Radiological Assessment of Typical

and Atypical Orbital Infections: A

Space-based Approach
eEdE-108

Blair A Winegar, M.D.

H. Christian Davidson, M.D.
Edward P Quigley, III, M.D. Ph.D.
University of Utah Neuroradiology
Disclosure Statement

• No financial interests to disclose

Purpose

• Illustrate the imaging features of typical

and atypical orbital infections
• Elucidate critical imaging findings which
affect clinical management
• Discuss disease entities which may mimic
the imaging appearance of orbital infection
 Orbital Anatomy

Anatomic
subsections:

• Preseptal

• Postseptal

• Extraconal

• Intraconal

• Ocular

Axial CT Axial T1
 Orbital Anatomy

Anatomic
subsections:

• Postseptal

• Extraconal

• Intraconal

Coronal CT (mid orbit) Coronal T1 (mid orbit)

Preseptal Space

• Preseptal and postseptal

spaces separated by orbital
septum

• Orbital septum is a sheet of

fibrous tissue which is
continuous with the
periosteum of the orbital rim
and fuses with the levator
aponeurosis (upper lid) and
tarsus (lower lid)

• Acts as boundary to extension

of pathology from preseptal to
postseptal space
Expected course of the
orbital septum
Preseptal Cellulitis

• Infection within soft

tissues anterior to the
orbital septum

• Typically polymicrobial
(e.g. Staphylococcus,
Streptococcus,
Pneumococcus,
Neisseria)

• Treated with outpatient

oral antibiotics, drainage
Left preseptal inflammation of abscess if present
consistent with preseptal cellulitis
Preseptal Cellulitis

Key Imaging Findings

• Inflammation/Swelling
anterior to expected
course of orbital
septum
Rim enhancing
fluid collection in
• Preseptal abscess –
left preseptal rim enhancing fluid
space consistent
with preseptal
collection in preseptal
abscess space
Acute Bacterial Conjunctivitis

• Infection of the conjunctiva –

inner layer of the eyelid &
outer layer of the anterior
eyeball

• Common organisms –
Staphylococcus,
Streptococcus, Haemophilus

• Typically initially unilateral (in

contrast to viral conjunctivitis,
which is typically bilateral)

Right conjunctival enhancement and T2

hyperintensity consistent with conjunctivitis
 Acute Bacterial Conjunctivitis
Left conjunctival rim
enhancing fluid collection
with air and preseptal soft
tissue swelling – bacterial
conjunctivitis
Key Imaging Findings
• Inflammation/Swelling
limited to the
conjunctiva
• Typically unilateral
• No drainable fluid
collection
Clinical image of same
patient demonstrating
conjunctival inflammation
and pus
Acute Dacryocystitis

• Infection of the lacrimal sac

at the medial canthus,
typically secondary to
nasolacrimal duct obstruction

• Common organisms:
Staphylococcus,
Streptococcus

• Treatment with oral

antibiotics, warm
compresses, possible
surgical relief of nasolacrimal
Dilatation of the left lacrimal sac with rim duct obstruction
enhancement consistent with acute
dacryocystitis
Acute Dacryocystitis

Key Imaging Findings

• Dilatation of the lacrimal

sac at the medial canthus

• Rim enhancement of the

lacrimal sac

• Surrounding inflammatory
change +/- abscess in the
preseptal soft tissues
Right rim enhancing fluid collection
at site of lacrimal sac and associated
preseptal soft tissue swelling
consistent with acute dacryocystitis
Postseptal – Extraconal Space
• Postseptal space is
posterior to the orbital
septum

• Extraconal space is
peripheral to the cone
formed by the four rectus
muscles and enveloping
sheet of fascial tissue
between these muscles

• Infection in postseptal
extraconal space are
typically extension from
Cone formed by the four rectus adjacent sinus infection
muscles and intermuscular fascia
and extraconal space
Subperiosteal Abscess

• Abscess confined
between orbital osseous
wall and periosteum
• Secondary to sinus
infection, therefore, seen
most commonly along
the medial or superior
orbital walls
Rim enhancing fluid collection along • More common in
left lamina papyracea with mass effect
on left medial rectus, and left ethmoid pediatric population
sinus disease consistent with
subperiosteal abscess
Subperiosteal Abscess

Key Imaging Findings

• Rim enhancing fluid

collection typically along
the medial or superior
orbital walls

• Internal T2 hyperintensity
and restricted diffusion on
MRI
Left superior extraconal rim enhancing • Adjacent sinus
fluid collection with adjacent frontal
sinus opacification consistent with opacification
subperiosteal abscess
Invasive Fungal Sinusitis

• Aggressive fungal infection

across tissue boundaries
with high morbidity/mortality

• Associated with
immunocompromised
states (e.g. uncontrolled
diabetes mellitus, absolute
neutropenia)

• Secondarily affects orbit

Ill-defined intraconal enhancement and
after extension from
nonenhancement of the left ethmoid paranasal sinuses
sinus mucosa consistent with invasive
fungal sinusitis
Invasive Fungal Sinusitis

Key Imaging Findings

• Ill-defined T2
hyperintensity and
enhancement of involved
soft tissues

• Adjacent paranasal sinus

opacification

Ill-defined enhancing inflammation in

• Nonenhancement of the
the right retrobulbar soft tissues and paranasal sinus mucosa -
nonenhancing necrosis of the right necrosis
palate compatible with invasive fungal
sinusitis
Acute Dacryoadenitis

• Inflammation/Infection
of the lacrimal gland
• Multiple infectious
etiologies: viral (most
common), bacterial,
protozoan/fungal
• Supportive treatment
(warm compresses)
Enlargement and enhancement of the with or without
left lacrimal gland consistent with
dacryoadenitis
antibiotics
Acute Dacryoadenitis

Key Imaging Findings

• Swelling/Inflammation
of the lacrimal gland
in superolateral
Rim enhancing fluid
collection in left extraconal soft
lacrimal gland tissues
consistent with
abscess, also left
paranasal sinus • Diffuse T2
disease, subdural
empyema, and
hyperintensity and
preseptal cellulitis enhancement
Postseptal – Intraconal Space
• Postseptal space is posterior
to the orbital septum

• Intraconal space is central to

the cone formed by the four
rectus muscles and enveloping
sheet of fascial tissue between
these muscles

• Intermuscular fascia is thicker

anteriorly – seen on cross-
sectional images

• Intraconal space infections are

Cone formed by the four rectus
muscles and intermuscular fascia
and intraconal space
typically a result of extension
of infection from the extraconal
space
Orbital Cellulitis
• Infection of the orbital soft tissues
posterior to the orbital septum
(intraconal or extraconal)

• Typically an extension of
paranasal sinus disease, but may
be from extension of preseptal
cellulitis, trauma/foreign body, or
hematogenous

• Potential for series complications:

vision loss, orbital abscess,
cavernous sinus thrombophlebitis,
intracranial abscess

• Requires more aggressive

Preseptal and postseptal antibiotic treatment and
enhancement with proptosis and surveillance than preseptal
posterior tenting of the left globe cellulitis
consistent with orbital cellulitis
Orbital Cellulitis
Key Imaging Findings

• Inflammatory fat
stranding, T2
hyperintensity, and
enhancement involving
the retrobulbar soft
tissues

• Possible exophthalmos,
posterior tenting of the
Inflammatory stranding within the left
retrobulbar (intraconal and extraconal)
globe at the optic nerve
soft tissues with proptosis and tenting insertion if severe and
of the left posterior globe consistent vision-threatening
with orbital cellulitis
Orbital Abscess

• Complication of orbital
cellulitis

• Requires surgical drainage

in addition to antibiotics

• Typically present with more

severe symptoms than
uncomplicated orbital
cellulitis: proptosis,
ophthalmoplegia, increased
pain with eye movements
Right preseptal and postseptal rim
enhancing fluid collection
consistent with orbital abscess
Orbital Abscess

Key Imaging Findings

• Defined rim enhancing fluid

collection in postseptal soft
tissues

• Central T2 hyperintensity
and restricted diffusion

• Exophthalmos and mass

effect upon adjacent
structures (e.g. optic nerve,
Rim enhancing fluid collection with
internal air in preseptal and postseptal
extraocular muscles)
soft tissues consistent with orbital
abscess
Cavernous Sinus Thrombophlebitis

• Life-threatening complication
caused by clot formation in the
cavernous sinus

• Symptoms/signs include: periorbital

edema, pain, proptosis, cranial
nerve palsies (e.g. ptosis,
ophthalmoplegia, dysesthesia to
face)

• May affect both eyes if clot extends

to involve contralateral cavernous
sinus

• Treatment with broad-spectrum IV

antibiotics, IV heparin
Right superior ophthalmic vein
(controversial), and IV steroid
thrombosis and cavernous sinus
(controversial)
thrombosis
Cavernous Sinus Thrombophlebitis

Key Imaging Findings

• Non-enhancement of the
affected cavernous sinus
secondary to indwelling
clot

• Expansion of affected
cavernous sinus

• Enlargement +/- non-

enhancement of the
Right superior ophthalmic vein
thrombosis and bilateral cavernous
superior ophthalmic vein
sinus thrombosis
Herpes Zoster Ophthalmicus

• Reactivation of the herpes

zoster virus affecting the soft
tissues supplied by cranial
nerve V1

• Typically confined to facial skin

supplied by CN V1

• However, severe infection may

affect globe, retrobulbar soft
tissues, optic nerve, or
cavernous sinus

Inflammatory changes in the preseptal • Treated with IV antiviral

and postseptal soft tissues and therapy (e.g. acyclovir)
cavernous sinus thrombosis – herpes
zoster ophthalmicus
Herpes Zoster Ophthalmicus

Key Imaging Findings

• In presented case:

• May demonstrate cranial nerve

enhancement and thickening –
affected additional cranial
nerves traversing cavernous
sinus

• May demonstrate T2
hyperintensity and
enhancement of optic nerve –
Inflammatory changes in the
associated optic neuritis
postseptal soft tissues and superior
ophthalmic vein thrombosis – herpes
zoster ophthalmicus
Ocular Space
• The globe can be separated into
anterior and posterior segments
• Anterior segment – structures anterior to
and including the lens, ciliary body, and
suspensory ligaments (includes anterior
and posterior chambers)
• Posterior segment – structures posterior
to the lens, ciliary body, and suspensory
ligaments (includes vitreous body and
posterior layers of the globe)

• Posterior ocular wall (inner to

outer) – retina, choroid, sclera,
episclera

• Imaging typically performed for

posterior segment pathology,
since anterior segment pathology
can be easily clinically assessed
Endophthalmitis/Panophthalmitis
FLAIR hyperintensity in the anterior/posterior
segments, posterior uveal thickening/enhancement
and preseptal/postseptal inflammation -
panophthalmitis
• Endophthalmitis is inflammation
involving the ocular cavities and
adjacent structures
• Panophthalmitis is inflammation
involving the entirety of the ocular
structures
• Typically a result of ocular surgery
(e.g. cataract surgery), penetrating
traumatic injury, or retained intraocular
foreign body
• Less commonly a result of
hematogenous spread (i.e. metastatic
endophthalmitis) in
immunocompromised patients (e.g.
diabetics)
• Typically polymicrobial and caused by
a variety of bacteria or fungi.
Endophthalmitis/Panophthalmitis

Key Imaging Findings

• Increased FLAIR hyperintensity

within the vitreous body

• Thickening and increase

enhancement of the posterior
ocular walls

• Possible extension of T2
hyperintensity and enhancement
to adjacent retrobulbar soft tissues

• Intraocular abscesses suggested

by internal restricted diffusion
Nodules of restricted diffusion along the inner
surface of posterior chamber wall –
subchoroidal abscesses
Intraocular Cryptococcus Infection

• Cryptococcus neoformans is a
ubiquitous encapsulated yeast
found in soil

• Can cause rare intraocular

infection in immunocompromised
state (e.g. AIDS)

• May result in endophthalmitis,

chorioretinitis, or vitreitis

• Treatment with oral, IV, or

intravitreal antifungals
Choroidal detachments with mildly hyperintense
T1 and isointense T2 signal with respect to
vitreous – Cryptococcus chorioretinitis
Intraocular Cryptococcus Infection

Key Imaging Findings

• Imaging finding dependent on

structures affected

• Chorioretinitis – enhancement
and thickening of the posterior
uvea, potential retinal or
choroidal detachments

• Vitreitis – FLAIR hyperintensity

within the vitreous

• Endophthalmitis – combination
Choroidal detachments with choroidal of vitreitis and chorioretinitis
thickening and enhancement –
Cryptococcus chorioretinitis
Mimics

• Many infiltrative,
inflammatory, and
neoplastic etiologies may
have similar imaging
appearance to infection

• Must rely on history,

symptoms, and additional
imaging findings to
separate potential
Right intraconal and ocular wall etiologies
enhancement in a patient with
idiopathic orbital inflammatory
syndrome
Mimic: Idiopathic Orbital Inflammatory
Syndrome (Orbital Pseudotumor)
• Benign, non-granulomatous
inflammatory process of yet unknown
etiology which may affect many sites
of the orbital soft tissues

• Diagnosis of exclusion

• Painful (in contrast to orbital

lymphoma which is painless)

• Many cases now linked to IgG4-

related disease

• Key Imaging – Ill-defined

Ill-defined contrast enhancement
expanding and surrounding the left medial
rectus muscle consistent with myositic
subtype of IOIS
enhancement, T2 isointense to
hyperintense (generally less than
infection)
Mimic: Idiopathic Orbital Inflammatory
Syndrome (Orbital Pseudotumor)
• Categorized by area
affected by inflammation:
myositic, lacrimal,
anterior, diffuse, or apical

• If inflammation affects the

cavernous sinus, given
name Tolosa-Hunt
Syndrome

Enhancement at left orbital apex extending

into the left cavernous sinus – Tolosa-Hunt
Syndrome
 Mimic: Orbital Lymphoma
• Non-Hodgkin lymphoma affecting
the orbital soft tissues

• Approximately 50% malignant

orbital tumors

• Adnexal Orbital MALT-lymphoma

associated with Chlamydia psittaci
infection

• Diagnosed by biopsy

• Treated with chemotherapy and

radiation

• Key Imaging – Diffusion

Enhancing, T2 hypointense, and restriction, homogeneous
diffusion restricting soft tissue in the enhancement, and T2
extraconal spaces of the bilateral orbits hypointensity
consistent with orbital lymphoma
Mimic: Orbital Amyloidosis
• Amyloidosis is a heterogeneous
group of diseases characterized
by deposition of amorphous
proteinaceous material

• There are systemic (multiorgan)

and localized (single organ) forms
of amyloidosis

• Localized orbital amyloidosis is

rare and requires biopsy for
definitive diagnosis and exclusion
of systemic forms of the disease

• Key Imaging – T2 hypointensity

and diffuse enhancement
Ill-defined enhancing, T2 hypointense lesion in
left medial extraconal soft tissues with linear
enhancement involving CN III – orbital
amyloidosis
Mimic: Granulomatosis with
Polyangiitis
Left retrobulbar enhancement, septal
perforation, medial maxillary sinus wall • Key Imaging – Ill-defined orbital T2
destruction, and diffuse paranasal sinus
inflammation consistent with
granulomatosis with polyangiitis
• Formerly known as Wegener
granulomatosis
• Autoimmune vasculitis of small to
medium-side vessels which primarily
affects the respiratory tract and
kidneys
• Orbital involvement is one of the most
frequently involved sites outside the
respiratory tract and kidney, and may
be a result of localized disease
involvement or extension of adjacent
upper respiratory inflammation
hyperintensity and enhancement,
septal perforation and destructive
paranasal sinus disease
Mimic: Vogt-Koyanagi-Harada
Syndrome • Presumed autoimmune disease
resulting in attack of melanocytes
in skin, uvea, meninges, and inner
ear

• Results in bilateral panuveitis and

retinal detachments

• Four phases: prodromal, uveitic,

convalescent, and chronic
recurrent

• Treated with aggressive

immunomodulatory therapy

• Key Imaging – Bilateral posterior

uveal thickening and
Bilateral posterior uveal thickening and
enhancement, possible retinal
enhancement compatible with Vogt-
Koyanagi-Harada Syndrome
detachment, and possible
meningeal enhancement
 Summary

• Orbital imaging evaluation is common in the setting of

suspected orbital infection as it can reliably detect
pathology, quantify severity of disease, and assess for
potential complications which would alter clinical
management.

• Knowledge of orbital anatomy and cross-sectional

imaging findings of orbital infections is paramount in
directing appropriate clinical care.

• Many inflammatory, infiltrative, and neoplastic processes

may mimic orbital infection.
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