Qualitative and Quantitative Magnetic Resonance Imaging in Bacterial Orbital Cellulitis.

PURPOSE: To summarise the qualitative and quantitative parameters of bacterial orbital cellulitis (OC) on magnetic resonance imaging (MRI) and explore their clinical correlations. METHODS: Multi-centre retrospective study with inclusion of patients of all ages with OC who underwent MRI. Patients with isolated pre-septal cellulitis, bilateral disease and poor-quality scans were excluded. An enlargement ratio for extraocular muscles (EOMs) was calculated by dividing maximal EOM measurements from the affected side by the contralateral side. RESULTS: Twenty MRI scans from twenty patients (Mean age: 40.8 ± 24.3 years old, M: F = 15:5) between 2011 and 2022 were analysed. Three (15.0%) cases were paediatric patients (<18 years old). All cases had both pre-septal and orbital fat involvement. The EOM were affected in nineteen cases, with the superior muscle complex (18/19, 94.7%) most commonly affected. Mean enlargement ratio (1.30, Range: 1.04-1.82) was greatest for the medial rectus on axial views on T1 and fat-suppressed contrast-enhanced T1 (FS CE T1). Optic peri-neuritis was present in eleven (55.0%) patients, whilst two (9.5%) cases had optic neuritis. A greater degree of proptosis was observed in patients with optic neuropathy and those who underwent surgical intervention compared to those without (p = .002 and p = .002, respectively). CONCLUSION: MRI remains an important imaging modality for evaluating complicated OC. However, qualitative features may lack accuracy and is not a reproducible means of analysis. Simple quantitative parameters, such as proptosis and EOM measurements, correlate with high-risk clinical features and may have utility in predicting clinical course.

Radiologic Features of Well-circumscribed Orbital Tumors With Histopathologic Correlation: A Multi-center Study.

PURPOSE: To delineate specific imaging characteristics of solitary fibrous tumors, schwannomas, cavernous venous malformations, and well-circumscribed orbital lymphoma. METHODS: Patients undergoing excisional biopsy of solitary fibrous tumor, schwannomas, cavernous venous malformations, or well-circumscribed orbital lymphoma with preoperative MRIs available for review were identified at 3 academic centers in the United States and Australia. An exploratory statistical analysis was performed to identify important radiologic features, which were subsequently included in a random forest model. Histopathologic correlates were evaluated in representative cases. RESULTS: A total of 91 cases were included with a mean age of 52.9 ± 17.2 years. Nearly all solitary fibrous tumors were located in the anterior or mid orbit (87.5%) and they more commonly demonstrated intralesional heterogeneity on T2-weighted imaging (45.5%) (p < 0.01). Compared with the other tumors, schwannomas tended to be intraconal (66.7%) and were often in the mid or posterior orbit (83.4%) (p < 0.01). Cavernous venous malformations characteristically demonstrated progressive contrast enhancement (93.9%; p < 0.01). Most lesions in all 4 groups were hypointense on T1-weighted imaging (80%-100%; p = 0.14) and only well-circumscribed orbital lymphoma tended to also be hypointense on T2 (81.8%) (p < 0.01). Finally, cases of lymphoma had significantly lower apparent diffusion coefficient ratios (0.9 ± 0.2) (p < 0.001), while the other 3 groups were not significantly different from one another (cavernous venous malformations: 1.8 ± 0.4; schwannomas: 1.8 ± 0.5; and solitary fibrous tumor: 1.6 ± 0.6) (p = 0.739). CONCLUSIONS: Key features that aid in the differentiation of these 4 tumors from one another include T2 intensity and homogeneity, early contrast-enhancement pattern, and ADC ratio.

Histopathological features of asymmetric lacrimal gland enlargement in patients with thyroid eye disease.

PURPOSE: Lacrimal gland enlargement can be a feature of thyroid eye disease (TED). Unilateral or asymmetric lacrimal gland enlargement is poorly described and may impede diagnosis. We present the histological and clinical findings of four patients with asymmetric lacrimal gland enlargement. METHODS: A retrospective case note review was performed for patients over two tertiary orbital clinics (Royal Adelaide Hospital, South Australia and the Sussex Eye Hospital, Brighton, United Kingdom) presenting with an asymmetrical lacrimal gland enlargement with a background of TED that underwent biopsy to exclude alternate diagnoses. Baseline data was collected for each patient and histopathological images and reports were reviewed. RESULTS: All four patients were hyperthyroid at time of lacrimal gland biopsy. Biopsy demonstrated nonspecific, lymphoid aggregates, typically of B cell type, with no diagnostic findings to support lymphocyte clonality or IgG4-related disease. One biopsy specimen demonstrated evidence of some fibrosis. CONCLUSION: Asymmetrical lacrimal gland enlargement can occur as part of the TED spectrum but may require biopsy to exclude alternate pathology. Histology demonstrates a non-specific lymphocytic infiltrate.

Dilated superior ophthalmic vein: systemic associations.

PURPOSE: To review systemic associations of patients with dilated superior ophthalmic veins (SOV) in the absence of orbital, cavernous sinus, or neurological disease. METHODS: Retrospective review of patients who had dilated SOVs with a diameter of ≥ 5.0 mm. Patients with a dilated SOV secondary to orbital, cavernous sinus or neurological disease were excluded. Patient demographics, past medical history, and SOV diameters on initial and follow up scans were collected. The maximum diameter of the SOV was taken perpendicular to the long axis of the SOV. RESULTS: Nine cases were identified. Patients ranged in age from 58 to 89 years and six out of nine were female. The dilated SOV involved both eyes in two cases, left eye in five cases and right eye in two cases. Three patients had dilated SOV likely secondary to raised venous pressures from decompensated right heart failure (n = 1), pericardial effusion (n = 1) and left ventricle dysfunction secondary to a myocardial infarction (n = 1). Five patients had a significant history of previous ischaemic heart or peripheral vascular disease. Two patients had risk factors for venous clotting disease whilst one patient had a history of giant cell arteritis and vertebral artery dissection. CONCLUSION: A dilated SOV may raise concern for life threatening conditions such as a carotid cavernous fistula and may prompt additional investigations. A dilated SOV may be reversible and secondary to raised venous pressures due to cardiac failure. Other cases may be seen in patients with significant cardiovascular risk factors, possibly due to changes in vasculature.

Orbital Artifacts on MRI.

PURPOSE: To describe artifacts on orbital MRI, which led to an incorrect radiology report. METHODS: Retrospective chart review of patients identified from the orbital databases at the Royal Adelaide Hospital and University of Wisconsin Hospital. Patients who had artifacts on orbital MRI that led to an incorrect radiology report were included. Records were evaluated for age at imaging, gender, MRI sequence, laterality, and location of artifact, radiological characteristics and misdiagnosis, and cause of artifact. RESULTS: Data were collected from 7 patients (3 male) who had a median age of 61 years at the time of imaging. Five artifacts resulted from fat-suppression failure with 4 of these cases misdiagnosed as inflammatory changes and 1 misdiagnosed as neoplastic infiltration. The OD was involved in 4 cases. Six cases were in the inferior orbit region. CONCLUSIONS: Fat-suppression failure artifacts may arise in the inferior orbit region and can be mistaken for inflammatory or neoplastic orbital disease. This may prompt additional investigations such as orbital biopsy. Clinicians should be aware of artifacts which can affect orbital MRI and lead to potential misdiagnosis.

Normative Quantitative Values for Dacryoscintigraphy and the Effect of Lid Massage.

Our objectives were to establish normative quantitative values for dacryoscintigraphy in an older population and to evaluate the effect of lid massage. Methods: We conducted a prospective study of 44 eyes of 22 participants aged between 54-90 y that had no symptoms of epiphora and no clinical tear film instability, lid abnormality, lacrimal system impairment, or patent lacrimal duct on syringing. Dacryoscintigraphy was performed and interpreted by a single nuclear medicine physician. The scan protocol involved instillation of 99mTc-pertechnetate in each eye, with a 45-min scan performed with 1-min frames. Lid massage and a sinus clearing maneuver were then performed, followed by a further 45 min of scanning. Results: The mean age of the 22 participants was 71.9 y. Quantitative analysis by half-clearance time (HCT) demonstrated a median presac HCT of 25.5 ± 15.0 min and a whole-eye HCT of 40.0 ± 19.5 min. There was no association between age or sex and HCT. Qualitatively, 29 of 44 eyes (66%) appeared to have at least 1 region of delayed clearance, with improvement noted in 23 after lid massage (79%). Conclusion: We report the quantitative values for dacryoscintigraphy in an asymptomatic older population who had normal findings on lacrimal examination. A high rate of delay in radiotracer transit on qualitative examination suggesting a low specificity. The false-positive rate was significantly improved with the novel approach of adding lid massage, and the significance of this finding merits further research.

Histopathological Characteristics of Lacrimal Gland Prolapse.

PURPOSE: Lacrimal gland prolapse is an acquired clinical condition that can present as an upper eyelid mass. Patients may undergo lacrimal gland biopsy when there is diagnostic uncertainty. We aim to describe the histopathological features of this patient group. METHODS: Retrospective case series involving 11 patients. RESULTS: The mean age at presentation was 52.3 ± 16.2 years (range: 31-77 years) with 8 patients (72.3%) being female. The most common presenting symptom was a palpable mass (9; 81.8%) followed by dermatochalasis (4; 36.4%). Three cases (27.3%) were bilateral. Common imaging findings include lacrimal gland enlargement and visualization of the prolapse. All biopsies demonstrated features of mild chronic inflammation with preserved glandular structures. Ten patients (90.9%) underwent surgical intervention involving lacrimal gland pexy and 1 patient (9.1%) was elected for observation only. One patient required repeat surgery after 4 years due to recurrence of symptoms. At the last follow-up, all patients had stable disease or complete resolution of symptoms. CONCLUSION: We present a case series of patients diagnosed with lacrimal gland prolapse who underwent a biopsy during their workup. All biopsies demonstrated features of mild chronic inflammation (dacryoadenitis). All patients had stable disease or complete resolution of symptoms. This case series suggests that chronic inflammation is a common finding in patients with lacrimal gland prolapse but bears minimal clinical consequence.

Orbito-cranial schwannoma-a multicentre experience.

OBJECTIVES: To describe the features, management approaches, and outcomes of orbito-cranial schwannomas. METHODS: Retrospective review of ten patients with orbito-cranial schwannomas managed in six orbital services over 22 years. Data collected included demographics, presenting features, neuroimaging characteristics, histology, management approach, complications, and outcomes. RESULTS: Mean age of the patients was 41.4 ± 19.9 years, and 6 (60%) were females. The majority presented with proptosis (90%), limited extraocular motility (80%), eyelid swelling (60%), and optic neuropathy (60%). Most lesions (80%) involved the entire anterior-posterior span of the orbit, with both intra- and extraconal involvement. All tumours involved the orbital apex, the superior orbital fissure, and extended at least to the cavernous sinus. Surgical resection was performed for all. Seven (70%) of the tumours were completely or subtotally resected combining an intracapsular approach by an orbital-neurosurgical collaboration, with no recurrence on postoperative follow-up (6-186 months). Three underwent tumour debulking. Of these, two remained stable on follow-up (6-34 months) and one showed progression of the residual tumour over 9 years (cellular schwannoma on histology) necessitating stereotactic radiotherapy (SRT) for local control. Adjuncts to the orbito-cranial resection included perioperative frozen section (n = 5), endoscopic transorbital approach (n = 2), and image-guided navigation (n = 1). Post-surgical adjuvant SRT was used in three subjects. CONCLUSIONS: These results highlight the possibility of successful surgical control in complex orbito-cranial schwannomas. A combined neurosurgical/orbital approach with consideration of an intracapsular resection is recommended. Recurrence may not occur with subtotal excision and observation may be reasonable. Adjunctive SRT for progression or residual tumour can be considered.

Normative orbital measurements in an Australian cohort on computed tomography.

PURPOSE: To determine the normal diameters of the extraocular muscles (EOMs) and optic nerve sheath complex (ONSD) and correlate with patient demographics in an Australian cohort. METHODS: Consecutive patients who underwent contrast enhanced computed tomography (CT) orbits between December 2017 and March 2021 were included. Patients with bilateral disease, previous orbital surgery, or poor scan quality were excluded. Normal orbit was used in patients with unilateral orbital disease. RESULTS: Two hundred one orbits from 201 patients were included. Normal measurements (mean ± SD) were as follows: medial rectus (MR) 4.22 ± 0.56 mm; inferior rectus (IR) 4.20 ± 0.70 mm; lateral rectus (LR) 3.40 ± 0.56 mm; superior muscle group (SMG) 4.13 ± 0.72 mm; superior oblique (SO) 2.60 ± 0.43 mm; inferior oblique (IO) on quasi-sagittal plane 2.19 ± 0.42 mm, and the ONSD 5.62 ± 0.82 mm. The mean diameters of the LR, SMG, IR, SO, and ONSD were significantly larger in male than female patients (p < .05). Statistically significant correlation was found between age and the diameters of the LR (r = 0.29, p < .01), SMG (r = 0.22, p < .01), IO on a coronal plane (r = -0.18, p < .01), and ONSD (r = 0.16, p = .02). CONCLUSION: This normative data may be used to diagnose pathological enlargement of the optic nerve and extraocular muscles, including involvement of the oblique muscles.

The use of the paramedian forehead flap alone or in combination with other techniques in the reconstruction of periocular defects and orbital exenterations.

PURPOSE: The paramedian forehead flap (PMFF) is a reconstructive option for large eyelid defects and orbital exenterations. We report a series of cases where PMFF reconstruction was carried out at various institutions in Australia. METHODS: This study was a multi-centre, retrospective, non-comparative case series investigating the clinical outcomes of the PMFF for reconstructing periocular defects and orbital exenterations. RESULTS: This case series describes twenty-seven patients (Female = 15, Male = 12), operated between 1991 to 2019, with a median age of 81 years (range: 45-93 years). Defect locations involved combinations of the medial canthus (16/27, 59.3%), upper eyelids (7/27, 25.9%), lower eyelid (4/27, 14.8%), both upper and lower eyelids (5/27, 18.5%), and orbital (7/27, 25.9%). There were no cases of flap necrosis. Minor post-operative complications were observed in ten patients with the most common being lagophthalmos. Median duration of follow-up was 17months (Range: 2months- 23years). CONCLUSIONS: The PMFF is a versatile reconstructive tool for a range of periocular defects and orbital exenterations with minor post-operative complications.

Radiological analysis of orbital lymphoma histological subtypes.

PURPOSE: To characterise the radiological features of orbital lymphoma subtypes. METHODS: This was a multicentre, retrospective study to analyse radiological and clinical characteristics of orbital lymphoma by histological subtype across two sites within Australia and the United States. RESULTS: A total of eighty-eight patients were included. The most common subtypes were extranodal marginal zone lymphoma [EMZL] (48, 54.5%), follicular lymphoma [FL] (16, 18.2%), and diffuse large B-cell lymphoma [DLBCL] (15, 17.0%). Clinically, significant associations were found between DLBCL and vision change (p < .01), pain (p < .01), extraocular movement limitation (p = .01), and optic neuropathy (p = .01). Radiologically, there was no significant difference between the individual histopathological sub-groups with respect to bone destruction (p = .30), optic nerve involvement (p = .30) and diffuse appearance (p = .84). However, if categorised as either aggressive or indolent, aggressive lymphoma subtypes were significantly more likely to demonstrate globe indentation radiologically than indolent subtypes (Odds Ratio = 5.5, 95% CI: 1.3, 23.3; p = .02). CONCLUSIONS: DLBCL was significantly associated with vision change, pain, extraocular movement limitation and optic neuropathy clinically. Aggressive lymphoma subtypes were significantly more likely to demonstrate globe indentation radiologically. Otherwise, there were no significant differences between lymphoma subtypes and radiological findings on MRI and CT.

Autoimmune markers in screening for orbital inflammatory disease.

PURPOSE: Immunogenic causes of inflammation may be difficult to differentiate in the work-up of orbital inflammatory disease. The study aims to investigate the utility of autoimmune markers in the screening for orbital inflammation. Markers studied included angiotensin-converting enzyme (ACE), antinuclear antibody (ANA), anti-neutrophilic cytoplasmic autoantibodies (ANCA), extractable nuclear antigen (ENA), anti-cyclic citrullinated peptide (Anti-CCP) and anti-double stranded DNA antibody (Anti-dsDNA antibody). METHODS: A retrospective single-centre study of consecutive patients with non-infective orbital inflammation screened for autoimmune markers at presentation. Serology was interpreted alongside clinical course and other investigations (e.g. radiographic features and histopathology). Tabulated data and Pearson's Chi-square allowed analysis of trends between serology, diagnosis and the decision to biopsy. RESULTS: 79 patients, between 1999 and 2021, were included (50 females, mean age was 50.4 ± 17.4 years). 28 (34.6%) patients had specific orbital inflammation and 53 (65.4%) patients had non-specific orbital inflammation (NSOI). Of the 12 patients with positive serology and a specific diagnosis, only 5 (41.7%) patients had concordant serological results. There was no association between serology results and the patient undergoing biopsy (P = 0.651). Serology was unable to exclude nor differentiate NSOI from other specific conditions and ANA had limited discriminatory value between specific conditions and NSOI. CONCLUSION: Serological testing alone may not provide a clear direction for further investigation of orbital inflammation and a biopsy may occur independently of the serological results. The value of autoimmune markers may lie in subsequent follow-up as patients may develop suggestive symptoms after an indeterminate positive result or initially seronegative disease.

Systemic inflammatory markers differentiate between orbital cellulitis and non-specific orbital inflammation.

PURPOSE: Bacterial orbital cellulitis (OC) and diffuse non-specific orbital inflammation (DNSOI) may be challenging to differentiate clinically. This study investigates the utility of systemic inflammatory markers, namely white cell count (WCC) and C-reactive protein (CRP), in differentiating between OC and DNSOI. METHODS: A single-centre retrospective study of patients diagnosed with OC or DNSOI, between 2003 to 2021, who had WCC and/or CRP obtained at presentation. The mean levels of these factors and the proportion of positivity were compared between OC and DNSOI. A receiver operating characteristic (ROC) analysis was conducted to calculate the specificity and sensitivity of WCC or CRP in each group. RESULTS: 49 patients were included in this study. The mean age was 56 ± 20 years, and 21 patients were females. 26 (53.1%) patients had OC, and 23 (46.9%) patients had DNSOI. Mean WCC for OC and DNSOI were 14.5 × 103/µL and 9.27 × 103/µL, respectively (P = 0.001). Mean CRP for OC and DNSOI were 104.4 mg/L and 10.0 mg/L, respectively (P < 0.001). The optimal CRP cut-off value of 20.2 mg/L demonstrated 90.9% sensitivity and 90.5% specificity (AUC = 0.946, P < 0.001) for differentiating between OC and DNSOI. CRP was more predictive of OC than WCC (P = 0.017). 7/26 (26.9%) OC patients with fever also had an elevated CRP, while 1/23 (4.3%) of DNSOI with fever had a normal CRP. CONCLUSIONS: An elevated WCC is suggestive of OC. However, a normal WCC can neither exclude nor differentiate between OC and DNSOI. CRP may be a more accurate predictor of OC compared to WCC.

Normative globe position values on orbital computed tomography in Australians.

OBJECTIVE: To determine normal globe position values, interzygomatic distance (IZD), and globe axial length and width on computed tomography in an Australian cohort. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients who underwent computed tomography of the orbits. Patients with bilateral disease, previous orbital surgery, or poor scan quality were excluded. METHODS: An axial slice through the midglobe was used to conduct the globe position measurements. Anterior globe position was defined as the perpendicular distance from the anterior globe margin to the interzygomatic line and posterior globe position as the perpendicular distance from the posterior globe margin to the interzygomatic line. RESULTS: The normal measurements (mean ± SD) were IZD, 97.4 ± 4.1 mm; anterior globe position, 18.8 ± 2.8 mm; posterior globe position, 6.2 ± 2.9 mm; axial globe length, 24.9 ± 1.1 mm; and axial globe width, 25.9 ± 1.2 mm. A significant positive correlation was seen between the IZD and the anterior globe position (r = 0.15, p = 0.03), axial globe length (r = 0.33, p < 0.01), and axial globe width (r = 0.30, p < 0.01). CONCLUSION: This normative globe position data may be used to diagnose radiologic exophthalmos or enophthalmos.

Blood-stained tears-a red flag for malignancy?

BACKGROUND: Blood-stained tears can indicate occult malignancy of the lacrimal drainage apparatus. This study reviews data on patients presenting with blood in their tears and the underlying cause for this rare symptom. METHODS: Patients presenting with blood in their tears, identified over a 20-year period, were retrospectively collected from a single tertiary ophthalmic hospital's database and analysed. RESULTS: 51 patients were identified, the majority female (58%) with a mean age of 55 years. Most cases were unilateral (96%) with blood originating from the nasolacrimal drainage system in 53%. The most common diagnosis for blood-stained tears was a lacrimal sac mucocele (n = 16) followed by a conjunctival vascular lesion (n = 4). Three patients had systemic haematological disorders. The rate of malignancy was 8% (n = 4), with 2 patients having lacrimal sac transitional cell carcinomas, one with a lacrimal sac plasmacytoma and the other with chronic lymphocytic leukaemia and bilateral orbital infiltration (with bilateral bloody tears). One patient had a lacrimal sac inverted papilloma, a premalignant lesion. Four patients had benign papillomas (of the lacrimal sac, conjunctiva and caruncle). CONCLUSION: Haemolacria was a red flag for malignancy in 8% of patients (and tumours in 18% of patients). A thorough clinical examination including lid eversion identified a conjunctival, caruncle, eyelid or canalicular cause in 27% of cases.

Periocular basal cell carcinoma recurrence following surgical treatment: Safe surveillance time.

BACKGROUND: To report the rate of primary periocular BCC recurrence following surgical excision in low-risk and high-risk BCCs, and to propose long term follow up guidelines. METHODS: Retrospective case series of primary BCC treated with surgical excision (Mohs micrographic surgery [MMS], wide local excision [WLE] or fast paraffin excision) who have histologically-confirmed BCC subtype and histologically-measured tumour clearance margins. RESULTS: 77 patients (78 eyelids) were included. Mean age was 72.0 ± 12.8 years with a female predominance (42, 54.5%). Most common histological BCC subtype was nodular (39, 50.0%). 44 (56.47.1%) patients underwent MMS. Tumour clearance was achieved in 59 (75.6%) eyelids after one surgery. 9 had further surgery to achieve tumour clearance while 10 were monitored. There was no statistical significance between recurrence rates in patients who had tumour clearance compared with patients with incomplete tumour clearance after initial surgery (p = 0.15). In patients with incomplete tumour clearance, there was no statistical significance between recurrence rates in those who underwent further surgery versus those monitored (p = 0.47). Average follow-up duration was 37.9 ± 17.2 months. Three (3.9%) cases had recurrent BCC. All three cases had high-risk BCC features (infiltrative subtypes and/or incomplete tumour excision after initial surgery). CONCLUSIONS: There was no evidence of recurrence of completely excised, low-risk BCCs at three years, regardless of type of surgical excision. We recommend patients with completely excised, primary BCCs without high-risk features be monitored for one year. Patients with any high-risk BCC features, such as incompletely excised tumours or high-risk histological subtypes, should be monitored for five years.

Normative lacrimal gland dimensions by magnetic resonance imaging in an Australian cohort.

PURPOSE: To report the normative dimensions of the lacrimal gland on fat-suppressed contrast-enhanced magnetic resonance imaging (MRI) in an Australian cohort. METHODS: Retrospective review of patients who underwent 3 T orbital MRI is presented. Two hundred eleven orbits were used to conduct lacrimal gland measurements. Orbits were excluded if there was ipsilateral orbital or lacrimal gland disease, prior surgery, or poor image quality. The length and width of the lacrimal gland were measured in axial and coronal sections using the largest image. RESULTS: The mean lacrimal gland axial length was 14.6 mm in the right orbit and 14.3 mm in the left orbit. The mean axial width was 4.9 mm in both orbits. Coronal lengths averaged 16.2 mm in the right orbit and 16.4 mm in the left orbit. The coronal width averaged 4.8 mm in both orbits. A significant negative correlation was found between age and the right axial length (r = -0.26, p < .01) and the left axial length (r = -0.26, p < .01) of the lacrimal gland. No statistically significant difference was found between genders or laterality. CONCLUSION: This study presents the normal lacrimal gland dimensions on fat-suppressed contrast-enhanced MRI in an Australian cohort. An inverse relationship exists between age and the axial length of the lacrimal gland. These data may be used to help diagnose enlargement of the lacrimal gland.

Optic nerve infiltration in systemic non Hodgkin lymphoma.

Optic nerve infiltration secondary to systemic non-Hodgkin lymphoma (NHL) is a rare phenomenon. We present a 55-year-old man with low-grade systemic NHL who initially presented with an isolated optic neuropathy and non-specific neurological symptoms. We further present a literature review of systemic NHL with radiological evidence of optic nerve infiltration. On magnetic resonance imaging, the characteristic features include optic nerve enhancement and enlargement, while leptomeningeal enhancement is uncommon. Cerebrospinal fluid analysis and optic nerve sheath biopsy can return false negative results, and when such investigations are inconclusive, biopsy of the optic nerve substance has a high diagnostic yield. Although rare, lymphomatous optic nerve infiltration must be considered in the differential diagnosis of a pale swollen optic disc.

Evaluation of orbital lesions with DCE-MRI: a literature review.

PURPOSE: To provide a major review on the applications of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in evaluating orbital lesions. This review also outlines selected scenarios where DCE-MRI may be helpful. METHODS: A comprehensive retrospective literature review of all English language publications on PubMed, EMBASE, and Google Scholar between 1994 and 2022. This literature review examined the specific applications and clinical scenarios surrounding the utility of DCE-MRI in orbital lesions and various findings that have been presented in the current literature. RESULTS: DCE-MRI provides information on tissue physiology and permeability, beyond the anatomical features displayed on static imaging. Various measured parameters (qualitative, semi-quantitative, and quantitative) obtained by DCE-MRI have been used to differentiate between benign and malignant lesions, specific orbital lymphoproliferative diseases (OLPD), lacrimal gland lesions, and various rare orbital tumours. DCE-MRI has a limited role as an initial diagnostic imaging modality. However, DCE-MRI may prove to have benefit in predicting and monitoring treatment response in orbital lymphoma as a critical imaging study, but literature specific to orbital malignancies remains limited. CONCLUSION: The value of DCE-MRI may be in situations of diagnostic uncertainty, where it may be an additional imaging aid following conventional imaging techniques. It may also act as a critical imaging modality for monitoring of orbital tumour treatment response, but the literature remains limited. Standardisation of imaging protocol, measured parameters, and statistical analysis remain limitations of this imaging technique.

Extensive orbital inflammation in an anophthalmic socket: is the Bioceramic implant a bystander or a participant?

Purpose: Porous orbital implants are commonly used materials following enucleation or evisceration. Implant-associated inflammation is a rare but serious complication which may necessitate explantation. Observations: We report a case of a patient who developed extensive orbital inflammation six months after implantation of a vicryl (polyglactin 910) mesh-wrapped Bioceramic (aluminum oxide) spherical implant. An orbital biopsy demonstrated an extensive fibroinflammatory reaction with multinucleated giant cells. Removal of the implant resulted in complete resolution of symptoms. Conclusions and importance: We surmise that the Bioceramic implant played a significant contributory role in this patient's orbital inflammation, a complication which has not been described previously.