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2 CASES OF EYE ASYMMETRY

This article discusses the theoretical considerations and clinical findings related to cases of eye asymmetry, including the approach to differential diagnosis and the mimickers of orbital inflammation. Two case studies are presented, one involving a painless exophthalmos in a 70-year-old female, diagnosed as B-cell non-Hodgkin lymphoma, and the other involving long-standing enophthalmos in a 50-year-old male, diagnosed as silent sinus syndrome.

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2 CASES OF EYE ASYMMETRY

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  1. 2 CASES OF EYE ASYMMETRY N. De Vos1,2 Prof. Dr. F. M. Vanhoenacker1,2,3 Prof. Dr. M. Mespreuve1,2 Dr. J. Van Haesendonck4 1. Department of Radiology, UZ Gent 2. Department of Radiology, AZ Sint-Maarten, Duffel-Mechelen 3. Department of Radiology, UZ Antwerpen 4. Department of otorhinolaryngology, AZ Sint-Maarten, Duffel-Mechelen

  2. THEORETICAL CONSIDERATIONS ORBITAL ANATOMY Tailor TD et al. Radiographics, 2013.

  3. THEORETICAL CONSIDERATIONS APPROACH TO DDx CLASSICAL APPROACH • Etiology: inflammation – infection – neoplasm – trauma • Comprehensive DDx: not clinically helpful LOCATION-BASED APPROACH • Anatomy: conal – intraconal – extraconal – intraocular • Concise DDx: helpful for clinician

  4. THEORETICAL CONSIDERATIONS APPROACH TO DDx CLINICAL FINDINGS • Age, duration, pain, uni- or bilateral • Crucial for further narrowing DDx MIMICKERS • Metastases, lymphoproliferative diseases, sarcoidosis, idiopathic orbital inflammation • Variety of imaging presentations • May involve several orbital structures

  5. CASE 1 CASE 1 • 70 year-old female • Painless left-sided exophthalmos • Since 3 months • Medical history: / • Fundoscopy: normal

  6. CASE 1 CECT Extraconal mass, inferomedial side of left orbit Extension to inferior nasal meatus Uniform contrast enhancement

  7. CASE 1 CECT Bone remodeling with dilation of nasolacrimal duct

  8. CASE 1 T1-WI T2-WI Low to intermediate signal intensity

  9. CASE 1 fs T1-WI + Gd Uniform enhancement Absence of necrosis

  10. CASE 1 DWI ADC Restricted diffusion

  11. CASE 1 DIFFERENTIAL DIAGNOSIS CRUCIAL FINDINGS • 70 year-old female • Rapid onset of painless exophthalmos • Extraconal orbital mass • MRI: low SI, diffusion restriction: high nuclear-cytoplasmic ratio DIFFERENTIAL DIAGNOSIS • Lacrimal sac tumor • Lymphoproliferative disease

  12. CASE 1 DIAGNOSIS AND TREATMENT BIOPSY: LYMPHOMA • B-cell non-Hodgkin lymphoma • 24% of all space-occupying orbital tumors in patients older than 60 years • 30% of patients will develop systemic lymphoma within next 10 years TREATMENT: CHEMOTHERAPY • Bendamustine + Rituximab

  13. CASE 2 CASE 2 • 50-year old male • Right-sided enophthalmos • Longstanding • Sensation of eye displacement when blowing nose • Medical history: /

  14. CASE 2 CT Right-sided enophthalmos No intra-orbital abnormalities

  15. CASE 2 CT Heterogeneous opacification of maxillary sinus Volume loss, inferior displacement of orbital floor

  16. CASE 2 CT CECT Thin-walled sinus, no erosions, small calcifications Minimal enhancement

  17. CASE 2 T1-WI T2-WI T1-WI: low SI T2-WI: high SI Fat proliferation in infratemporal fossa

  18. CASE 2 fs T1-WI + Gd Mucosal enhancement

  19. CASE 1 DIFFERENTIAL DIAGNOSIS CRUCIAL FINDINGS • 50 year-old male • Longstanding right-sided enophthalmos • Right-sided maxillary sinus • Complete opacification • Volume loss • Thin osseous walls

  20. CASE 2 DIAGNOSIS SILENT SINUS SYNDROME Case courtesy of Prof Frank Gaillard, Radiopaedia.org, rID: 9447

  21. TAKE HOME MESSAGES ORBITAL IMAGING • Location-based: globe – muscle cone – extraconal – intraconal • Clinical findings • Mimickers: lymphoproliferative diseases, metastases, sarcoidosis, idiopathic orbital inflammation • Paranasal sinuses

  22. REFERENCES Meltzer, DE. Orbital imaging: a patter-based approach. Radiol Clin N Am. 2015;53:37-80. Tailor TD, Gupta D, Dalley RW, Keene CD, Anzai Y. Orbital neoplasms in adults: clinical, radiologic, and pathologic review. Radiographics. 2013;33(6):1739-58. Choi JW, Kim HJ, Kim ST, Lee HB. CT and MR imaging findings of tumors and tumor-like conditions of the lacrimal sac. EPOS. 2011. http://dx.doi.org/10.1594/ecr2011/C-1926 Illner A, Davidson HC, Harnsberger HR, Hoffman J. The silent sinus syndrome: clinical and radiographic findings. AJR Am J Roentgenol. 2002;178(2):503-6.

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