This Eye Does Not Look Right.
An Imaging Overview of Common
Oculoplastic and Orbital Surgeries.
eEdE-109
Farbod Nasseri
S. Ali Nabavizadeh
PENN RADIOLOGY
Laurie A. Loevner
Arastoo Vossough
THE ROOTS OF
RADIOLOGICAL
Suyash Mohan
EXCELLENCE
Neuroradiology Division
Department of Radiology
University of Pennsylvania
Disclosure statement
• Neither the authors nor their immediate family members have a
financial relationship with a commercial organization that may
have a direct or indirect interest in the content.
Baltimore,
Maryland
Perelman
School of Medicine
at University of Pennsylvania
Penn Radiology
Purpose
• To present a comprehensive and systematic review of the
imaging spectrum of the oculoplastic and orbital surgeries
including various types of orbital implants and prostheses.
• To review imaging features of potential surgical complications
and discuss plausible pitfalls.
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Approach
• Orbital surgeries
 Reconstruction, augmentation, decompression
 Enucleation, evisceration, exenteration
• Lacrimal apparatus surgery
• Lens surgery & implants
• Eyelid surgery
• Strabismus surgery
• Glaucoma surgery
• Retinopexy & scleral buckles
• Intraocular injection
Baltimore,
Maryland
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at University of Pennsylvania
Penn Radiology
Discussion
• The development of new surgical techniques, as well as advances in the
prostheses offer a wide range of novel alternatives for orbital and
oculoplastic surgeries.
• Imaging plays a critical role in the postoperative setting, enabling early
diagnosis of complications as well as long term follow-up evaluation.
• A comprehensive pictorial review of postoperative orbit will be presented.
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Orbital wall reconstruction/augmentation
Titanium
Traditional
Silicone
Autologous cartilage or bone
Implant material
New
Porous polyethylene
Pros
Cons
Porous polyethylene
Allow vascularization
Improved biocompatibility
No need for fixation
Infection
Titanium
Accurate contour
Large defect
Cost
Needs fixation
Imaging: To assess for complications:
•
Foreign body reaction (allograft implant)
•
Infection
•
Extrusion, deformity, subsiding
•
Rectus muscles impingement, optic nerve compression
•
Lacrimal sac obstruction
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6 Y/F with fibrous dysplasia & left optic nerve compression
symptoms treated with frontal orbital advancement &
reconstruction of the left orbital roof
Coronal
CT
*
Coronal
T1 MR
3-D volume rendered CT
*
Extensive involvement of left
calvarium with fibrous dysplasia
causing narrowing of left orbital
apex & left eye proptosis.
Orbital decompression and
orbital roof reconstruction
using bone grafts.
Coronal CT
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Postop
3-month follow-up
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53 Y/M with facial & orbital floor (blow-in) fractures
after falling off skateboard
Pre op
Coronal CT
Multiple facial bone fractures
including the inferior wall of
the left orbit. Small displaced
bone fragment in left orbit.
Post op
Coronal CT
Post op
3-D volume rendered CT
Reconstruction of the inferior wall of the
left orbit with a metallic mesh.
Fixation of left lateral orbit & inferior
orbital rim using screws/plates.
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53 Y/M with sinonasal undifferentiated carcinoma (SNUC) of right maxilla
& orbit, status post right maxillectomy & exenteration followed by left radial
forearm free flap reconstruction 2 years later
Pre op
Heterogeneously mass within the
right maxillary sinus with extension
into the right nasal cavity & into
right orbital floor, abutting the right
inferior rectus muscle
Post op
Coronal T1
Axial T1
Coronal T1
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Post op
Coronal
Axial T1
T1
3-D volume rendered CT
Orbital exenteration, maxillectomy
reconstruction using metallic
mesh, sphenoidotomy &
ethmoidectomy. Radial forearm
free flap reconstruction
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Orbital Decompression
•
Indication: Thyroid-related immune orbitopathy (TRIO)
Proptosis and intraocular pressure.
Improve
Visual acuity
•
Techniques: resection of the medial, lateral, or inferior orbital walls
•
Imaging:
• Bulging enlarged orbital fat and rectus muscles through these defects.
• Resection of portion of paranasal sinuses.
•
Complications: globe displacement  diplopia, CSF leak, optic neuropathy,
orbital cellulitis, excess herniation of orbital contents  sinus obstruction.
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71 Y/F with thyrotoxic exophthalmos &
compressive optic neuropathy
Enlargement of bilateral extraocular muscles.
Coronal CT
Coronal
T1
Coronal
T1
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Bilateral orbital decompression with
defects of the medial orbital walls.
Continued enlargement of the extraocular
muscles.
Decreased crowding at the orbital apices
(left more than right) with mild medial
deviation left optic nerve.
Penn Radiology
Orbital Enucleation / Evisceration
Evisceration: removal of globe contents, preserving the sclera & extraocular muscles.
Enucleation: removal of globe contents entirely, preserving the extraocular muscles.
Intraocular malignancies
Indication
Irreparable globe rupture
Prevention of sympathetic ophthalmia
Globe implants: provide orbital volume for cosmesis following enucleation.
Cover shell / eye prosthesis (anterior)
Implant
Components
Orbital implant (posterior)
Materials: metallic (old), hydroxyapatite, solid silicone, & Medpor (new).
www.oasa.org.za
Pitfall: Diffuse linear enhancement surrounding the implant (no clinical significance).
Complications: rotation, infection, inflammation, & exposure.
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76 Y/F with history of right supraorbital/ frontal scalp
squamous cell carcinoma status post Mohs surgery
T2 & enhanced T1 images show right
supraorbital & frontal scalp tumor with
perineural spread along supraorbital
nerve.
Coronal
T2
Coronal
T1 post
Postop: right eye evisceration.
Axial CT
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Orbital Exenteration
Primary orbital malignancies
Indication
Orbital invasion by periorbital malignancies
Subtotal: sparing of the eyelid
Exenteration types
Total (extended): removal of eyelid + orbit
Radical: removal orbit + periorbial structures
•
Complications: fistulae, necrosis, dehiscence, infection.
Baltimore,
Maryland
Perelman
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at University of Pennsylvania
Penn Radiology
56 Y/F with right sinonasal melanoma treated
with orbital exenteration
*
*
*
Melanoma filling the nasal
cavity, ethmoid air cells,
extending into the maxillary,
frontal, and sphenoid
sinuses, with intraorbital
extension to the medial
extraconal fat, and the
trochlea, medial rectus, and
inferior muscle complex,
involving the planum
sphenoidale, and mild dural
extension. Complicated with
bilateral subdural effusions.
Orbital exenteration & myocutaneous free flap reconstruction extending into the right
maxillary sinus, nasal cavities & ethmoid air cells.
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25/M with gunshot wound, extensive post-traumatic changes
presented with an orbital mass.
*
Axial CT
Left globe prosthesis. Patient
developed extra-osseous
mucocele postoperatively in the
region of the left superior orbital
rim. Notice: Right globe is absent.
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*
Axial CT
Extra-osseous enlarging mucocele
on 3-month follow-up. Left globe
prosthesis.
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Lacrimal apparatus surgery
Dacryocystorhinostomy
Relieve lacrimal obstruction
Nasolacrimal duct stents or Jones tubes
Dacryocystorhinostomy (Preferred treatment)
• Remove bone from medial canthus  connect nasolacrimal duct with nasal cavity.
• External
• Endonasal
• Complications: Restenosis
Nasolacrimal duct stents / Jones tubes:
•
Composed of metalor plastic. Tubular structure + “mushroom” component
•
Complications: stent malposition or migration, inflammation, pneumorbit
•
Poor long-term patency
•
Up to 65 % of stents become occluded by granulation tissue or mucoid debris
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60 Y/M with right lacrimal sac carcinoma s/p right
maxillectomy with reconstruction, presents with epiphora
Sequential Coronal CT
Coronal T2 MR
Right dacryocystorhinostomy with stent placement, extending into the nasal cavity
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Lens surgery and implants
•
Optic
Cataracts are common causes of vision loss
Intraocular lens implant: Replacement after lens extraction
Intraocular
lens
implants
Optic (clear lens)
Haptics (stabilizing arms)
Haptics
www.nature.com/eye/journal
•
Imaging: Lens prostheses are very thin structures in profile.
•
Optic: radiodense on CT , low signal intensity on both T1 & T2 MRI.
•
Haptic: may not visible at 1.5 T MRI or on thin-section CT.
•
Intraocular lens prostheses do not normally enhance.
•
Complications: retained lens fragments, displacement, dislocation, calcifications.
Lensectomy:
•
Resection of the crystalline lens (transscleral retrociliary incision).
•
Mainly for treatment of pediatric cataracts.
•
Imaging: no apparent separation between the anterior chamber and the globe.
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Intraocular lens implant
Right prosthetic lens implant: optic and
haptics. Native left lens.
Axial T1
Dystrophic calcification on the surface
of the right intraocular lens implant.
Axial T1
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Eyelid surgery
Eyelid Weights
• Indication: Facial nerve deficits  lagophthalmos  keratitis
• Implanted subcutaneously in the upper eyelid
• Secured to the tarsus  enabling eye closure
• Gold eyelid weights: MRI compatible
• >90 % improved visual acuity
• Complications:
• Infection, allergic reaction, migration, & extrusion
The patient has a history of left facial nerve palsy. A
left upper eyelid weight which causes streak artifacts
on CT & susceptibility artifact on MRI.
Coronal CT
Axial CT
Axial T2
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Perelman
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Eyelid surgery
Blepharoplasty
•
Surgical reconstruction of the eyelids.
•
Indications: ptosis, thyroid orbitopathy, and facial cosmesis.
Sling blepharoplasty: suspend the eyelid to the frontal bone.
Blepharoplasty
techniques
Augmentation blepharoplasty: using implants or tissue repositioning.
Reduction blepharoplasty: removal of excess tissue.
•
•
Imaging:
•
Often no appreciable imaging correlate
•
Some materials used for augmentation can be seen
•
Sling blepharoplasty anchors
Complications:
• eyelid malposition, strabismus, scarring, & persistent edema
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Strabismus surgery
Diplopia (nerve palsy)
Reduced binocularity
Indications
Constricted visual field secondary to strabismus
Abnormal head position secondary to ocular misalignment
•
Repositioning portions of the rectus muscle bellies onto the sclera
Changes in size and morphology of the rectus muscles
Imaging
Improved ocular alignment
Evaluating postoperative complication
• Complications: rectus muscle rupture/slippage, infection
Baltimore,
Maryland
Perelman
School of Medicine
at University of Pennsylvania
Penn Radiology
Pre op
6 m/F with Axenfeld Rieger syndrome presented with
congenital hypoplastic lateral rectus muscles
Post op
The globes are rotated internally. The lateral rectus muscles are hypoplastic.
Status post right strabismus surgery, involving transposition of superior and
inferior rectus laterally. Resolution of internal rotation of the globes.
New right hypertropia and dissociated vertical deviation due to unbalanced
transposition (slight overcorrection).
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Glaucoma surgery
• Purpose: to reduce intraocular pressure by decompression of aqueous humor
Non-valved: Molteno, Baerveldt.
Types of shunt
implants
Valved: Ahmed, Krupin.
Valve
Valve shunt
Plate: implanted underneath the conjunctiva
Tube: inserted into the anterior chamber
www. sanantonioeyeinstitute.com
• Bleb (Reservoir): A fibrous capsule forms around the aqueous humor
• Glaucoma valve implants are MRI compatible
• Low signal on both T1- and T2-WI surrounded by a small amount of fluid in the reservoir
• Complications: malposition, obstruction, giant bleb formation, infection, choroidal detachment
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2 Y/F with Sturge-Weber syndrome
and a glaucoma shunt
Sagittal T1
www. sanantonioeyeinstitute.com/
glaucoma-tube-shunts/
Coronal T2
Sagittal CT
Left Ahmed shunt valve supralateral to the left optic globe shows linear low signal on
T1 and T2 images & linear hyperdensity on CT which is surrounded by fluid (blebs).
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2 Y/F with Sturge-Weber syndrome and bilateral glaucoma
s/p bilateral Ahmed valved shunts
Coronal T2
Coronal & axial T2 images show bilateral
linear low signal Ahmed valved shunts
surrounded by fluid blebs. Larger amount
fluid on the left which indents the globe.
Out-pouching of fluid signal within the left
orbit, anterior to the valve.
Axial T2
Coronal T2
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Perelman
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Penn Radiology
Retinopexy & scleral buckles
•
Scleral buckles or bands: circular devices positioned around the globe for
treatment of retinal detachment. The buckles exert pressure to appose the layers
of the retina together.
Hydrophilic hydrogel polymers (fluid density)
Composition
Silicone
Solid rubber bands (high density)
Sponges (air density)
http://www.webmd.com/
scleral-buckling-surgery-postoperative
•
Complications: infection, scleral invasion & extrusion
•
Hydrogel implants: less stiff (less scleral erosion), can swell (permeable to water).
Pitfall: mimic orbital mass or infection.
Surgical history, tubular configuration of the implant encircling the globe & lack
of restricted diffusion helps in differentiating from infection.
Baltimore,
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Perelman
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85 Y/F with history of retinal detachment,
s/p scleral buckle retinopexy
Axial CT
http://vissioneyes.com/
retinal-detachment-treatment.html
High-density scleral buckles
surrounding the right globe.
Pitfall: Scleral buckles may mimic senile calcifications, hemorrhage, or masses.
Axial CT
Senile calcifications
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48 Y/M with retinal detachement
s/p rubber band silicon retinopexy
The scleral band are low signal intensity
on T1 & T2 MR.
Axial T2
Mild indentation on the globe is an
expected finding & should not
considered abnormal.
Axial T1
Coronal T2
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Intraocular injections
Indication: To tamponade the retina following retinal detachment until chorioretinal adhesions form.
Pneumatic Retinopexy (Intraocular gas injection): (Effective up to 80 %)
•
To restore intraocular volume during scleral banding
•
A variety of gases: air, hexafluoride, & perfluoropropane
•
Imaging: Air lucency is present antidependently in the vitreous body, creating an air-fluid
level
•
Complications: secondary glaucoma, gas migration, vitreous hemorrhage, endophthalmitis &
proliferative vitreoretinopathy
Intraocular Silicone Injection:
•
The silicone oil used for tamponade is usually removed after 8 weeks, but may remain
permanently, depending on the risk of recurrent detachment
•
Imaging: On CT, silicone oil is hyperdense & globular, measuring up to 120 HU
•
Complications: choroidal detachment, scarring, cataracts, & optic nerve atrophy
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58 Y/M with history of retinal detachment
following pneumatic retinopexy
Intraocular air is seen as non dependent
hypointensity on T1 & T2 images within the
vitreous.
Axial T1
It creates an air-fluid level left orbit.
Pitfall: Pneumatic retinopexy can mimic orbital
abscess & post traumatic orbital emphysema.
Axial T2
Sagittal T2
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36 Y/M with traumatic brain injury & retinal detachment.
Intraocular silicone injection for retinopexy.
Axial CT
Bilateral globular hyperdense silicon in the globes
Pitfall: Silicon can mimic blood, but blood typically
layers dependently & is not as dense as the silicone.
The intraocular silicone is isointense to muscle &
hyperintense to fluid on T1 while hypointense on T2.
Axial T1
Chemical shift artifact, at the interface between the
silicone and the vitreous, can distinguish the silicon
from blood.
Axial T2
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Fat saturation pulses can also help distinguishing the
two by causing some degree of signal suppression.
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Conclusion
Familiarity with imaging findings of the wide-ranging spectrum of
postoperative changes are crucial to differentiate expected
postoperative findings from complications.
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Thank you for reviewing our exhibit
 Farbodnasserimd@gmail.com
 Suyash.mohan@uphs.upenn.edu
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Leong SC, White PS (2010) Outcomes following surgical decompression for dysthyroid
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Christmas NJ, Gordon CD, Murray TG, Tse D, Johnson T, Garonzik S, O’Brien JM (1998)
Intraorbital implants after enucleation and their complications: a 10-year review. Arch Ophthalmol
116(9):1199–1203
Tyers AG (2006) Orbital exenteration for invasive skin tumours. Eye (Lond) 20(10):1165–1170
Nishida Y, Inatomi A, Aoki Y, Hayashi O, Iwami T, Oda S, Nakamura J, Kani K (2003) A muscle
transposition procedure for abducens palsy, in which the halves of the vertical rectus muscle
bellies are sutured onto the sclera. Jpn J Ophthalmol 47(3):281–286
Freedman J (2010) What is new after 40 years of glaucoma implants. J Glaucoma 19(8):504–508
Chan CK, Lin SG, Nuthi AS, Salib DM (2008) Pneumatic retinopexy for the repair of retinal
detachments: a comprehensive review (1986–2007). Surv Ophthalmol 53(5):443–8
Mathews VP, Elster AD, Barker PB, Buff BL, Haller JA, Greven CM (1994) Intraocular silicone oil:
in vitro and in vivo MR and CT characteristics. AJNR 15:343–347
Kartush JM, Linstrom CJ, McCann PM, Graham MD (1990) Early gold weight eyelid implantation
for facial paralysis. Otolaryngol Head Neck Surg 103(6):1016–1023
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