:Attachedatopticdiscwballeduptissuecentrally&anteriorly
ClinicalExam:OpticPapillitis
75yFwithunilateraldiscedemaOSVisualacuity20/25
Primaryocularlymphoma
CasecourtesyWilliamHills,MD
DDxincludesinfection,neoplasm,´ischemia
44yFmigraineurwithrightupperquadrantanopsiaOS+RAPD
Intrinsic!T1signal
IntraocularMelanomaT2hypointense
Enhancing
Melanomamostcommonintraocularmalignancyinadults
OcularMelanoma
• Mostcommon(primary)intraocularmalignancyinadults
• 5%ofallmelanomas
Opticglioma
• Twotypes:SporadicvsNF1associated• Sporadictypesaretreatedaggressively• NF1associatedgliomasusuallyhaveabenignclinicalcourseandaretypicallynottreated– Spontaneousregressioncommon– Nottreatedunlessbecomesymptomaticornewenlargementand/orenhancementonimaging
– Radiationmay"malignantdegeneration
OpticGlioma
ExpansionofnerveproperEnhancingcystictosolidmasses
19montholdFwithprogressiveLproptosis;nofindingsofNF1
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OcularMetastasis
• Mostcommonocularmalignancyinadults
• Breast,lungmostcommonprimaries
• MRI:T2hypointense&enhancing
Lungcancerwithintraocularmetastasis
Secondaryglobeinvolvement:SCCAeyelid"globe
Associatedchoroidaleffusion(")
OCULARIMAGINGSUMMARY• Recognizenormalvariants• Knowappearanceofcommonimplants• CTbestscreenfortrauma&earlyinfection• MRIbestforsofttissuedetail• Endophthalmitis,scleritis• Fungalinfectionsorinvasivediseaseconcerns• Inflammatorydisorderscharacterization• Tumorassessment&extension• Secondary(extraocular)areasofinvolvement