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

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

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

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)

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

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

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

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

Retinoblastomawithdetachment

AnyocularmassmaycauseretinaldetachmentRetinoblastomamayalsocausemildasymmetricsmallerglobe

Imaging:Attachedatopticdiscwballeduptissuecentrally&anteriorly

ClinicalExam:OpticPapillitis

75yFwithunilateraldiscedemaOSVisualacuity20/25

Primaryocularlymphoma

CasecourtesyWilliamHills,MD

DDxincludesinfection,neoplasm,&acuteischemia

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

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