9
The Basics of Orbital Imaging
Paul Rosel
C
omputed tomography (CT) and magnetic reso-
nance imaging (MRI) are performed for the de-
tection and definition of orbital space-occupying
lesions. Both studies are highly sensitive for lesion de-
tection and are frequently complementary in generat-
ing a differential diagnosis. Imaging guidelines are well
established via protocols dedicated to orbital imaging.1
This chapter reviews quality imaging, highlighting
goals and limitations of both modalities. Basic anat-
omy of the orbit related to imaging is also reviewed.
COMPUTED TOMOGRAPHY
The basis of CT is the measurement of different tis-
sue absorption values, following exposure to x-rays.
The tissue absorption values are defined arbitrarily by
Hounsfield units (HU). Water is assigned an HU of
zero. HU values ranging from ⫺1000 (air) to ⫹1000
(bone) are obtained in the region of orbit and perior-
bital tissues. What is important in routine CT exam-
inations is the relative absorption value of a given tis-
sue to neighboring structures. This relativity in tissue
density is usually described with the terms “iso-
dense,” “hypodense,” and “hyperdense.” Normal
brain tissue, which usually appears gray, is said to be
isodense; hypodensity is seen in tissues with high wa-
ter content, as in edema, and appears dark gray to
black; hyperdensity represents tissues with high ab-
sorption of x-rays, such as cartilage and bone, and ap-
pears white (Table 9.1).
Computed tomography was the first modality that
allowed high quality imaging of orbital contents.2
There has been continuous improvement of CT since
its introduction. Today’s CT studies have evolved to
a spiral (helical) technique with multiple detectors or
a rotating detector system.3,4 This technique allows
one to scan in only a single plane, usually axial. Thin
slice, high-resolution images can then be reformatted
or reconstructed in any plane allowing very revealing
views of essential orbital structures. The patient re-
ceives approximately 35 mGy of radiation for single
slice spiral CT.5 On the other hand, for conventional
CT done under the biplane (axial and coronal) proto-
col, the patient receives approximately 75 mGy. The
new, multidetector spiral CT is capable of obtaining
84
multiple, very thin sectioned scans within minutes
and can reformat the data in any plane required.3 For
routine orbital scanning purposes, sliced thicknesses
of 2 to 3 mm are used, and standard imaging proto-
cols are followed for axial and coronal views.2 In ax-
ial scanning, the slices are acquired parallel to the in-
fraorbitomeatal line; the coronal images are obtained
perpendicular to the axis of the orbit (i.e., the axial
cut). The window selected for orbital studies should
be appropriate for orbital tissue absorption properties,
with a width of 350 to 400 HU and a level of 80 to
100 HU. For better examination of the bone, a win-
dow wider than 1000 HU is necessary; this is called a
bone window. The apex of the orbit is very crowded
and therefore difficult to define. For this area, 1 mm
slices, parallel to a line from the posterior foramen
magnum to the hard palate, are utilized. Pre- and post-
contrast scanning are essential for full evaluation of
orbital lesions; this is most useful in suspected vas-
cular lesions. Specifics of a given study are usually
summarized on the films, which offer valuable infor-
mation (Figure 9.1 and Box 9.1).
The images depicted in this chapter are examples
of the capabilities of spiral CT with multidetector
scanning.4 The extraocular muscles are well defined
in the axial and coronal views. The extraocular recti
muscles outline the intraconal compartments well
(Figure 9.2A,B). The muscles themselves are best iden-
tified in the coronal plane. Parasagittal reconstruc-
tions can show detailed views of the entire optic nerve
within the orbit and through the optic canal, all the
way to the optic chiasm (Figure 9.2C). The optic chi-
asm is best viewed on the coronal reconstruction (Fig-
ure 9.2D). The lacrimal gland is also best seen in the
coronal view (Figure 9.2E).
Lesions affecting the orbital and extraorbital fat
can be well visualized in almost any plane with re-
constructions. Tumors involving the globe with or
without orbital extension may also be depicted with
CT, but MRI serves this purpose better. If bony in-
volvement is clinically suspected, bone algorithm re-
construction is the study of choice (Figure 9.3). Algo-
rithms for bone represent an artificially enhanced edge
contrast and are applied as filters during reconstruc-
tion. CT is also very sensitive for detecting calcifica-
tions within orbital lesions, which can be very help-
 CHAPTER 9: THE BASICS OF ORBITAL IMAGING
TABLE 9.1. Commonly Encountered Absorption Values
in Orbital CT.
Hounsfield unit Fluid or tissue
⫺1000 Air
⫺70 to ⫺100 Fat
0 Water
4–10 Cerebrospinal fluid
35–45 Brain
⫹1000 Bone
ful in generating a differential diagnosis (Figure 9.4).6–8
For orbital tumors with bony involvement, CT is su-
perior to all other modalities (Box 9.2).
The main advantages of CT are availability and
speed. With spiral scanning and multidetector ma-
chines, images can be obtained in a single plane vir-
tually in moments, and reconstructions can be per-
formed in any plane. CT does, however, present some
risks to patients.9–18 The main disadvantage of CT
over other imaging modalities is that CT uses ioniz-
ing radiation (Table 9.1).11–13 Radiation dose is related
to CT technique, but 5 rads to the orbit and lens is
common. This is well below a dose that could induce
cataracts.18 There is some risk of subsequent tumor
induction to the patient, particularly in the pediatric
age group.14–17 This risk is, however, very small. With
the use of intravenous contrast medium, the possibil-
ity of an allergic reaction is always present. The risk
can be reduced with the use of nonionic contrast ma-
terials and prophylaxis if allergy is a consideration. Al-
lergy is usually addressed with nonionic contrast ma-
terial and a combination of steroids, Benadryl, and a
histamine (H2) blocker such as Zantac. Diabetics or
FIGURE 9.1. Sample CT scan parameters.
85
BOX 9.1. CT Imaging Parameters
for Orbits
High resolution orbits
0.63 mm axials
Pitch 1
Table speed 1.25 cm/s
Intravenous contrast medium
Field of view 13 cm
patients with borderline renal function are at risk for
contrast-induced renal failure.9,10 The risk of contrast
material-induced renal failure is higher in patients
with renal failure, multiple myeloma, and other hy-
perviscosity syndromes and dehydration. In patients
with a serum creatine value higher than 1.5 mm/dl, a
nonionic contrast agent should be used. In patients
with known hyperthyroidism, iodized contrast agents
should be avoided.
CT Artifacts
Artifacts of CT studies (Figure 9.5A–G) include high
density foreign bodies such as a shotgun pellet in
the right orbit and face causing streak artifact (Fig-
ure 9.5C). More significant metallic streak artifacts
can be seen from dental fillings (Figure 9.5A). By
viewing the image at bone window, most of that ar-
tifact can be reduced (Figure 9.5B). Circular or ring-
type artifacts are usually related to detector prob-
lems. Figure 9.5D is an axial CT scan that was
performed on a machine with a detector failure. Mo-
tion can degrade the quality of imaging and intro-
duce artifacts at the time of scanning (Figure 9.5G).
Positioning artifacts can also be misleading. On oc-
casion, one may get the impression of proptosis
due to an artifact. For example, a positioning arti-
fact (Figure 9.5E,F) makes the left globe appear to
be proptotic. The normal position of the globe in
adults is 9.4 mm behind the interzygomatic line
(range, 5.9–12.8 mm).18 Other artifacts include par-
tial voluming, where the scanning voxel will in-
clude tissues of two widely different densities such
as cerebrospinal fluid and brain. When these two
densities are averaged together they may create the
illusion of a lesion. Beam-hardening artifact
(Hounsfield artifact), which is mostly seen in the
posterior fossa in the middle cranial fossa and or-
bit, represents increased attenuation of the x-ray
beam due to the density and thickness of bone in
these areas. The beam-hardening artifacts present a
problem, particularly in the apex of the orbit and
the optic canal.
86 PART TWO: DIAGNOSIS OF ORBITAL TUMORS

FIGURE 9.2. Axial orbital CT images with contrast (A) at level of Orbital coronal reconstruction of the orbits at midlevel. (E) Coro-
the optic nerve and (B) showing the optical canal. (C) Parasagittal nal orbital reconstruction with contrast at the equator level of the
reconstruction of orbital CT along the course of the optic nerve. (D) globe.

MAGNETIC RESONANCE IMAGING
MRI is also very useful for detecting and evaluating
orbital mass lesions because of its excellent tissue res-
olution.19–21 This technique allows one to generate
cross-sectional images of the tissues without using x-
rays. It is based on a physical phenomenon called the
nuclear magnetic resonance effect on the atomic nu-
clei, primarily hydrogen atoms of water molecules
within human tissues. When an external, static mag-
netic field is applied to the tissues, the random dis-
tribution of the atomic dipoles is distorted, and they
tend to align in the direction of the field. When the
applied radiofrequency pulse is discontinued, the
macroscopic, magnetic field returns to its original
state by emitting electromagnetic waves with preci-
sional frequencies. The waves emitted during the re-
formation of the magnetic status (relaxation) are
measurable and represent contrast values, corre-
sponding to the brightness of the individual pixels,
which, in turn, construct the images with the use of
mathematical algorithms.

FIGURE 9.3. Bone windows: (A) normal axial CT, (B) normal coronal reconstruction, and (C) normal
sagittal reconstruction.
 CHAPTER 9:
FIGURE 9.4. Orbital mass with focal density. (B) The CT number,
shown as 451.29, is consistent with calcification, which is evidence
of a phlebolith in a lymphangioma.
There are two types of relaxation: longitudinal (T1)
relaxation and transverse (T2) relaxation. During the
T1 relaxation, the excess energy is transferred from
the nuclei to the environment. The T2 form, which
is also termed spin–spin relaxation, represents the de-
cay of the signal vector perpendicular to the strong
magnetic field. These signals, which are obtained from
biological tissues, depend on the water concentration
of tissues, which can be excited. The degree of this ex-
citation depends on the relaxation characteristics of
the protons in water molecules of the tissues being
BOX 9.2. Indications for CT and MRI
CT
Orbitocranial trauma
Orbitocranial hemorrhage
Detection of orbital masses
Evaluation of orbital bones
Evaluation of sinuses
Detection of calcification
THE BASICS OF ORBITAL IMAGING 87
examined. The water reveals a high concentration of
excitable protons and a slow relaxation. In contrast,
protons bound to macromolecules would reveal a fast
relaxation. The relaxation times are therefore deter-
mined by the composition of the MRI characteristics
of different types of tissues. A summary of signal char-
acteristics of orbital tissues listed in Table 9.3 and Fig-
ure 9.6 gives MRI nomenclature and parameters,
respectively. Orbital MRI examinations are also per-
formed and interpreted according to predetermined
neuroradiology protocols (Box 9.3).20 MRI first became
widely available in 1986 and gadolinium contrast en-
hancement in 1988.21
Currently MRI is most often done with a 1.5-
tesla unit using either a head coil or a specially de-
signed surface coil. Fast spin-echo sequences greatly
reduce scan time over what is possible with tradi-
tional spin-echo techniques. Studies should include
pre- and postcontrast T1-weighted axial and coro-
nal images of the orbits extending through the op-
tic chiasm. Fat suppression is done on postcontrast
images, to increase lesion conspicuity by removing
high-signal fat. Following intravenous administra-
tion of contrast agents, such as gadopentate, di-
meglumine (Gd-DPTA), a different take-up by the
tissues is seen in MRI studies. The axial pre- and
postcontrast images should also be interlaced to op-
timize imaging of the optic nerves (Figure 9.7A–C).
This is done with 100% gap or an interlace tech-
nique. T2-weighted images should also be obtained
routinely through the orbits and optic nerves (Fig-
ure 9.7D). Many protocols also include a routine
brain scan consisting of precontrast T1-weighted ax-
ial and sagittal images, diffusion axial, T2-weighted
axial, FLAIR (fluid attenuation inversion recovery),
and postcontrast T1-weighted axial, sagittal, and
coronal images of the brain. MRI is also very sen-
sitive for detection of intra- and extraconal orbital
lesions. The optic nerve and chiasm are also very
well defined. Optic nerve lesions that are not de-
tected with CT may be well delineated with MRI.
MRI offers tissue resolution superior to that avail-
able from CT scanning, allowing better detection of
MRI
Detection of orbital masses
Evaluation of orbital and ocular masses
Evaluation of sinuses
Evaluation of optic pathway
Orbital changes secondary to ocular tumors
Orbitocranial hemorrhage
88 PART TWO: DIAGNOSIS OF ORBITAL TUMORS

TABLE 9.2. Advantages and Disadvantages of CT and MRI.

Advantages Disadvantages

CT Availability and fast examination time Ionizing radiation

Evaluation of bony involvement Contrast reaction
Beam-hardening and other artifacts
MRI Detects virtually all lesions of the orbit Motion and other artifacts
except trauma Missile and thermal injuries
No ionizing radiation Incompatible with a number of medical devices and metal implants
Longer scanning times
Overweight and claustrophobic patients cannot be accommodated

FIGURE 9.5. CT artifacts. (A) Dental fillings causing streak artifacts. (B) Artifact in the patient shown in (A) is reduced in bone win-
dows. (C) Shotgun pellets causing streak artifacts. (D) Detector artifact. (E,F) Positioning artifacts. (G) Distortion due to patient motion.
 CHAPTER 9: THE BASICS OF ORBITAL IMAGING 89
TABLE 9.3. Commonly Encountered Signal Types in Orbital MRI.
Signal type

Tissue type Tl-weighted T2-weighted Fat suppression

Globe Hypo (dark gray) Hyper (white) Hypo (dark gray)

Fat Hyper (white) Hypo (white) Intermediate (gray)
Extraocular muscle Hypo (dark gray) Hypo (light gray) Hyper (white)
Optic nerve Hyper (light gray) Hypo (light gray) Hyper (light gray)
Cerebrospinal fluid Hyper (dark gray) Hyper (white) Hypo (dark gray)
Bone Void (black) Void (black) Void (black)
Vessels Void (black) Void (black) Void (black)

BOX 9.3. MRI Parameters for

Orbital Study

Axial T1-weighted: 3 mm with 100% gap

Coronal T1-weighted: 3 mm with 100% gap
Coronal T1-weighted: 3 mm with 10% gap
Postcontrast fat-saturated T1-weighted axial and
coronals: 3 mm with 100% gap
A routine brain scan is often included.

small lesions. Changes of the globe, such as retinal

FIGURE 9.6. Sample MRI parameters.
or choridal detachment and scleral compression,
which may happen secondary to orbital tumors, also
are properly evaluated with MRI. Furthermore, tis-
sue characterization by MRI is useful in leading to
a differential diagnosis of the space-occupying le-
sions in the orbit.

FIGURE 9.7. Fat-saturated

postgadolinium images: (A)
coronal image through poste-
rior orbit, (B) axial image
through optic nerve, and (C)
coronal T2-weighted image
through the optic chiasm.
(D) Direct coronal T2-
weighted image at midorbit.
90 PART TWO: DIAGNOSIS OF ORBITAL TUMORS

FIGURE 9.8. (A) Coronal T1-

weighted image of a relatively
homogeneous mass in right orbit,
isointense to the ocular muscles.
(B) This T2-weighted image shows
a multicompartment cystic mass
with high signal indicating fluid.
The lesion was a lymphangioma.

TABLE 9.4. MRI Artifacts. In particular, cystic or vascular lesions are better
Artifact Cause
characterized on MRI and its multisequenced param-
eters.5–7 For example, a lymphangioma of the orbit can
Wrap around Wrong field of view
Bioinhomogeneity Magnetic field distortion by metal objects be suggested with a high level of confidence based on
Motion Patient motion during procedure the T1- and T2-weighted relaxation characteristics
Flow or pulsation Misregistration with resulting artifacts (Figure 9.8).6
Chemical shift Usually related to fat protons’
resonating at a frequency different Since the MRI does not use ionizing radiation, it
from water protons does not pose any significant patient risk. Because
Partial volume Related to two different tissues being MRI utilizes high-strength magnetic fields, however,
measured in a single voxel, the
resultant display is an average of the injuries can occur. The deflection of aneurysm clips
two tissues or other metallic devices can cause injury to the pa-

FIGURE 9.9. MRI artifacts. (A) Wraparound artifact due to wrong field of view. (B) Distortion because of the
iron pigment in patient’s mascara. (C) Surgical clip results in distortion or shielding of magnetic field. (D)
Metal artifact (dental hardware). (E) Ghosting from orbital motion. (F) Distortion due to head motion.
 CHAPTER 9: THE BASICS OF ORBITAL IMAGING
FIGURE 9.10. Radiographs from views of a right internal carotid
angiogram. (A) Anterior–posterior (AP) view shows a typical high-
flow fistula from the right carotid artery to the cavernous sinus. (B)
Lateral view: typically type A fistulas are treated endovascularly
from the arterial side.
tient.22.23 In addition, there are case reports of ocular
injuries due to deflection of small metallic fragments
present in the orbits of sheet metal workers when
these patients were placed in the magnet.24 Thermal
91
FIGURE 9.12. Proptosis with chemosis, congestion, and tortuosity
of the conjunctival vessels in a carotid cavernous fistula.
injuries can occur with pacing or monitoring wires
that form a loop adjacent to the skin.25
MRI Artifacts
MRI artifacts far outnumber CT artifacts.26–30 The
main cause of this is the prolonged acquisition time
for MRI: the longer the time, the greater the extent of
motion artifacts because of eye movements. Some of
the common MRI artifacts are listed in Table 9.4 and
shown in Figure 9.9.
ANGIOGRAPHY AND
ORBITAL INTERVENTIONS
With the development of magnetic resonance angiog-
raphy (MRA) and computed tomographic angiography
(CTA), the use of catheter diagnostic angiography has
diminished dramatically. Catheter diagnostic angiog-
raphy is not commonly used for orbital tumor diag-
nosis other than for vascular lesions. This imaging
technique, however, remains the examination of
choice for evaluating some of the vascular patholo-
gies, particularly carotid cavernous fistula. The cath-
FIGURE 9.11. Angiograms
of a right internal carotid
artery after placement of a
detachable balloon: (A) AP
view and (B) lateral view.
92 PART TWO: DIAGNOSIS OF ORBITAL TUMORS

FIGURE 9.15. Tip of microcatheter in cavernous sinus; microcoils

at level of fistula.

eter angiogram is essential to classify the arteriove-

nous fistula and also determines the best treatment
option.31,32 Angiography is briefly reviewed in this
chapter because of its limited role in differential di-
agnosis of lesions occupying orbit–cranial space. Bar-
row and coworkers classify spontaneous carotid cav-
ernous fistulas as follows:31

Type A: Direct high flow fistula between the internal

carotid artery and the cavernous sinus (Figures 9.10,
9.11, and 9.12)
Type B: Dural shunts between meningeal branches of
the internal carotid artery and the cavernous sinus
(Figures 9.13, 9.14, and 9.15)
Type C: Dural shunts between meningeal branches of
FIGURE 9.13. A type B fistula: (A) lateral angiogram and (B) en- the external carotid and the cavernous sinus
larged lateral angiogram.
Type D: Dural shunts between the meningeal
branches of both the internal and external carotid
arteries and the cavernous sinus

FIGURE 9.14. (A) Sheath placed into the superior ophthalmic vein. (B) Lateral view of microcatheter and contrast injection into the su-
perior ophthalmic view and cavernous sinus. Radiographs of a right internal carotid angiogram after placement of a detachable balloon
in the cavernous sinus to seal the fistula; the balloon was introduced from the arterial side.
 CHAPTER 9: THE BASICS OF ORBITAL IMAGING
References
1. Som PM, Cutin HD. Head and Neck Imaging. 4th ed. St. Louis:
CV Mosby, 2003:451–452.
2. Muller-Forell WS. Computed tomograpy. In: Muller-Forell WS,
ed. Imaging of Orbital and Visual Pathway Pathology. Berlin:
Springer-Verlag; 2002:15–17.
3. Hu H, He HD, Foley WD, Fox SH. Row helical CT: image qual-
ity and volume coverage speed. Radiology 2000;215:55–62.
4. Jones R, Kaplan RT, Lane B, et al. Single versus multi-detec-
tor row CT of the brain: quality assessment. Radiology 2001;
219:750–755.
5. Lakitis A, Prokesch R, Scholda CH, et al. Helical and conven-
tional CT in the imaging of metallic foreign bodies in the or-
bit. Acta Ophthalmol Scand 2000;789:79–83.
6. Graeb DA, Rootman J, Robertson WD, et al. Orbital lym-
phangiomas: clinical, radiologic and pathologic considerations.
Radiology 1990;175:417–421.
7. Gunalp I, Gündüz K. Cystic lesions of the orbit. Int Ophthal-
mol 1997;20:273–277.
8. Savoiardo M, Stradas L, Passerini A. Cavernous hemangioma
of the orbit: value of CT, angiography and phlebography. Am
J Neuroradiol 1983;4:741–744.
9. American College of Radiology Committee of Drugs and Con-
trast Media. Manual on Contrast Media. 4th ed. 2001.
10. Katzbert RW. Urography into the 21st century: new contrast,
renal handling, imaging characteristics and nephrotoxicity. Ra-
diology 1997;204:297–312.
11. Barns E. Studies shed doubt on low level radiation dangers.
2003. www.auntminnie.com
12. Rehani MM. CT: caution on radiation dose. Indian J Radiol
Imag 2000;10:19–20.
13. Hidajat N, Wolf M, Nunnerman, et al. Survey of conventional
and spiral CT doses. Radiology 2001;218:395–401.
14. Donnely LF, Emery KH, Brody AS, et al. Minimizing radiation
dose for pediatric body applications of single-detector helical
CT: strategies at a large children’s hospital. AJR Am J
Roentgenol 2001;176:303–306.
15. Brenner DJ, Elliston CD, Hall EJ, Berdon WE. Estimates of the
cancer risks from pediatric CT radiation are not merely theo-
retical: comment on “point/counterpoint: in x-ray computed
tomography, technique factors should be selected appropriate
to patient size against the proposition.” Med Phys 2001;28:
2387–2388.
16. Paterson A, Frush DP, Donnelly LF. Helical CT of the body:
93
are the settings adjusted for pediatric patients? AJR Am J
Roentgenol 2001;176:297–301.
17. Rodgers L. Taking care of children: check out parameters used
for helical CT. AJR Am J Roentgenol 2001;176:287.
18. Maclennan AC, Hadley DM. Radiation dose to the lens from
computed tomography scanning in a neuroradiology depart-
ment. Br J Radiol 1995;68:19–22.
19. Wichmann W. Magnetic resonance imaging (MRI). In: Muller-
Forell WS, ed. Imaging of Orbital and Visual Pathway Pathol-
ogy. Berlin: Springer-Verlag; 2002:18–23.
20. Ettl A, Kramer J, Daxer A, et al. High resolution magnetic res-
onance imaging of neurovascular orbital anatomy. Ophthal-
mology 1997;104:869–877.
21. Wichmann W, von Ammon K, Fink V, et al. Aneurysm clips
made of titanium: magnetic characteristic and artifacts in MR.
AJNR Am J Neuroradiol 1997;18:939–944.
22. Landrigan C. Preventable deaths and injury during magnetic
resonance imaging. N Engl J Med 2001;345:1000–1001.
23. Dempsy MR, Condon B, Hadley DM. Investigation of the fac-
tors responsible for burns during MRI. J Magn Reson Imaging
2001;13:627–631.
24. Hornak JP. The basics of MRI. Ch 11. Image artifacts. www.-
vibrantljue.com.
25. Tope WD, Shellock FG. Magnetic resonance imaging and per-
manent cosmetic (tattoos): survey of complications and ad-
verse events. J Magn Reson Imaging 2002;15:180–184.
26. Basics of MRI—artifacts. Department of Radiology, Nagasaki
University Site. www.med.nagasakiu.ac.Jr/Radiology%20of%
20The 20%foot/mri-cnduh/nf-artifacts.html
27. Shellock FG, Kanal E. Aneurysm clips: evaluation of MR Imag-
ing artifacts at 1.5 tesla. Radiology 1998;209:563–566.
28. Roeltgen DP. Orbital vascular mass, ability to assess. http://
www.shcares.org/services/IRC/CME.
29. Kim DH, Adalsteinsson E, Spielman DM. Spiral readout gra-
dients for the reduction of motion artifacts in chemical shift
imaging. Magn Reson Med 2004;51:458–463.
30. Chang CJ, Chen YR, Noordhoff MS, et al. Facial bone fracture
associated with carotid-cavernous fistula. J Trauma 1990;30:
1335–1339.
31. Meyers PM, Halbach VW, Dowd CF, et al. Dural carotid-
cavernous fistula: definitive endovascular management and
long-term follow-up. Am J Ophthalmol 2002;134:85–92.
32. Debrun GM, Vinuela F, Fox AJ, et al. Indications for treatment
and classification of B2 carotid-cavernous fistulas. Neuro-
surgery 1998;22:285–289.