Review Textbook

Chapter 66 Orbita (part II)

Pembimbing: dr. Farah Hendara Ningrum,
Sp.Rad (K)
Penyaji: Irni Dwi Aprianty Ibrahim
 ANATOMY MALIGNANT NEOPLASM
01 05

ORBITAL PATHOLOGY PEDIATRIC NEOPLASM

PART II
PART I
02 06

BENIGN NEOPLASMS ORBITAL TRAUMA

03 07

VASCULAR LESION RETRO ORBITAL

04 VISUAL PATHWAY 08
Malignant Neoplasms

Uveal Melanoma
• Uveal melanoma is the commonest
intraocular primary malignancy in adult
and commonly presents with progressive
visual loss.
• Extensive spread beyond the globe is
common, even in the presence of only a
small ocular lesion, resulting in the typical
‘collar button’ lesion.
• Tumour morphology can vary from
nodular to plaque-like lesions and diffuse
infiltration.
 Malignant Neoplasms
Metastatic Disease Lymphoproliferative
Malignancy
Metastases from Orbital lymphoma and
extraorbital cancers are leukaemia constitute a large
most frequently located share of orbital malignant
within the uveal layer, neoplasms. Malignant
but can involve any lymphoma may demonstrate
intraorbital or adexal hyperdensity on CT both
structure (Fig. 66-26). pre- and post-contrast
(Fig. 66-27).
Adenoid Cystic Carcinoma
This represents the most
common malignant epithelial
neoplasm of the lacrimal gland
and most commonly is the result
of malignant transformation of a
benign mass, there are
convincing aggressive features
(Fig. 66-28)
FIGURE 66-26 ■ Ocular and orbital metastases.
Post-contrast axial (A) and coronal (B) CT
examination demonstrating an enhancing left orbital
metastatic lesion involving the entire left globe.
Post-contrast axial (C) and coronal (D) CT
examination showing an extensive paranasal sinus
carcinoma with local invasion into the nasal aspect
of the left orbit and intracranially through the
cribriform plate and frontal sinuses. Post-contrast
axial CT examination on soft-tissue (E) and bone (F)
algorithms demonstrating a prostatic carcinoma
metastatic deposit of the left sphenoid trigone
causing expansion and sclerosis of the bone as well
as an associated soft-tissue component occupying
the temporal aspect of the left orbit resulting in left
proptosis.
FIGURE 66-27 ■ Orbital lymphoma. Post-contrast axial (A) and coronal (B) CT
examination demonstrating enhancing soft tissue encasing the subtotal
circumference of the right globe and extending into the retrobulbar and temporal
aspects of the right orbit, causing proptosis and hypoglobus.
FIGURE 66-28 ■ Adenoid
cystic carcinoma. Post-
contrast axial CT on a soft
tissue (A) and coronal CT on
a bone (B) algorithms
demonstrating a
heterogeneous, peripherally
enhancing left orbital mass
with central coarse
calcification indistinguishable
from the lacrimal gland. Note
the proptosis, deformation of
the posterotemporal aspect
of the left globe and left
lateral orbital wall erosion
and bony remodelling by the
mass.
Paediatric Neoplasms
Retinoblastoma

FIGURE 66-29 ■
Retinoblastoma. Axial (A)
and coronal (B) CT
examination in a child
demonstrating a lesion
involving the inferior
aspect of the globe,
extending into the vitreous
and containing areas of fine
punctate calcification.
Rhabdomyosarcoma

FIGURE 66-30
■ Rhabdomyosarcoma. Coronal
STIR (A) and postcontrast T1-
weighted (B) orbital MRI in a
child demonstrating a superonasal
enhancing mass and
inferotemporal displacement and
some distortion of the right globe.
 ORBITAL TRAUMA

Injury to the orbital region represents a significant proportion of emergency

01 Injury to Orbital
Region
department attendances and is common in patients with multisystem trauma: for
example, following motor vehicle accidents.
Certain eye injuries, such as superficial lacerations and a proportion
02 Eye Injury of globe ruptures, may be evident on clinical examination.
Plain radiography has limited sensitivity in identifying orbital
fractures and cannot reliably assess the intraorbital soft tissues.
03 Ultrasound (US) Ultrasound (US) may be of value when there is concern regarding
intraocular injury such as traumatic retinal detachment
The technique of choice for the evaluation of suspected
04 CT orbital injury is thin-section (0.625–1.25 mm slice thickness)
CT with multiplanar bone and soft-tissue reconstructions.
MR imaging is less commonly employed in acute
05 MR Imagining trauma and is inferior to CT in identifying
fractures.
 Orbital fracture
• Herniation of fat or muscle into a defect
-- ophtalmophlegia
• Para/anaesthesia of the maxillary
division of the trigeminal nerve when
involving the infraorbital canal/nerve
• Lamina papyracea is another common
site for fractures
• Review the orbital apex - small fracture
can be associated with optic nerve injury
and require urgent surgical intervention
• Evaluation of the orbital soft tissues may
reveal fat stranding, haematoma or gas
Foreign bodies
• Metallic and glass are of increased
attenuation and best delineated on CT.
• The appearance of wood on CT can be
of similar attenuation to air, thus
mimicking intraorbital gas.
• A wood or organic foreign body should
be suspected when there is a low
attenuation collection with a geometric
margin.
• Potential mimics of penetrating injury
with presence of gas include previous
gas injections and placement of low-
attenuation silicone sponges for the
treatment of retinal detachment.
Globe rupture
• Signs of globe rupture include loss of
globe volume and contour, the flat tyre
sign and intraocular gas.
• Retinal detachment shows as a
characteristic V-shape structure within
the globe, because the retina is relatively
fixed at the optic disc posteriorly and at
the ora serrata anteriorly.
• Choroidal detachment can occur as a
result of ocular pressure loss.
• Increased depth of the anterior chamber
is a more subtle sign of open globe
injury.
• Decreased depth of the anterior
chamber may occur due to corneal
laceration or anterior lens subluxation.
• Phthisis bulbi refers to a shrunken
calcified globe as long-term sequelae of
(penetrating) injury
FIGURE 66-32 ■ Ocular foreign bodies. Axial (A) and coronal (B) CT showing a metallic
radiodense intraocular penetrating foreign body and vitreal air. Axial CT on soft-tissue (C) and
bone (D) algorithms demonstrating a linear hypodensity, resembling air, traversing the nasal
aspect of the left globe in a patient with penetrating injury from a wooden splinter. A small
locule of air is also seen in the anterior chamber of the eye.
● FIGURE 66-34
● ■ Globe Rupture. CT shows collapse of the left globe with a characteristic “flat tyre” appearance.
There is no evidence of intraocular air or foreign body. Typical thickening of posterior sclera is seen
(arrow, image A) and the left globe has a hazy outline (arrowhead - image B)
 THE RETRO-ORBITAL
VISUAL PATHWAY
 INTRODUCTION
 Various diseases have potential to affect the
retro-orbital visual pathway, whereby the
clinical deficit is usually determined by the
anatomical location of the abnormality more
than its histological nature.
 Because the optic nerve is a fibre tract of the
brain rather than a true cranial nerve, it may
be affected by the same disease processes as
the brain and meninges. We provide a brief
overview of retro-orbital visual pathway
anatomy and pathology according to the
As a result of the partial decussation
and anatomical distribution of nerve
fibres, the primary visual cortex of each
cerebral hemisphere receives
information from the contralateral
visual field and visual information is
projected upside down; i.e. visual
signals from the caudal retina are
projected into the cranial aspect of the
visual cortex and vice versa (Fig. 66-
35)
 Pathologies of The Anterior Visual Pathway (Optic
Nerves, Chiasm and Optic Tracts)

1 2 3 4

Congenital Intrinsic Tumours Inflammatory/Demyelinat Extrinsic compressions

1. Low grade (pilocytic ing Lesions • Compressive symptoms
1. Hypoplasia/aplasia of
astrocytoma); 1. Retrobulbar optic can occur secondary to a
the optic nerve;
2. Cavernoma host of different
2. Septo-optic dysplasia neuritis;
intracranial pathologies
2. Granulomatous
such as pituitary
inflammation in TB or macroadenoma,
sarcoidosis craniopharyngioma,
Rathke’s cleft cyst, etc.
 B

A
FIGURE 66-36
SEPTO-OPTIC DYSPLASIA C
 FIGURE 66-37
■ Optic pathway
cavernoma. Post-contrast
axial CT (A) showing a
hyperattenuating mass in
the left suprasellar cistern,
thought initially to be an
aneurysm. Corresponding
axial T2*- (B), sagittal T1-
(C) and coronal T2-
weighted (D) MRI
demonstrating the classic
‘popcorn’ appearance of a
cavernoma intrinsic to the
left optic chiasm and tract.
 A

FIGURE 66-38
Optic neuritis in
multiple sclerosis

B
Pathologies of The Posterior Visual Pathway (Lateral Geniculate
Nucleus, Optic Radiation and Visual Cortex)

01 LGN
Although there are no diseases
which specifically target the
02
ISOLATED LGN PATHOLOGY
Isolated LGN pathology is rare, but
this is known to produce a specific
03
PCA INFARCTION
Posterior cerebral artery (PCA)
infarction is a common central cause
visual deficit of homonymous sector
LGN, this may be involved by for acute-onset visual impairment,
defects on the horizontal meridian.
intracranial pathology in its with the field defect being
proximity determined by location and extent of
ischaemia.

04
SPACE OCCUPYING MASSES
Space-occupying masses may
produce symptoms either due to
direct infiltration or secondary to
compression of neural structures.
05
OTHER ETIOLOGIES
Other aetiologies, include encephalitis,
abscesses, posterior reversible encephalopathy
syndrome (PRES), progressive multifocal
leukencephalopathy (PML) and arteriovenous
malformations
 Posterior cerebral artery (PCA)
infarction

FIGURE 66-41 ■ Posterior cerebral artery (PCA) infarction. Axial T2- (A) and diffusion-weighted (B)
MRI illustrating an acute right occipital and thalamic infarct with restriction on DWI. Axial CT (C) of a
basilar artery thrombosis with pontine and bilateral PCA territory hypodense infarcts
Axial T2- (F), post-contrast
T1- (G) and diffusion-
weighted (H) MRI of a right
occipital lobe abscess. Axial
CT angiogram (I) and 3D
surface-rendered
reconstruction (J) of a large
right occipital lobe arterio-
venous malformation.
OTHER NEURO-OPHTHALMOLOGICAL
CONDITIONS

Idiopathic Intracranial
Hypertension
Idiopathic intracranial hypertension (previously known
as pseudotumour cerebri) is a disease of unknown
aetiology, typically affecting young obese women and
producing a syndrome of raised intracranial pressure that
is not related to an intracranial disorder, a meningeal
process or cerebral venous thrombosis. Associated
imaging findings include tortuosity and ectasia of the
optic nerve sheaths, flattening of the posterior globes
(Fig. 66-43),
 Papilloedema in idiopathic

A B C D
 TERIMAKASIH
Mohon asupan & saran
US may be widely employed in the study
of ocular conditions. Its main indications are
opacification of transparent media resulting from
cataracts; vitreous hemorrhage or extreme miosis,
making ophthalmoscopic evaluation of the posterior wall
difficult; and ocular globe lesions such as
posterior wall masses and retinal detachment (1).
Contraindications for ocular US are rare; the
main contraindication is suspected ocular globe
rupture in patients with trauma or who recently
underwent surgery because it may cause extrusion of ocular
contents.
TIPE 1 TIPE 2 TIPE 4
1. Cara membedakan adenoma pleomorphic dan
adenoid cystic carcinoma

1. Tadi tidak dijelaskan mengenai medullo epithelioma.

Bagaimana membedakan medulloepithelioma dengan
retinoblastoma secara imaging, terutama
medulloepithelioma yang tumbuh di retina?
2. Tadi pada retinoblastoma disebutkan bahwa untuk
pemeriksaan awal dengan menggunakan USG. Bisa
dijelaskan teknis USG pada orbita?
3. kLASIFIKASI DARI CAVERNOUS MALFORMATION