1. Queens School of Medicine 2. Department of Ophthalmology, - PowerPoint PPT Presentation

Joseph Yang 1 , Nancy Chen 2 , Ian Silver 3 , Jonathan Butler 3 , Donatella Tampieri 3 , Omar Islam 3 , Martin ten Hove 4 , and Benjamin Kwan 3 1. Queen’s School of Medicine 2. Department of Ophthalmology, University of Ottawa 3. Department of Radiology, Queen’s University 4. Department of Ophthalmology, Queen’s University

• Globe abnormalities can present as a conundrum on CT or MRI images and are often under-recognized • Abnormalities can be divided based on anatomical location and can involve neoplastic, infection, traumatic, iatrogenic and inflammatory processes • Common surgical hardware involving the globe will also be presented Cases References Anatomy Conclusion Introduction

• Globe abnormalities can present on CT or MRI and may be incidental findings • Correlation of imaging findings with clinical eye exam helps guide diagnosis • Precise understanding of orbital anatomy and characteristic imaging features leads to timely diagnosis and appropriate management plan Cases References Anatomy Conclusion Introduction

Anterior chamber Bounded anteriorly by the cornea and posteriorly by lens and iris. Pathologies include: • Rupture of the globe • Hemorrhage: also known as anterior hyphema • Cataract • Keratitis: inflammation of the cornea • Periorbital cellulitis Lens Posterior chamber A very small area posterior to the iris. Posterior chamber cannot be discerned on imaging. Pathologies include: • Glaucoma • Uveitis • Ciliary melanoma. Reference: http://www.radiologyassistant.nl Cases References Anatomy Conclusion Introduction

Vitreous body pathology: • Rupture • Hemorrhage • CMV infection: especially in HIV • Persistent Hyperplastic Primary Vitreous Retina pathology : • Retinoblastoma (child) • Hemangioblastoma: (adult) associated with von Hippel Lindau disease • Retinal Detachment Choroid pathology : Vitreous • Melanoma body • Metastases: the choroid is the most vascular part of the globe • Detachment: usually post- traumatic Reference: http://www.radiologyassistant.nl Cases References Anatomy Conclusion Introduction

Clinical Information: Patient presents with significant myopia. Affected eye may be enlarged, or protruding 1 Epidemiology: 19% to 90% in patients with highly myopic eyes 1 Pathophysiology: Caused by thinning of the scleral layer of the globe. Most commonly congenital or due to severe myopia 2 Key Imaging Characteristics: Usually results in a posterior bulge and enlargement of the affected eye. Increased AP diameter with focal deformation of the globe lateral to the head of the optic Axial T2 MR images of the orbits demonstrates a nerve. 3 posterior bulge (arrow) which is eccentric to the Reference: 1. Numa, S., et al. (2018). "Prevalence of posterior staphyloma and factors optic nerve insertion and enlargement of the associated with its shape in the Japanese population." Scientific Reports 8(1): 4594 2. https://www.aao.org/eye-health/ask-ophthalmologist-q/staphyloma globe, consistent with posterior staphyloma. 3. Osborne D et al. Computed tomographic analysis of deformity and dimensional changes in the eyeball. Radiology. 1984;153 (3): 669-74. Cases Introduction References Anatomy Conclusion

Clinical Information: Patients can present with unilateral or bilateral microphthalmia and inferior ocular deviation 1 Epidemiology: 1 in 10,000. In 10%, there are other CNS anomalies with coloboma 2 Pathophysiology: Congenital defect in which certain ocular tissues are absent. Failure of closure of the choroidal fissure posteriorly during development 2 Key Imaging Characteristics: On CT or MRI, the affected globe is small and has a focal posterior defect in the globe with vitreous herniation. A retrobulbar cyst may be present 2 Axial T2 MR image demonstrates bilateral focal posterior defect (arrows) which is centrally located Reference: 1. Gregory-Evans, C. Y., et al. (2004). Ocular coloboma: a reassessment near the optic nerve insertion which represent in the age of molecular neuroscience 41(12): 881-891. 2. Harnsberger HR, Glastonbury CM, Michel MA et-al. Diagnostic bilateral colobomas. Imaging: Head and Neck. Lippincott Williams & Wilkins. (2010) ISBN:1931884781 References Introduction Cases Conclusion Anatomy

Clinical Information: Patient presents with atrophy and a small eye; blindness if at end stage 1 Pathophysiology: End-stage eye disease characterized by shrinkage and visual loss of the affected eye. Associated with trauma, surgery, infection, inflammation, malignancy, retinal detachment, and vascular lesions 2 Key Imaging Characteristics: Reduced globe size (usually <20 mm) with a thickened/folded posterior sclera. Ocular calcification or ossification is also present 3 Axial T1 MR and CT images demonstrate small Reference: left globe, thickened posterior sclera (blue 1. Pernick, N. Globe: phthisis bulbi. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/eyeglobephthisisbulbi.html . Accessed January 29th, 2019. arrow) and calcifications (red arrow), 2. Tripathy, K et al. (2018). Phthisis Bulbi — a clinicopathological perspective. Seminars in Ophthalmology, 33(6), 788-803. doi:10.1080/08820538 consistent with phthisis bulbi. 3. Kashyap S, Meel R, Pushker N et-al. Phthisis bulbi in retinoblastoma. Clin. Experiment. Ophthalmol. 2011;39 (2): 105-10. Cases References Conclusion Introduction Anatomy

Clinical Information: Patients presents with headache, possible nausea/vomiting. Decreased visual field on physical exam 1. . Optic disk swelling on funduscopic exam. Epidemiology: 1 -2 per 100,000 in general population 2 Pathophysiology: swelling of the optic disc from increased intracranial pressure (ICP), possibly due to space-occupying lesions, inflammation, or blockage in CSF drainage Key Imaging Characteristics: MRI may show flattening or bulging of the optic nerve head. Needs clinical correlation using fundoscopy 3 Axial T2 MR (top left) and CT (bottom) demonstrating bilateral indentation of the posterior globe with optic nerve indentation Reference: 1. Vaphiades MS. The disk edema dilemma. Surv Ophthalmol. Mar-Apr 4. 2002;47(2):183-8. (arrows). Example image (top right) on fundoscopy 2. Rigi et al. (2015). Papilledema: epidemiology, etiology, and clinical management. Eye and Brain; 7, 47-57 demonstrating optic disk swelling consistent with papilledema, 3. Passi, N., et al. (2013). MR Imaging of Papilledema and Visual Pathways: Effects of Increased Intracranial Pressure and with no vessel obscurations or vessel tortuosity. Pathophysiologic Mechanisms. 34(5): 919-924. Introduction Cases References Anatomy Conclusion

Clinical Information: Patients are usually asymptomatic; rarely may have transient visual impairments. Fundoscopy shows small optic disk with irregular margins 1 Epidemiology: 3-24 per 1000; M:F equal 2 Pathophysiology: Small protein-like deposits form around the optic disc, resulting in blood supply comprise, slowed axoplasmic flow, and the formation of calcific excrescences. Usually bilateral 2 Key Imaging Characteristics: CT preferred over MRI. White spots of calcification can Axial CT images demonstrate punctate calcification at the be seen, usually between 1-4mm in size 3 posterior left globe at the optic nerve insertion. Fundoscopic image demonstrates optic nerve drusen which Reference: can be mistaken for papilledema, however there is a more 1. Lee, K. M., et al. (2018). Factors associated with visual field defects of optic disc drusen. PLOS ONE 13(4): 1.30;13(4) distinct nodular appearance in optic nerve drusen and no 2. Auw-HaedrichC, Staubach F, Witschel H. Optic disk drusen. Surv Ophthalmol. 2002 Nov-Dec;47(6):515-32. vessel obscurations. 3. Bec P et al. Optic nerve head drusen. High-resolution computed tomographic approach. Arch. Ophthalmol. 1984;102 (5): 680-2 Introduction Anatomy Cases Conclusion References

Clinical Information: Patients with narrow angle glaucoma may complain of intermittent headaches/nausea/photophobia and halos, but during the majority of the time if the IOP is normal they may be asymptomatic. May report blurry vision and limited visual fields at end stage. Correlate through IOP, fundoscopy, gonioscopy and slit lamp exams 1 Epidemiology: The global prevalence for population aged 40 – 80 years is 3.54% 2 Pathophysiology: Retinal ganglion cell loss leads to cupping of the optic disc with corresponding visual field defects. Likely due to abnormal drainage angle, can to increased IOP 1 Key Imaging Characteristics: A shallow anterior chamber can suggest glaucoma. Recent research has Axial CT images demonstrate shallow anterior also shown promise of imaging with MRI where glaucoma can be identified by a decrease in optic chamber in the left globe in a patient with nerve diameter, localized white matter loss and decrease in visual cortex density 3 narrow angle glaucoma. The funduscopic Reference: 1. Prum, B. E. et al. (2016). Primary Open-Angle Glaucoma Suspect Preferred Practice Guidelines. Ophthalmology 123(1): 112-151. pictures shows 0.6-7 cup to disc ration, which is 2. Tham, Y.-C et al. (2014). Global Prevalence of Glaucoma and Projections of Glaucoma Burden through 2040: A Systematic Review and Meta-Analysis. Ophthalmology, 121(11), 2081-2090. consistent with glaucomatous optic nerves. 3. Fiedorowicz M, DydaW, Rejdak R, Grieb P. Magnetic resonance in studies of glaucoma. Med Sci Monit. 2011;17(10):RA227-32. Anatomy Cases Conclusion References Introduction