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Pediatric Ocular Sonography
Cicero J Torres A Silva, MD Associate Professor of Radiology
Yale University
School of Medicine
2016 SPR Pediatric Ultrasound Course
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Disclosures
None
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Objectives of Presentation
Overview of differential diagnoses and sonographic findings of
intra- and extraocular pediatric abnormalities
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Ocular sonography - indications
Following ophthalmoscopic examination:
• Inconclusive examination
• Suspicion of mass underlying retinal detachment
• Work-up of mass
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Technique
High-frequency linear transducer, small footprint
Eyes closed, scan through eyelid
Low power settings (MI < 0.28)
Lots of gel!
FOV to include retrobulbar structures
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Eye anatomy
•Cornea
•Anterior Chamber
•Lens
•Vitreous
•Ciliary Body •Optic disk
Vitreous
Optic disk
•Optic nerve
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Lesions
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Retinal Detachment
Separation of retinal layers
Fixation points at optic disk and ora serrata
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Eye anatomy
•Cornea
•Anterior Chamber
•Lens
•Vitreous
•Ciliary Body •Optic disk
Vitreous
Ora serrata
Optic disk
•Optic nerve
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Retinal Detachment
Separation of retinal layers
Fixation points at optic disk and ora serrata
Causes:
•Trauma (most often)
•Retinoblastoma
•Coats’
•Retinopathy of prematurity
•Coloboma
•High myopia
•Complication of eye surgery
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Retinoblastoma • Most common pediatric ocular tumor; highly malignant; 1/3 bilateral
• Retinal detachment
• Heterogeneous solid mass w calcifications
• Increased risk for metastasis – invasion of:
– Optic nerve
– Anterior segment
– Orbital rim (choroid/sclera)
• MRI for staging (extraocular and intracranial involvement)
• Ultrasound at diagnosis and follow-up
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Cataract • Any opacity in the lens (echogenic on sonography)
• Congenital: secondary to infection
• Childhood: steroids and radiotherapy (such as for retinoblastoma)
• Opacity in the lens obscures ophthalmoscopic view
-> Ultrasound to evaluate for associated conditions:
– Retinoblastoma
– Vitreous inflammation
– Persistent fetal vasculature
normal lens cataracts
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Persistent Fetal Vasculature
• Fetal blood supply to the eye fails to resorb
• Vascularized plaque from lens to optic disk
• Unilateral
• Cataract
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Coats’ disease
• AKA primary retinal telangiectasia
• Blood-retinal barrier defect -> exudate -> retinal detachment
• Unilateral
• Peaks between 6 and 8 years
• Ultrasound to document absence of subretinal mass
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Retinopathy of prematurity
• Proliferation of fibrovascular tissue in the retina
• Premature infants treated with oxygen
• Bilateral
• May extend to vitreous:
– Hiperecoic tracts from retina to vitreous
– Vitreous hemorrhage
• Advanced cases: retinal detachment
• Ultrasound to document absence of subretinal mass
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Coloboma
• Incomplete closure of embryonic optical fissure
• Anywhere from eyelid to optic nerve
• Widening of optic disk
• Retinal detachment
• Differential: cupping of the optic disk
simple-med.blogspot.com
nei.nih.gov
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Cupping of the optic disk
• Increased intra-ocular pressure (such as glaucoma)
• High myopia
myopia Coloboma
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Papilledema
• Elevation of the optic disk, due to elevated intracranial pressure
• Usually bilateral
• Increased optic nerve sheath diameter (normal ≤ 4-6 mm)
• Differential: Drusen
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Drusen
• Benign calcium deposits at optic nerve head
• Usually bilateral
• Clinically may be confused with papilledema
• Echogenic focus in optic nerve head, not associated with increased ONSD
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Differential between drusen and papilledema:
• Decrease gain
• Change probe orientation
=> Drusen remains echogenic
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Choroidal Detachment
• Transudation or hemorrhage followed by detachment
• Spontaneous (glaucoma, high myopia), trauma or surgery
• Biconvex lateral lesions anchored outside optic disk
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Vitreous Hemorrhage
• Bleed into the vitreous chamber
• Most cases from trauma
• Other causes: Coats’, retinopathy of prematurity, retinoblastoma, persistent fetal vasculature, leukemia, hemophilia
• Bleed obscures ophthalmoscopic view
-> Ultrasound to evaluate for underlying conditions
• Increased vitreous echogenicity to massive bleed w levels
• Differential: vitreous inflammation
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Vitreous Inflammation
• Infection or autoimmune
• May be complicated by cataract
• Inflammation +/- cataract obscures ophthalmoscopic view
• Ultrasound: strands of increased echogenicity in vitreous
• Findings resemble vitreous hemorrhage
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Choroid inflammation
• Infection, autoimmune, or trauma
• Ultrasound:
– Thickening of orbital rim
– Increased flow on Doppler
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Mucopolysaccharidoses
• Reports of thickening of orbital rim, likely due to scleral deposition of mucopolysaccharides
• Differential with choroid inflammation
• Other reports: optic nerve head protrusion, widening of optic nerve sheath complex
Courtesy of José Jarrín, MD
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Ocular Toxocariasis
• Parasites Toxocara canis and Toxocara cati
• Larvae may migrate to eye
• Usually unilateral
• One of three forms:
– Focal lesion along peripheral retina (peripheral granuloma)
– Focal lesion near optic disk (posterior pole granuloma)
– Vitreous inflammation
• May be associated with retinal detachment
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Retinal astrocytic hamartoma
• Congenital lesion, associated with tuberous sclerosis
• About 50% of TS patients have retinal astrocytic hamartomas
• Small focal lesions along orbital rim
• Bilateral in 50% of cases, stationary, requires no treatment, may calcify
• May be clinically indistinguishable from retinoblastoma
Courtesy of José Jarrín, MD
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• Accumulation of blood in anterior chamber
• Trauma
• Ultrasound: fluid-fluid levels
• Bleed obscures ophthalmoscopic view
-> Ultrasound to evaluate for associated conditions:
– Retinal detachment
– Globe rupture
– Intraocular foreign body
Hyphema
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Foreign Body
• Usually hyperechoic focus with posterior shadowing
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Hypopyon
• Accumulation of sediments in anterior chamber
• Inflammation, infection, leukemia
• Ultrasonographic findings similar to hyphema
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Juvenile Xanthogranuloma
• Rare
• Histiocytic proliferation, with skin papules and nodules
• Eye - most frequent extracutaneous site (up to 10%)
• Typically present before age 2 years
• Iris mass
• Differential with primary iris cyst
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Primary Iris Cyst
• Controversial pathogenesis, probably congenital
• Differential with juvenile xanthogranuloma
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Ciliary Body Cyst
• Common
• Most are congenital or from trauma
• Often too small and seen only on ultrasound biomicroscopy
• When large may displace iris anteriorly and cause glaucoma
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Dacryoadenitis • Inflammation of lachrymal gland
• Subtype of orbital pseudotumor (idiopathic orbital inflammation)
• Gland enlargement
• Hypervascularity
• Differential w neoplastic processes - biopsy in clinically equivocal
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Infantile hemangioma
• Most common pediatric tumor overall
• Extraocular location
• Benign proliferation of endothelial cells
• Typical history
• Soft tissue mass
• High vessel density
• Vessels usually too small to be seen on grayscale
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Lymphatic Malformation
• Lymphatic maldevelopment
• Congenital, grows with patient
• Extraocular location
• Multiseptate cystic lesions
• Flow only on septatations, or no flow at all
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Quiz
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a. Retinal detachment
b. Vitreous hemorrhage
c. Coloboma
d. Foreign body
e. Choroidal detachment
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a. Retinal detachment
b. Vitreous hemorrhage
c. Coloboma
d. Foreign body
e. Choroidal detachment
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a. Coloboma
b. Choroidal detachment
c. Disk cupping
d. Papilledema
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a. Coloboma
b. Choroidal detachment
c. Disk cupping
d. Papilledema
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a. Retinal detachment
b. Vitreous hemorrhage
c. Choroidal detachment
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a. Retinal detachment
b. Vitreous hemorrhage
c. Choroidal detachment
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Pediatric Ocular Sonography
Cicero J Torres A Silva, MD Associate Professor of Radiology
Yale University
School of Medicine
2016 SPR Pediatric Ultrasound Course