Orbital Pathology Research Articles

Predictive validity of ultrasonography for orbital lesions in a tertiary care teaching center in South India: A cross-sectional study

Background: The superficial location of the eye and its cystic composition make ultrasound ideal for imaging the eye. Ultrasonography (US) provides highly informative images and is a noninvasive, low-cost, and well-tolerated diagnostic technique. Aim: The present study was conducted to determine the predictive validity of ultrasonography in diagnosing orbital lesions. Materials and Methods: The study population consists of 85 patients with orbital lesions who attended the department of radiology and imaging during the study period. All clinical and ultrasound examinations were performed by a single investigator to identify ocular lesions. A linear high-frequency probe (5-9 MHz) of the LOGIQ P5 ultrasound system was used for the study. Histopathological and computed tomography (CT) and magnetic resonance imaging were used as applicable for final diagnosis. Diagnostic statistics such as sensitivity and specificity have been used to find the correlation of CT scan with the final diagnosis. coGuide was used for statistical analysis. Results: Out of 85 participants, 42 (49%) were male and the remaining 43 (51%) were female. Ultrasound showed an overall sensitivity, specificity, and accuracy of 94.2%, 98.8%, and 94.9% for ocular pathologies and 98.8%, 99.2%, and 95.2% for extraocular pathologies, respectively. Conclusion: US had overall high diagnostic validity and accuracy in localizing and characterizing orbital pathologies. Further evaluation with higher cross-sectional imaging modalities (CT) was indicated in certain cases; for the evaluation of bony involvement, extension to adjacent structures, and intracranial extensions.

Magnetic resonance imaging of the orbit, Part 2: Characterization of orbital pathologies.

In this article we focus on a systematic approach to assess common orbital lesions on magnetic resonance imaging (MRI). The identification of the probable compartment or structure of origin helps narrow the differential diagnosis of a lesion. Analyzing the morphology, appearance, and signal intensity on various sequences, the pattern, and degree of contrast enhancement are key to characterize lesions on MRI. Imaging features suggesting cellularity and vascularity can also be determined to help plan for biopsy or surgery of these lesions. MRI can also distinguish active from chronic disease in certain pathologies and aids in selecting appropriate medical management. MRI may thus serve as a diagnostic tool and help in guiding therapeutic strategies and posttreatment follow-up.

Normative Measurement of Orbital Structures in Computed Tomography

Introduction: Normal orbital dimensions are important for diagnosing orbital pathologies. Computed tomography (CT) of the orbit is an important modality offering high accuracy for precise measurements of orbit. The study was disbursed to ascertain criteria for the normative values of the various orbital dimensions using computed tomography in patients visiting Tribhuvan University Teaching Hospital, Kathmandu. Methods: Orbital volume, ocular diameter, length of the interzygomatic line (IZL), the distance of the posterior extent of the globe from the interzygomatic line, globe position, diameters of extraocular muscles (medial, lateral, superior group, and inferior rectus) and lens density were measured in each eye of 172 patients undergoing CT examination of paranasal sinuses. The correlations with age and sex were also analyzed. Results: Mean values (mean±SD) of orbital volume, ocular diameter, IZL, globe position and lens density were 24.54±2.57 cm3, 2.44±0.22 cm, 94.3±6.2 mm, 12.3±2.4 mm and 141.43±16.62 HU respectively. Mean diameters of extraocular muscles were 3.67± 0.52 mm, 3.36± 0.50 mm, 3.74±0.42 mm and 3.87±0.38 mm for medial rectus, lateral rectus, inferior rectus and the superior group respectively. There was no significant age and gender difference in most of the measurements. There was significant positive correlation of age with lens density, orbital volume and ocular diameter (p<0.05). Conclusion: Normative data of different orbital measurements were obtained. The present result may help radiologists and ophthalmologists to accurately assess various orbital parameters, particularly in Nepalese populations.

Normative Measurement of Orbital Structures in Computed Tomography

Introduction Normal orbital dimensions are important for diagnosing orbital pathologies. Computed tomography (CT) of the orbit is an important modality offering high accuracy for precise measurements of orbit. The study was disbursed to ascertain criteria for the normative values of the various orbital dimensions using computed tomography in patients visiting Tribhuvan University Teaching Hospital, Kathmandu.
 MethodsOrbital volume, ocular diameter, length of the interzygomatic line (IZL), the distance of the posterior extent of the globe from the interzygomatic line, globe position, diameters of extraocular muscles (medial, lateral, superior group, and inferior rectus) and lens density were measured in each eye of 172 patients undergoing CT examination of paranasal sinuses. The correlations with age and sex were also analyzed.
 ResultsMean values (mean±SD) of orbital volume, ocular diameter, IZL, globe position and lens density were 24.54±2.57 cm3, 2.44±0.22 cm, 94.3±6.2 mm, 12.3±2.4 mm and 141.43±16.62 HU respectively. Mean diameters of extraocular muscles were 3.67± 0.52 mm, 3.36± 0.50 mm, 3.74±0.42 mm and 3.87±0.38 mm for medial rectus, lateral rectus, inferior rectus and the superior group respectively. There was no significant age and gender difference in most of the measurements. There was significant positive correlation of age with lens density, orbital volume and ocular diameter (p<0.05).
 ConclusionNormative data of different orbital measurements were obtained. The present result may help radiologists and ophthalmologists to accurately assess various orbital parameters, particularly in Nepalese populations.

English

BACKGROUND In recent times, due to advancement in sinus endoscopes and sinus surgery instruments and the acquirement of skills, the variety of sinonasal diseases being treated and the indications for transnasal endoscopic approaches have increased dramatically. They include chronic rhinosinusitis and sinonasal polyposis to sinonasal tumours, skull base and orbital pathology. We wanted to study the role and outcome of endoscopic sinus surgery in the management of sinonasal disease. METHODS A cross sectional study was conducted among 200 patients attending the Department of ENT, Govt. Medical College, Kozhikode, over a period 2 years with sinonasal diseases. Demographic details, ENT examination, CT scan Paranasal Sinuses (PNS) and endoscopic examination of the nasal cavity were performed in all patients. Clinical signs were recorded and classified according to their pathologies. All the patients were subjected to functional endoscopic sinus surgery. Operative methods and results were recorded. RESULTS Among the 200 patients, 144 (72 %) were males and 56 (28 %) were female patients in the present study. Among the 200 patients, 126 (63 %) were in the age group of 21 to 50 years. 40 / 200 (20 %) patients belonged to the age group of 0 to 20 Years. 34 / 200 (17 %) patients belonged to the age group of 51 to 70 years. CONCLUSIONS The diseases of the nose and paranasal sinuses ranged from inflammatory aetiology to neoplasms. Use of conventional tools for diagnosis and management of such a variety of diseases had their own limitations and demerits. Whereas endoscopic view of the disease sites was exceptionally clear and well-illuminated, giving an added edge to the ability to inspect the recesses with angled distal endoscopes. Definition of micro anatomical sites was well defined by the CT scan especially around osteo-meatal complex, and its anatomical variants. Functional endoscopic sinus surgery was an excellent and safe procedure. The prognosis in surgically treating sinonasal pathologies with FESS was good in terms of lesser morbidity and minimal chances of recurrence. KEYWORDS Sinusitis, Endoscopic Sinus Surgery, CT Scan PNS, Skull Base Surgery, Sinonasal Tumours

Spotlight on the pediatric eye: a pictorial review of orbital anatomy and congenital orbital pathologies.

Orbital lesions in the pediatric population vary from adults in terms of their presentation, unique pathology, and imaging characteristics. The prompt and accurate diagnosis of these lesions is imperative to prevent serious consequences in terms of visual impairment and disfigurement. Along with dedicated ophthalmologic examination, imaging is instrumental in characterizing these lesions, both for accurate diagnosis and subsequent management. In our pictorial essay, we provide a basic review of orbital embryology, anatomy, and congenital orbital pathologies, with emphasis on radiological findings.

Spectrum of Orbital Cellulitis on Magnetic Resonance Imaging.

IntroductionOrbital infection is an ophthalmological emergency as it can lead to blindness and intracranial spread. Imaging is needed to determine the extent of the infection, to localize an abscess, and for surgical planning. The role of magnetic resonance imaging (MRI) is well established in the evaluation of orbital pathologies, including orbital cellulitis and abscess, mainly due to its ability to evaluate early intracranial involvement. The objective of the study was to highlight the spectrum of MR imaging findings and the pattern of spread in fifteen patients with orbital cellulitis.MethodsA prospective study was conducted in a tertiary care hospital. Fifteen patients of all age groups, of either sex, presenting with clinical findings suggestive of orbital cellulitis, referred for MRI of orbits, were included in the study. Written informed consent was obtained prior to the study. Patients’ demographic data such as age and gender, associated co-morbidities, complications, and the pattern of spread of disease on MRI were recorded and evaluated. Descriptive statistics were used.ResultsOrbital/periorbital abscess was found to be the most common complication of orbital cellulitis (eight cases, 53.3%), followed by optic neuritis/perineuritis (four cases, 26.67%), intracranial involvement (four cases, 26.67%), dacryoadenitis (three cases, 20%) and cavernous sinus thrombophlebitis (three cases, 20%). Seven cases (46.67%) had right orbital involvement. Sinusitis was found to be the most common predisposing factor. Amongst the cases associated with sinusitis, the commonest inflamed paranasal sinus was found to be the ethmoid sinus (twelve cases). Amongst the fifteen cases of orbital/periorbital cellulitis, there were only two cases of isolated preseptal cellulitis (13.33%), five cases of postseptal cellulitis (33.33%) and eight cases of both preseptal and postseptal orbital cellulitis (53.33%).ConclusionMRI is the imaging modality of choice in the evaluation of orbital cellulitis because of its superior soft tissue and contrast resolution. It is vital to evaluate the extent of the orbital infection, underlying paranasal sinus involvement, as well as detect complications of orbital cellulitis, especially intracranial spread.

Endoscopic Endonasal Approach for Intra- and Extraconal Orbital Pathologies.

Endoscopic endonasal approaches offer an important alternative in the management of posterior inferomedial orbital pathology. Beginning with endoscopic orbital decompressions for Graves' disease, the endonasal corridor for the management of intra- and extraconal pathologies has continued to evolve. Endonasal removal of orbital cavernous hemangiomas is well described in the literature; however, many other benign and malignant pathologies of the medial orbit can be accessed through this approach. Advantages of the endonasal approach include improved visualization and decreased manipulation of orbital contents in the medial and posterior orbit. Additionally, for tumors that extend from the paranasal sinuses into the orbit, this corridor may be ideal for concurrent management. The current literature for this approach will be reviewed including the oncologic results, complications, limitations, and reconstructive needs along with pertinent anatomy. In addition, data from our own institution will be reviewed.

Anatomy of the Orbit.

The orbit is a paired, transversely oval, and cone-shaped osseous cavity bounded and formed by the anterior and middle cranial base as well as the viscerocranium. Its main contents are the anterior part of the visual system, globe and optic nerve, and the associated neural, vascular, muscular, glandular, and ligamentous structures required for oculomotion, lacrimation, accommodation, and sensation. A complex stream of afferent and efferent information passes through the orbit, which necessitates a direct communication with the anterior and middle cranial fossae, the pterygopalatine and infratemporal fossae, as well as the aerated adjacent frontal, sphenoidal, and maxillary sinuses and the nasal cavity. This article provides a detailed illustration and description of the microsurgical anatomy of the orbit, with a focus on the intrinsically complex spatial relationships around the annular tendon and the superior orbital fissure, the transition from cavernous sinus to the orbital apex. Sparse reference will be made to surgical approaches, their indications or limitations, since they are addressed elsewhere in this special issue. Instead, an attempt has been made to highlight anatomical structures and elucidate concepts most relevant to safe and effective transcranial, transfacial, transorbital, or transnasal surgery of orbital, periorbital, and skull base pathologies.

Combined Surgical Approaches In and Around the Orbit.

Orbital pathology requiring surgery can be planned based on the nature of the disease and the position of this relative to the globe and optic nerve complex. Multidisciplinary treatment is now common, and this sometimes includes multiple surgical corridors employed for approach. The orbit is also now frequently used as a corridor to intracranial pathology, and these same processes may be applied. Combined surgical approaches, whether at the same time or staged, allow for minimization of manipulation of critical neurovascular structures in complex skull base pathology.

A Systematic Approach to Orbital CT Scans: Integrating the BALPINE Method into Ophthalmology Curriculum

Abstract Objective While multiple approaches to the evaluation of orbital computed tomography (CT) imaging have been proposed in both ophthalmology and radiology literature, there remains a paucity of standardized approaches to orbital CT interpretation education for the ophthalmologist in training. To address this, the bones, anterior chamber, lens, posterior globe, intraconal orbit, neurovascular structures, and extraocular muscles (BALPINE) method was selected and its utilization tested as an education tool to improve resident competency in the proper assessment of orbital CT imaging. Methods The BALPINE method is an established systematic approach to reading orbital CT scans. This approach was selected as a standardized education tool after a systematic review of orbital CT evaluation methods in the ophthalmology and radiology literature. A 15-item test, comprised of frequently diagnosed orbital pathologies developed in conjunction with a radiologist, was designed to test a group of ophthalmologists in training across multiple residency programs. The in-training ophthalmologists were first given this test prior to being taught the BALPINE standardized method to assess orbital CT imaging. The study participants were then administered a lecture describing the BALPINE method approach to orbital CT imaging. The same study participants were then administered the same test to assess improvement. The lecture was developed and administered by a board-certified Oculoplastic surgeon. The lecturer was blinded to the images included in the examination during lecture development. The radiologist was blinded to the lecture and the BALPINE method; thus, the images selected were not specific to the method being taught. Results Overall, 27 residents, interns, and medical students completed the prelecture test, BALPINE method curriculum lecture, and postlecture test. There was an average of a 2.3-point (15%) significant improvement per test score (p < 0.0001). Each level of training demonstrated improvement pre- and posttest and overall scores improved with each additional year of training, indicating the test was an appropriate measurement of ability and understanding. Conclusion Teaching a systematic approach to the evaluation of orbital CT scans improves an ophthalmologist in training's ability to diagnose orbital pathology efficiently and effectively. Widespread residency curriculum adoption of the BALPINE method would enhance the training ophthalmologist's diagnostic capability.

Posterior Scleritis: About A Case

Posterior scleritis is a rare and often unknown condition that can simulate many conditions including intraocular tumor or orbital pathology. We report the case of a 44-year-old patient with left eye pain and redness followed by a significant decrease in visual acuity. Clinical examination showed papillary hyperemia, chorioretinal folds at the posterior pole, venous tortuosity, and absence of hyalitis or vasculitis in the fundus oculi associated angiography retinal. Orbital-cerebral MRI and B ultrasound allowed the diagnosis of posterior scleritis

Aging of the Adult Bony Orbit.

Accurate quantitative data of the adult bony orbital volume and dimension are needed for treatment optimization. In the present study, the authors aim to evaluate adult orbital volume and corresponding linear dimensions according to age, volume, and individual symmetry. Seventy computerized tomography facial scans of adults were randomly chosen from an institutional database and 3-dimensionally reconstructed. Studies were excluded for orbital pathology or incomplete radiographic data. Anatomic landmarks were marked. Interval linear distances and orbital volumes were calculated. Data were analyzed using paired T-tests, independent T-tests, linear regression analysis, and 1-way analysis of variance. A total of 140 orbits from 70 patients were analyzed (female = 35, male = 35), ranging from 20 to 88 years of age. Orbital volume was similar between an individual's left and right side; however, a difference was observed in vertical orbital height, orbital width, inferior orbital rim position, orbital roof length, orbital width, and medial orbital wall length (0.45, 0.64, 0.4, 0.77, 0.97, and 5.1 mm, respectively; P < 0.05). In comparison to females, males averaged larger orbital volume by 3.07 cm (29.58 cm versus 26.51 cm, P = 0.0002), medial wall length by 2.66 mm (P < 0.05), and orbital width by 2.66 mm (P < 0.05). Orbital volume did not correlate with patient age, while lateral wall length was correlative. This accurate normative data of the adult bony orbit impacts key aspects of patient diagnosis and treatment and also suggest clinical signs of periorbital aging are not due to bony orbital changes.

Quantifying Eye Alignment in Orbital Fracture Patients: The Digital Hess Screen.

Background: Quantifying diplopia to determine management and track outcomes for orbital fracture patients is vital for standardization between visits, physicians, and coordination among the multiple specialties that manage these patients. However, standardization is challenging, as diplopia is often reported subjectively. This study sought to describe the utility of the digital Hess screen in patients with orbital fractures compared with a control group. Materials and Methods: A prospective pilot study was designed in which adult patients who presented with orbital fractures between November 2017 and January 2019 without prior history of orbital pathology were recruited. Subjects underwent digital Hess screen testing, in which they wore anaglyph glasses and aligned targets on a computer screen to quantify static eye alignment. The degree of any eye misalignment was analyzed and compared with controls. Results: Ninety-one patients and 35 controls were enrolled. All participants were able to complete the digital Hess screen. Average cumulative deviation score of orbital fracture patients within 1 month of injury was 0.65°, compared with 0.28° in controls. This was a statistically significant difference (p < 0.01, 95% confidence interval -0.18 to 0.18). Conclusion: The Hess screen has been used to quantify phoria as a correlate of eye alignment and diplopia, but older versions were cumbersome and difficult to analyze. This study is the first to report on using the digital Hess screen to quantify phoria in orbital fracture patients and provides a more concise and standardized means to track clinical and surgical outcomes of eye alignment.

Computed Tomography Evaluation of Normal Lacrimal Gland Dimensions in the Adult Pakistani Population

ObjectivesTo estimate the normal dimensions of lacrimal glands (LGs) in the Pakistani population using computed tomography (CT) scan and to determine the associations of LG dimensions with age, sex, and laterality.MethodsThe study population included subjects aged ≥16 years without orbital pathology who underwent CT evaluation of both the right and left LGs at Dr. Ziauddin University Hospital from June 2018 to November 2019. The mean axial length (AL), axial width (AW), coronal length (CL), and coronal width (CW) of each LG were measured separately.ResultsThe 108 subjects enrolled in this study included 75 (69.4%) men and 33 (30.6%) women, with a mean age of 49±20 years. Right and left LG dimensions were similar, including mean AL (13.53±1.80 mm vs. 13.35±1.72 mm), mean AW (4.20±0.81 mm vs. 4.05±0.93 mm), mean CL (15.46±1.97 mm vs. 15.26±1.87 mm), and mean CW (3.99±0.80 mm vs. 3.86±0.81 mm). The AL of both LGs and the CL and CW of right but not left LGs were significantly lower in women than in men. Age showed significant correlations with the AL and CL of both LGs.ConclusionThese findings establish the normal range of LG dimensions in adult Pakistani populations. Some LG dimensions are smaller in women than in men, as well as correlating with age.

“Round the clock”: Surgical access to the orbital apex pathologies

“Round the clock”: Surgical access to the orbital apex pathologies

In Vivo Measurement of the Human Vitreous Chamber Volume Using Computed Tomography Imaging of 100 Eyes.

PurposeTo accurately measure the vitreous chamber volume (VCV) in humans using high-resolution computed tomography (CT) scanning techniques combined with three-dimensional analysis software. Potential relationships between age, axial length, and VCVs were also explored.MethodsIn this retrospective study, the eyes of 100 healthy individuals were studied. Scans were acquired during clinical care and did not show any signs of orbital pathology. Exclusion criteria included any ocular history. CT scans were acquired with a slice thickness of 0.7 mm, and volumetric analysis was carried out using the MIMICS image analysis software version 19.0 (Materialise, Leuven, Belgium).ResultsThe final sample included 100 eyes from 50 patients (30 women, 20 men). The mean age was 48.67 ± 20.72 years, and the age range was 18 to 91 years. The mean VCV was 4.649.99 ± 0.426.54 mm3 for women and 4.969.0 ± 0.465.20 mm3 for men. We found a significant correlation between age and VCV (P < 0.001), axial length and VCV (P < 0.001), and age and axial length (P < 0.005).ConclusionsThe VCV appears to be greater than the current consensus suggests. This work also suggests that the VCV is associated with age and axial length, indicating that it is dynamic and may change throughout adulthood.Translational RelevanceThis information regarding the volume of the vitreous chamber is useful for our understanding of proper dosage and behavior of agents we commonly insert into the vitreous chamber.

Orbital venous varices: modern diagnostic methods and differential diagnosis

To study the possibility of the modern CT and MRI methods in diagnostics of the orbital venous varices (OVV), discover the special characteristics of these lesions concerning their hemodynamic and differential diagnosis with other orbital lesions. In the period from 2012 to 2019 ten patients with OVV were evaluated. Four of them were men, three - women and three - children (boys aged 7, 10, and 12 years). Age of the patients varied from 7 to 75 years old (mediana - 34). The majority of the OVV was localized in the medial compartments and apex of the orbit. Left sided lesions were found in 6 cases, right - 3. One patient had both sided OVV. In one of the cases in 10-year-old child, we revealed malformation of the Galen vein associated with bilateral varicose enlargement of the intraorbital veins (secondary OVV). Diagnosis of orbital vascular pathology requires an understanding of the classification of vascular lesions, the integration of the patient's medical history with epidemiological data, as well as a through analysis of the results of instrumental diagnostic methods. CT or MRI, including scanning in the prone position, as well as minimally invasive CT- and MR-TRICKS-angiography and ophthalmological studies of the patient, determine a comprehensive approach to the diagnosis and selection of adequate treatment for orbital venous varices.

An update on thyroid eye disease: Current knowledge, preferred practice patterns, and future therapies

Thyroid-associated ophthalmopathy (thyroid eye disease [TED], thyroid-associated orbitopathy, or Graves' orbitopathy) is the most common, yet a complex and poorly understood autoimmune orbital pathology. It occurs in association with systemic dysthyroid states, most commonly presenting with hyperthyroidism, but also occurs in association with hypothyroidism or euthyroidism. Despite the ongoing research, the pathogenesis and effective treatment strategies remain obscure, hence presenting a challenge for the treating ophthalmologist. The ocular presentation can vary from mild disease to severe irreversible sight-threatening complications. Ocular manifestations can follow the thyroid dysfunction, present parallel to it, or seldom precedes it. The ocular disease has its own natural course divided into an active and inactive phase. Scoring individual patients for the severity of disease has been frequently revised. The clinical examination, activity, and severity aid the ophthalmologist to decide the stage of the disease and come up with the treatment strategy for each patient. Management strategies include a multidisciplinary team effort. Recently, we have witnessed a leap to newer targeted biologic therapy that not only improves the course of the disease but also the quality of life of these patients. In this review, we present an update of the current understanding of etiopathogenesis, clinical features, and management options for this common yet challenging orbital inflammatory disease.

Management of Orbital Masses: Outcomes of Endoscopic and Combined Approaches With No Orbital Reconstruction.

IntroductionThe endoscopic endonasal approach to management of orbital pathology has expanded. Due to the rarity of these conditions, most reports in the literature consist of small case reports. We report a series from a single institution with a focus on outcomes.MethodsA retrospective chart review was carried out between 2010 and 2018.ResultsTwenty-four patients were identified (average age 58 years, 15 males, 9 females). Average follow-up was 14.9 months. Most common etiologies included cavernous hemangioma (7), metastases (6), idiopathic orbital inflammatory syndrome (6), orbital hematoma/clot (2), and schwannoma (1). Most common presenting symptoms were decreased visual acuity (8), proptosis (8), diplopia (7), and incidental findings (2). All patients underwent endoscopic medial wall orbital decompressions. Sixteen involved a combined open approach by an ophthalmologist. Pathology was either biopsied (15), resected (6), or could not be identified (3). No intraoperative complications were noted. No patients underwent orbital reconstruction of the medial wall. Six patients developed postoperative sinusitis successfully managed with antibiotics. One patient developed epistaxis managed conservatively. In 5 patients, Sino-Nasal Outcome Test-22 scores increased immediately postop and then decreased, whereas scores only decreased in 6 patients. Six patients noted reduced proptosis. There were no new cases of diplopia or worsening visual acuity.ConclusionsA combined endoscopic endonasal and external approach can be useful for managing orbital lesions. Patients tolerated the procedure well with improvement in ocular symptoms and minimal sinonasal complications. Reconstruction of the medial wall may not be warranted to prevent postoperative diplopia.