Journal of Medical Imaging and Radiation Oncology  (2019) –

MEDICAL IMAGING—REVIEW ARTICLE

Radiation dose and risk to the lens of the eye during CT

examinations of the brain

Journal of Medical Imaging and Radiation Oncology

Rebekah Poon1 and Mohamed K Badawy1,2
1 Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health
Sciences, Monash University, Clayton, Victoria, Australia
2 Monash Imaging, Monash Health, Clayton, Victoria, Australia

R Poon BRadMedImag; MK Badawy PhD, Summary

MAppSci, BSc.
Correspondence
Dr Mohamed K Badawy, Monash Imaging,
Monash Health, 246 Clayton Road, Clayton,
Vic. 3168, Australia.
Email: mohamed.badawy@monashhealth.org
Conflict of interest: The authors declare no
conflict of interest or financial funding.
Submitted 14 April 2019; accepted 19 August
2019.
doi:10.1111/1754-9485.12950
Cataracts are the leading cause of blindness and visual disability worldwide.
Of the known contributing factors to this condition, ionising radiation is con-
sidered the primary concern in a radiological context given the particular
radiosensitivity of the lens of the eye. In light of the substantially increased
application of computed tomography in brain imaging, an investigation of the
relevent literature is warranted to assess thresholds, lens radiation doses and
dose reduction techniques in respect to the cataractogenic risk of such exami-
nations. The value and very existence of a lens dose threshold is debatable
given different considerations of radiation dose, latency, opacity classifications
and historical sample populations, though ICRP guidelines suggest a threshold
of 0.5 Gy. Documented CT-specific radiation doses to the eye following scans
of the brain are highly variable between studies (2–130 mGy), primarily owing
to discrepancies in scanning technique. These findings, when coupled with the
relative ambiguity of known threshold values, present difficulties in assessing
the overall risk of cataracts following serial CT examinations to the head. In
the absence of definitive risk evaluations, a cautionary approach is advised.
The implementation of gantry tilt along the supraorbital margin is recom-
mended as standard practice on account of its highly effective radiation dose
reduction outcomes. Organ-based tube modulation and reductions in tube
current may also be considered beneficial. Bismuth eye shielding is only
advised where gantry tilting is unachievable, and in such cases, ensure careful
adherence to appropriate shield placement and infection control measures.

Key words: computed tomography; lens dose; radiation cataracts; radiation

dose optimisation.

the exponentially increasing demand for CT scans, which

Introduction
Rapid technological advances in computed tomography
(CT) within recent years have seen its contribution to
diagnostic imaging services increase significantly, with
over 3.2 million examinations reported in Australia in
2017.1 Of these, almost 500,000 cases involved CT scans
of the brain, 5.7% of which were performed on paediatrics
and young people ages 0–24 years old. Despite continu-
ous endeavours in technological advances and awareness
in regards to radiation safety, it has been purported that
the average medically induced radiation dose per capita is
increasing, particularly in well-developed countries. For
the most part, this upward trend can likely be attributed to
contributes to approximately one half of the overall effec-
tive radiation dose from medical procedures per capita in
the United States.2
While diagnostically valuable and relatively quick to per-
form, CT scans of the head do not come without risks. In
conjunction with the consequences associated with direct
irradiation of the brain, the formation of visually impairing
opacities and radiation cataracts in the lens of the eye
may be of concern.3 When paired with a lack of standard-
ised scanning techniques and the growing tendency for
brain scans to be over-referred,4,5 the potential for radia-
tion cataracts to become a more widespread phenomenon
becomes tangible. This paper aims to assess the evidence

© 2019 The Royal Australian and New Zealand College of Radiologists 1

R Poon and MK Badawy
regarding radiation dose thresholds to the lens of the eye,
the estimated radiation dose to the lens of the eye follow-
ing CT scans of the brain, and the most effective strategies
in reducing these radiation doses. By assessing the most
relevant and up to date literature, the authors seek to
develop an understanding as to the current risk status of
radiation-induced cataracts, and how any risks may be
minimised in future practice.
Radiation cataracts
The lens of the eye is considered one of the most
radiosensitive tissues in the body, with the primary con-
cern being the development of cataracts and lens opaci-
ties following radiation exposure.6 The term ‘cataract’
refers to the clouding of the lens of the eye, and it is the
leading cause of blindness and visual disability world-
wide.7 It is proposed that the condition arises from errors
in cell division following damage to the epithelial layer of
the lens. Cataracts are categorised as either cortical,
nuclear or posterior subcapsular (PSC) opacities depend-
ing on their anatomical position.8 Contributing risk fac-
tors are age, radiation exposure, genetics, the use of
systemic steroids and physiological conditions such as
diabetes.6,7 Radiation-induced cataracts are most com-
monly associated with PSC opacities. However, it is
important to bear in mind that once a cataract has
formed, it is difficult to definitively identify the opacity as
radiation-induced. It should also be noted that associa-
tions have been made between radiation exposure and
cortical lens changes, albeit to a markedly lesser
extent.9
As with several other radiation-induced effects, the
latency of cataractogenic effects has an inverse relation-
ship with dose, as well as an affiliated age modulating
disposition.8 Once the progression of cataracts reaches a
stage of ‘visual impairment’, the only means of treatment
is via surgical removal of the damaged lens and replace-
ment with an artificial substitute. While this surgery is
considered non-invasive and has a relatively high suc-
cess rate, the economic and societal burden of this pro-
cedure is predicted to worsen accordingly in the context
of booming ageing populations.7,8 Furthermore, the
operation carries risks of infection, suprachoroidal haem-
orrhaging, retinal detachment and unsuccessful overall
visual restoration.10 As a consequence of the anatomical
location of radiation-induced PSC opacities, it has been
suggested that the potential exists for significant visual
impairment to occur despite minor cellular changes,6 and
thus, an investigation into the origins of radiation catar-
acts is warranted.
Radiation threshold for cataractogenic
effects
Extensive bodies of work have been collated over the
years analysing the effects of radiation on the eye with
2 © 2019 The Royal Australian and New Zealand College of Radiologists
varying results. These reports have predominantly
looked at cases of atomic bomb exposure, radiotherapy
patients and occupationally exposed medical profession-
als, as well as Chernobyl survivors, building contamina-
tions, diagnostic imaging examinations and even
astronauts.7,11 Overall, the consensus suggests that the
formation of radiation-induced cataracts is deterministic
(a tissue effect), with a threshold response which esca-
lates in severity with increased dose and reduced
latency.6,8,11 In response to the data presented in the
studies above, the International Commission on Radio-
logical Protection (ICRP) introduced threshold values
under which it was assumed that cataracts are not a
common risk factor. This threshold was initially intro-
duced as a lifetime equivalent dose of 15 Sievert (Sv) in
1977, however, was lowered to 5 Sv for acute exposure
(and 8 Sv for a protracted or fractionated exposure) in
1984, and eventually to an absorbed dose of 0.5 Gray
(Gy) in 2012.12 This reduction was made following the
development of newer research studies which were sug-
gestive of lower threshold limits. These studies noted
that evidence supporting the previous threshold had a
scarcity of data for low-dose investigations, significant
variations in the type of radiation exposure, short follow-
up periods which were inconsiderate of latent effects,
and potentially inept methods of detecting early lens
developments.6,8
It is worth noting, however, that the value of this
threshold is still a controversial and dynamic affair.
Suggestions have been made by multiple parties that the
threshold is non-existent and that cataractogenic effects
may be purely stochastic. Research conducted by Neri-
ishi et al.13 is a fundamental component in such an argu-
ment, where the incidence of cataract surgeries was
investigated among atomic bomb survivors approxi-
mately 50 years after the event. The best estimate
threshold of 0.1 Gy was reported, with a zero value
threshold included within 95% confidence intervals (CI).
This confirmed and extended conclusions made by Naka-
shima et al.14 the year prior, who also speculated a lack
of threshold within 95% CI. More recently, it has even
been proposed that these thresholds may have been
conservative given that some participants were relatively
young at the time of re-evaluation and therefore may
not yet have developed operable cataracts. Some sub-
jects were also reported to have forgone surgery in light
of age or medical complications, which may have further
distorted the actual incidence of cataract development.8
In a later study involving low-dose exposures to radio-
logical technologists in the United States, Chodick
et al.15 also reported a correlation between dose and cat-
aract formation with no discernible threshold, which fur-
ther supports the notion that cataractogenic effects may
be more stochastic than first assumed.
The 2007 study performed by Neriishi et al.13 also
addressed one of the most significant issues associated
with radiation cataract studies; the point at which lens

opacification results in clinically relevant visual disability.
While affiliations had been made between radiation
exposure and cataract formation in the past, the point at
which these opacifications become visually impairing to
the point of requiring actionable outcomes had yet to be
quantifiably studied. Given the aforementioned depen-
dency of dose versus latency, early stages of opacifica-
tion may not initially result in visual impairment at low
doses and therefore could be considered inconsequential.
The point at which surgery is warranted, however, is cir-
cumstantial and subjective depending on the extent to
which cataracts impact one’s quality of life, and this in
itself may potentially skew the analyses.
Conversely, arguments have also been made that the
ICRP’s lowering of the dose threshold was not suffi-
ciently evidenced in the context of chronic expo-
sures.7,16 These views have been put forward based on
multiple considerations, such as the variability of self-
reporting studies and differences in the opacity classifi-
cation system if one was even used. Age at exposure
also needs to be recognised as an essential component
given that some studies were built on the follow-up of
individuals irradiated as children, a population which is
known to be more sensitive to cataractogenic effects
than adults.17 Furthermore, despite the dose/latency
relationship revealing a higher incidence of cataracts
where follow-up studies extended their follow-up peri-
ods, consideration must also be given to the naturally
high occurring frequency of cataracts in the older gener-
ations. It is argued by Thome et al.7 that the conse-
quences of a possibly unsubstantiated reduction in
threshold dose may result in economic afflictions. These
may be in the form of potential requirements for addi-
tional shielding, dosimetry devices and other radiation
safety equipment, as well as radiation safety training
for occupationally exposed workers.
Very little data specific to CT and diagnostic imaging is
known to contribute to such threshold discussions
and that which does exist relies heavily on self-reporting
and radiation doses which had not been directly deter-
mined. As reported in the Beaver Dam Eye Study Cohort
in 1993, an odds ratio (OR) of 1.45 for PSC opacities and
1.28 for nuclear opacities was calculated in relation to
head CT scans; however, past medical imaging history
was self-reported, and thus, specific dose values were
unable to be resolved.18 Subsequent re-evaluation of this
same sample population with at least a five-year latency
demonstrated similar figures; however, when CT scans
were compared to all other forms of head X-ray imaging,
the results proved statistically insignificant.19 In a study
conducted by Hourihan et al.20 in Australia, no clear cor-
relation could be made between a history of single head
CT scans and the incidence of cataracts. However, this
study had a relatively broad spectrum of latency between
individuals at the time of the survey (1–18 years), and
again this data was reliant on self-reporting, and dose
values were not made known.
© 2019 The Royal Australian and New Zealand College of Radiologists
CT Brains and the risk of cataracts
Nonetheless, across these three studies, a repeated
verdict was reached that the cataractogenic risk of CT
scans was likely increased with multiple examinations.
This concept was supported by a retrospective analysis
conducted by Yuan et al.21 via the use of a database
published by the National Health Research Institutes in
Miaoli Taiwan. It is worth noting that this study was also
inclusive of scans to the neck as well as the head.
Despite having a more accurate record of the number of
scans performed, and therefore eliminating the unrelia-
bility associated with self-reporting, the radiation doses
administered to the patients remained unknown. The use
of a national database did, however, allow for compar-
ison of the sample population with age and sex-matched
equivalents who had never been irradiated, and from
these comparisons, it was suggested that the threshold
for cataractogenic effects might be as low as 0.25 Gy.
For a more realistic indication as to the risk of cataracts
following CT scans of the head, a thorough examination
of the actual radiation dose to the lens of the eye during
these scans needs to be conducted.
Radiation Dose to the Lens of the Eye
During CT Scans of the Head
Current literature regarding the specific dose to the lens
of the eyes following CT scans of the brain is variable
and somewhat complicated to navigate. This variability is
primarily due to inconsistencies in scanning technique,
CT scanners, means of dose measurement and study
methodology. As per Table 1, recorded dose values range
from 2 to 130 mGy. Of the trials which utilised a degree
of gantry tilt as a component of their reference scanning
technique, doses were significantly lower overall, mainly
where alignment could be achieved along the supraor-
bital margin such that the lenses of the eyes were no
longer within the primary irradiation beam. However, of
these studies, the majority of those who were able to
achieve adequate alignment were phantom trials.3,22
While the use of anthropomorphic phantoms in such
studies allows precise documentation of absorbed dose,
variations in patient size and position are not able to be
taken into account. Furthermore, errors in patient posi-
tioning, inappropriate gantry tilt and movement before
or during the scan are all reflective of clinical realities
and may influence the degree to which the lens of the
eye is included in the primary scanning range.23 In vivo
dosimetry and clinical trials are therefore the only way of
determining the actual dose to the patient. However,
dose comparisons between these studies are multivari-
ate and require considerations of individual scanning
parameters, different patient positioning and resulting
image quality.
Studies which indicated no gantry tilt or unsuccessfully
attempted gantry tilt23–25 were generally nondescript in
defining the exact extent to which the lens of the eye
was included in the primary irradiation beam. Even in
3
R Poon and MK Badawy
Table 1. Reported radiation dose to the lens of the eye from CT scans to the head
References Scanner
McLaughlin Toshiba GX Xpress
and Mooney26
Heaney and Norvill22 Toshiba Medical Systems
Asteion 4 slice
Abdeen et al.24 16 slice (Lightspeed 16; General
Electric) and 64 slice (VCT;
General Electric)
Wang et al.25 Dual-source Definition Flash;
Siemens Health care
Lai et al.3 Discovery CT750 HD with
Adaptive Statistical Iterative
Reconstruction (ASiR)
Nikupaavo et al.29 128 slice Somatom Definition
AS+; Siemens Health care
Ploussi et al.23 16 slice (Brightspeed; GE Health
care)
†Hard palate: a line running parallel to the hard palate.
‡Reid’s baseline: a line joining the superior border of the external auditory meatus of the infra-orbital margin.
§Supraorbital line: a line running from the upper border of the orbits to the midpoint of the external auditory meatus, parallel to the base of the
skull.
studies where the value of the tilt was specified,3 the
region of the lens included in the primary beam was
not explicitly determined. Given that the natural posi-
tion of the head/phantom can vary substantially with
or without the addition of a head holder, particularly in
clinical settings in regards to patient size, presentation
and anatomy, the inclusion of the lens changes accord-
ingly, and thus, the comparability of these findings in
an attempt to converge on an ‘average’ lens dose is
complicated.
Another consideration to take into account is the
method of dose measurement. The number and place-
ment of dosimeters differ from each trial, which could
affect the consistency and reproducibility of the results
with only one or two devices. As well as this, the inclu-
sion of the dosimeter in the scout images, as opposed to
being attached after the scout images have been taken,
could have implications on the end dose;3,26 however,
admittedly its contribution would likely be relatively low.
Cataractogenic Risk of Brain CT
Despite the majority of the aforementioned CT brain
studies involving lens radiation doses much lower than
the speculated 0.5 Gy threshold dose, Suzuki et al.27
and Wang et al.25 raise the concern that patients may
often be subjected to multiple examinations, as well as
repeat imaging and/or multi-phase contrast studies. As a
result, these cumulative radiation doses may still have
the potential to provoke a cataractogenic response. Fur-
thermore, this must be considered in the context that
4 © 2019 The Royal Australian and New Zealand College of Radiologists
Method Gantry tilt Lens dose (mGy)
Clinical trial (1 thermoluminescent Supraorbital line 6.0
dosimeter [TLD] on the right eye only)
Phantom trial (2 TLDs on the right eye Hard palate† 120.0
only) Reid’s baseline‡ 130.0
Supraorbital line§ 15.0
Clinical trial (metal–oxide– Angulation to the Sequential: 61.5
semiconductor field-effect transistor skull base was Helical: 43.5
[MOSFET] system taped to the attempted
patients’ eyelid)
Phantom trial (1 optically stimulated Not specified 32.2
luminescence detector per eye)
Phantom trial (5 TLDs per eye) 0-degree tilt 30.7
30-degree cranial tilt 2.4
Phantom trial (1 MOSFET per eye) Angled from the skull base to 18.3
the radix nasi
Clinical trial (2 TLDs per eye) Angulation to the supraorbital 0.8-1 yo: 10.5
line was attempted (but 2.0-4.9 yo: 29.9
unsuccessful in some cases) 5.5-15.5 yo: 34.2
present arguments regarding the value and existence of
a threshold value are still ongoing.
Worth noting is that the radiation risk of opacity for-
mations is difficult to differentiate from the risk of visual
impairment. The majority of the suggested dose values
for cataracts formation are in regards to the formation of
opacities, which in and of themselves may not present as
a concerning factor. As mentioned above, studies have
been performed to address such matters based on the
incidence of cataract surgeries.13,14 The concept of visual
impairment or deterioration, however, is highly subjec-
tive and likely dependent on an individual’s sight toler-
ance. Consequently, self-reporting and access to surgical
intervention may affect dose-effect conclusions. The risk
of global visual disability may also be confounded by
existing co-contributing factors such as diabetes or sys-
temic steroid use, making the influence of radiation
effects alone challenging to appreciate.
In light of these discussions, it is therefore challenging
to pinpoint the exact cataractogenic risk posed by CT
examinations of the brain. In the absence of such a
definitive argument, it is therefore advisable that all
practical measures be taken to reduce the radiation dose
to the lens of the eye to as low as reasonably achievable.
Radiation reduction strategies
Gantry tilt
The inclusion of the orbits is deemed mostly unnecessary
in the majority of CT brain examinations, and so it stands

to reason that emphasis should be made on excluding
the lens of the eyes from the primary irradiation beam
where possible.28 In cases where this is adequately
achieved, any dose to the lens of the eye should there-
fore solely be the result of scattered radiation.26 Cur-
rently, the overarching consensus suggests that tilting
the gantry along the supraorbital line, based on topo-
gram planning, is the most effective method of dose
reduction, with reductions reported as high as
92%.3,22,28,29 For this sort of outcome to be achievable,
additional forward tilting of the head with the aid of a
dedicated head holder or sponge may also be necessary
for scanners where the degree of gantry tilt is limited.24
No literature was found at the time of writing regard-
ing the dose reduction potential while solely using for-
ward head tilt, which involves aligning the supraorbital
line perpendicularly to the scanning table with zero gan-
try tilt. While this practice has been observed clinically
by the authors and should theoretically achieve the same
geometric advantages as gantry tilting, we hypothesize
that forward head tilting alone may be less effective in
lens radiation dose reduction than appropriately utilised
gantry tilting. This is because the positioning of the
patient may have more of an operator bias and is based
on an external visual assessment of the head as opposed
to being planned on a topogram image. With the lens of
the eye being such a small structure, even a few degrees
of deviation could potentially affect the overall radiation
lens dose. Moreover, patients with large necks, neck stiff-
ness or trauma history may struggle to achieve such
positioning.
Some studies have proposed that the application of
gantry tilt may cause difficulties in being able to appreci-
ate pathology in the base of the skull as a result of beam
hardening and partial volume averaging.3,22 Nikupaavo
et al.29 even found an absolute difference of 3 Hounsfield
Units (HU) in the posterior fossa where this technique
was used, which, given that contrast between grey and
white matter can vary as little as 4-5 HU, could be con-
sidered substantial. However, helical acquisitions coupled
with a thin slice CT technique have been shown to reduce
such effects.22,24,30 Interestingly, earlier research con-
ducted by Yeoman et al.28 noted that the presence of
posterior fossa artefacts in their study was not consid-
ered statistically significant and that it was also possible
for these artefacts to occur where scans were inclusive
of the lenses.
It is best to note that the gantry tilting technique may
not be as effective in isolation where full exclusion of the
lens of the eyes is clinically unachievable, such as with
patients wearing an immobilisation collar. Additionally,
many scanners are incapable of gantry tilt, and certain
protocols may necessitate a non-angled gantry. In such
cases, it is recommended that alternative dose reduction
techniques, as discussed below, are considered where
practicable.
© 2019 The Royal Australian and New Zealand College of Radiologists
CT Brains and the risk of cataracts
Bismuth shielding
Bismuth shielding is effective in reducing radiation dose
to superficial tissues, including the lens of the eye. Dose
reductions of approximately 30% are possible assuming
a 0-degree gantry tilt technique.3,22,25,26,31 However, the
commercial viability of single-use shields is a compelling
concern. While the concept of multi-use shields may pre-
sent itself as a more economically feasible alternative,
the maintenance of suitable infection control measures
must then become a consideration.25,26 Erroneous place-
ment of the shields on the face before scout imaging
may also result in a compensatory increase in tube cur-
rent, and therefore increase in lens dose, where auto-
matic exposure control (AEC) is utilised.29
The use of bismuth shields not only reduces the dose
to anterior structures such as the eye, but it also attenu-
ates what would be potentially diagnostic photons from
reaching the detector,32 giving rise to streaking, scatter
artefacts and altered CT numbers. In addition to dimin-
ishing the overall image quality, these undesirable
changes in CT number values also have the potential to
influence the outcomes of certain quantitative diagnostic
examinations, such as brain perfusion analyses.25 As a
means to overcome this, it has been suggested that
increasing the separation between the surface of the eye
and the shield may significantly decrease the associated
image artefacts.25 Increasing the distance of the shield
from the skin surface, however, also slightly reduces its
dose reduction efficacy. In any case, the presence of
artefacts which originate from appropriately placed
shields are generally thought to be contained to the orbi-
tal region and therefore are not believed to have any sig-
nificant impact on the regions of the brain typically
required for diagnostic imaging.29,31 Dose reduction ver-
sus image quality considerations should be made in this
situation.
The benefit of bismuth shielding in examinations
where adequate gantry tilt is obtainable has at times
been considered unjustified given that some studies
demonstrate no discernible differences with or without
the addition of shields.22 However, McLaughlin and
Mooney26 did find an 18% decrease in dose with bis-
muth shielding relative to a gantry tilted reference
scan. Nikupaavo et al.29 also found the addition of bis-
muth shielding partially consequential in its combined
use with gantry tilt, with overall results demonstrating
a further 8% decrease compared to gantry tilt alone.
Nonetheless, given that the dose associated with
appropriate gantry tilt could be considered relatively
modest in the first place, some as low as 2 mGy, the
rationale for its use in these circumstances may be dis-
putable. Furthermore, the use of shielding may not be
advisable for emergency patients, paediatrics or dis-
abled individuals who are unable to tolerate the use of
the shield.
5
R Poon and MK Badawy

of modulation was arranged such that the tube current

Organ-based tube current modulation (TCM)
Organ-based TCM involves modulation of the tube cur-
rent based on longitudinal or angular position around the
patient. In a study conducted by Wang et al.25, this form
was decreased by 75% for the anterior 120 degrees of
the tube rotation (where it is assumed the eyes would be
in a correctly positioned patient). For the remaining 240
degrees, the current was increased by 25% to give the

Table 2. The effectiveness of varying strategies for the reduction of radiation dose to the lens of the eye

References Base Scan Dose Reduction Strategy Lens Dose Image Quality
Reduction (%)

Yeoman et al.28 Non-shielded scan with no gantry Angulation to the supraorbital line 87% No significant differences in posterior
tilt fossa artefacts compared to a non-
tilted reference scan
McLaughlin and Non-shielded scan with angulation Bismuth shielding 18% Not assessed
Mooney26 from the superior orbital margin
to the base of the skull
Heaney and Dose reductions associated with Angulation to the supraorbital line 87% Not assessed
Norvill22 angulation to the supraorbital Bismuth shielding and angulation along: 43%
margin were calculated against -Hard palate† 48%
the doses recorded when angling -Reid’s baseline‡ 0%
to the hard palate or Reid’s -Supraorbital line§
baseline.
Dose reductions associated with
bismuth shielding were calculated
against the doses recorded along
its corresponding angulation
plane when unshielded.
Abdeen et al.24 Sequential scan with attempted Helical scan with attempted angulation 29% Image quality is comparable
angulation to the base of the skull to the base of the skull
Wang et al.25 Non-shielded scan with no organ- Bismuth shielding 26% Image noise increased for all reduction
based TCM or decreased tube (1 layer) 42% methods.
current utilised. No angulation of Bismuth shielding 30% CT numbers increased with the use of
the scanning plane was specified (2 layers) 47% the bismuth shield
Organ-based TCM 30%
Bismuth shielding and organ-based
TCM
Decreased tube current
Ryska et al.2 Non-shielded scan with no gantry Iterative reconstruction protocol with 33% Image noise slightly increased relative
tilt using a filtered back projection associated reduction in tube current to standard filtered back projection,
protocol (reference mAs value set (reference mAs value lowered to 200 but differences in diagnostic quality
to 300) mAs) not deemed significantly significant
Lai et al.3 Non-shielded scan with no gantry Bismuth shielding 24% Significant drift in mean CT number
tilt Bismuth shielding with face shield (air 22% observed with bismuth shielding
gap) 32% alone, the effects of which gradually
Bismuth shield with bolus 35% decreased as air gaps and bolus were
Bismuth shield with bolus and air gap 92% introduced
30-degree cranial tilt
Nikupaavo Non- shielded scan with no gantry Bismuth shield after scout image 17% Organ-based TCM demonstrated an
et al.29 tilt or organ-based TCM. Bismuth shield before scout image 19% increase in noise in the posterior and
Bismuth shield with gantry tilt 55% central regions of the brain relative to
Gantry tilt 47% the reference scan (absolute change
Gantry tilt with half the recommended 14% of 1.5 HU).
angle 28% An absolute difference of 3HU
Organ-based TCM 54% observed in the posterior fossa where
Organ-based TCM with gantry tilt gantry tilt was used.

†Hard palate: a line running parallel to the hard palate.

‡Reid’s baseline: a line joining the superior border of the external auditory meatus of the infra-orbital margin.
§Supraorbital line: a line running from the upper border of the orbits to the midpoint of the external auditory meatus, parallel to the base of the
skull.

6 © 2019 The Royal Australian and New Zealand College of Radiologists


same compensatory tube current–time product as with
the reference scan. This specific allocation of increased
current to the posterior and lateral positions was to allow
for adequate penetration to these regions.
The advantage of using angular TCM is that it avoids
compensational increases in tube current based on dense
materials such as shielding, and so the use of this tech-
nique in conjunction with bismuth shields has been sug-
gested as beneficial.25 However, Nikupaavo et al.29
recommend that the combination of organ-based TCM
and bismuth shielding should be used with caution
granted that the increased tube output at the posterior
aspect of the patient could cause significant backscatter
into the patient with the presence of the shield. This
approach also requires the optimal positioning of the
patient’s head with their eyes pointed directly upwards.
It may therefore not be appropriate for use in emergen-
cies or with paediatric or disabled individuals where posi-
tioning circumstances may not be ideal.
Global reduction of tube current
A phantom study performed by Wang et al.25 utilising a
global reduction of tube current produced similar reduc-
tions in lens dose to those found with tube current mod-
ulation or bismuth shielding (~30%). This approach
involved a 30% reduction in the tube current over the
full 360-degree rotation such that the same dose would
be given to the lens of the eye if a single layer of bismuth
shielding had been used. In the results that followed,
previously mentioned CT number errors and image arte-
facts associated with bismuth shielding were eliminated,
although the detected levels of noise were increased by
approximately 1 HU when compared to the reference
scan. An additional reported benefit of the reduced tube
current technique was a ~29% reduction in the overall
CTDIvol relative to the reference scan, which should be
expected given the linear proportionality between the
CTDIvol and tube current. Given these advantages, if the
observed slight increases in noise can be diagnostically
tolerated, this method could potentially be considered
more beneficial than the use of bismuth shielding, partic-
ularly in scanners not equipped with Organ-based TCM
or iterative reconstruction.
More recently, reductions in global tube current, with-
out significant compromises in image quality, have
become more feasible following the introduction of more
effecient iterative reconstruction methods. In a clinical
trial, Ryska et al.2 observed an overall 33% decrease in
average effective dose with such techniques, with an
ensuing 33% decrease in dose detected at the eyes.
Other studies have also demonstrated potential reduc-
tions in effective dose with the use of iterative recon-
struction;33–35 however, direct inferences regarding any
reductions in dose to the lenses of the eyes were not
specified in these cases.
© 2019 The Royal Australian and New Zealand College of Radiologists
CT Brains and the risk of cataracts
Helical versus sequential scanning
Investigation as to the implications of helical versus
sequential scanning techniques has also been attempted
in the past24 with statistically significant results implying
that helical scanning is associated with lower radiation
doses to the lens of the eye (about two thirds of that
seen in sequential scans). An increased kVp to the poste-
rior fossa during sequential scans and differences in
scanning geometry are thought to be the main contribu-
tors to these outcomes. In terms of the use of helical
multislice CT scanning in conjunction with a dose reduc-
tion technique such as gantry tilting, Geleijns et al.36
makes an interesting note commenting that this combi-
nation of practices may in effect be counterintuitive
depending on the extent of over-ranging in the z-direc-
tion. While this is a theoretically plausible argument, it
has yet to be specifically evidenced. Therefore, it is still
suggested that helical brain CT acquisitions remain the
more advantageous scanning technique with regards to
irradiation of the eyes when compared to their sequential
scanning equivalent.
While all of the above techniques have been reported
to significantly reduce the dose to the lens of the eye
(see Table 2), it is important to note that this may not
necessarily correlate to an absolute reduction in the for-
mation of radiation cataracts. No explicitly direct links
have been made at the time of writing between the use
of these strategies and a decreased risk of cataracto-
genic effects; the reduction in risk is instead inferred
owing to the discussion above as to whether cataracts
are considered as a deterministic or stochastic effect.
The dose reduction percentages as outlined in Table 2
should be observed with caution given that they may
vary depending on whether the reference scan had a
0-degree gantry tilt or was aligned to the supraorbital
margin.
Conclusion and Recommendations
In the absence of a wholly agreed upon lens dose thresh-
old evidenced by all relevant and up to date studies, it is,
therefore, prudent to act with caution and reinforce the
utilisation of dose reduction techniques. Important to
note, however, is that the use of the strategies outlined
above is only recommended on the condition that image
quality remains unaffected or at least remains diagnosti-
cally acceptable since being able to address the clinical
concern remains the primary focus.
Overall, the implementation of gantry tilt along the
supraorbital margin is recommended as standard prac-
tice owing to the current evidence which suggests it to
be the most effective dose reduction technique for the
lens of the eye. This strategy also has the additional ben-
efit of not requiring any further financial considerations
which may arise with methods such as single-use
7
R Poon and MK Badawy
bismuth shields. The supplementary global reduction of
tube current, the use of iterative reconstruction, and the
application of organ-based TCM could also be beneficial
in reducing the radiation dose to the lens of the eye. If
sufficient gantry tilting is not clinically feasible, the use
of bismuth eye shields is then advised. However, care
should be taken in regards to appropriate placement and
cleanliness of the shields to minimise artefacts and infec-
tion control implications. A possible avenue for future
research on cataractogenic risks would be for longitudi-
nal studies to be performed solely in regards to medical
radiation exposures, with the use of comprehensive
health care and imaging databases to account for radia-
tion doses, numbers of scans, comorbidity factors and
the incidence of reported opacities or cataract surgeries.
The compilation of such data would, however, be a con-
siderably extensive task and decades of follow-up infor-
mation would be required in order to make an informed
assessment.
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