Case Studies In the Orbit

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Case Studies In the Orbit Ethan Neufeld MD Department of Radiology and Imaging Sciences University of Utah Health Sciences

Demonstrate how appropriate localization of a finding will determine the differential. 2.

Focus on using signal characteristics and patterns to come to a favored diagnosis.

mass-like along optic nerve Axial T1 FS pre and post Elevated T2 signal eccentric to the nerve Fat normal Mass-like on both

1 Case Studies In the Orbit Ethan Neufeld MD Department of Radiology and Imaging Sciences University of Utah Health Sciences Center Salt Lake City, Utah, USA Case Studies In the Orbit Learning objectives: 1. Demonstrate how appropriate localization of a finding will determine the differential. 2. See how a few pieces of clinical information can affect the differential. 3. Focus on using signal characteristics and patterns to come to a favored diagnosis. Case # 1 63 year old female with progressive painless right visual field loss Thickening of right optic nerve Eccentric mass-like along optic nerve Axial T1 FS pre and post Elevated T2 signal eccentric to the nerve Fat normal Mass-like on both sides of the nerve Axial T2 FS and Sagittal T1 FS post Intraconal Around the optic nerve Eccentric mass-like Unilateral Conal/Extraconal tissues normal Optic nerve sheath meningioma Optic pathway glioma the nerve Lymphoma Orbital pseudotumor Enlargement of nerve itself and not around 1

Optic nerve sheath meningioma Optic pathway glioma the

itself and not around Infiltrative, typically low T2

meningioma Optic pathway glioma Lymphoma Orbital

the nerve Infiltrative, typically low T2 signal

structures Orbital lymphoma Case # 1 = Optic Nerve

DEEP to the dura and thus are contained by and spread

2 Optic nerve sheath meningioma Optic pathway glioma the nerve Lymphoma Orbital pseudotumor Enlargement of nerve itself and not around Infiltrative, typically low T2 signal intensity Optic nerve glioma Optic nerve sheath meningioma Optic pathway glioma Lymphoma Orbital pseudotumor Enlargement of nerve itself and not around the nerve Infiltrative, typically low T2 signal intensity Painful condition that affects multiple structures Orbital lymphoma Case # 1 = Optic Nerve Sheath Meningioma Benign tumor from arachnoid cap cells DEEP to the dura and thus are contained by and spread along dura F>M Mean age ~40 years old Associated with NF2 (MISME) Orbital pseudotumor 2

Optic Nerve Sheath Meningioma Presentation Painless visual field loss in >90% of cases Worse with

Sheath Meningioma Findings T1 isointense, T2 iso/hyperintense to nerve Homogenous Tubular most common,

perioptic cyst formation associated with optic nerve sheath meningioma Cystic dilation of optic nerve

3 Optic Nerve Sheath Meningioma Presentation Painless visual field loss in >90% of cases Worse with lesions near apex Painless proptosis present in majority Worse with lesions near globe Optic Nerve Sheath Meningioma Findings T1 isointense, T2 iso/hyperintense to nerve Homogenous Tubular most common, exophytic rarer Calcifications on CT Perioptic cysts can develop between globe and tumor Distal perioptic cyst formation associated with optic nerve sheath meningioma Cystic dilation of optic nerve sheath Case # 2 35 year old male with rapid onset bilateral painless vision loss Case courtesy of Dr. Richard Wiggins. Nerves normal in size/signal, no Axial T2 FS and Coronal T1 FS post Restricted diffusion of bilateral retrobulbar optic nerves Axial DWI and ADC Intraconal Optic nerve High diffusion signal Bilateral No STIR signal or 3

Optic neuritis Optic pathway glioma Ischemic optic neuropathy Painful process, rarely bilateral/symmetric,

Posterior Ischemic Optic Neuropathy Patient underwent prolonged spinal surgery in the prone position and

Posterior Ischemic Optic Neuropathy Rarer than AION Associated with prolonged surgeries (CABG) Prolonged

4 Optic neuritis Optic pathway glioma Ischemic optic neuropathy Painful process, rarely bilateral/symmetric, causes STIR signal and Optic Neuritis Optic neuritis Optic pathway glioma Ischemic optic neuropathy Painful process, rarely bilateral/symmetric, causes STIR signal and Enlarged nerve with STIR signal Case # 2: Posterior Ischemic Optic Neuropathy Patient underwent prolonged spinal surgery in the prone position and awoke with complete vision loss Patient underwent partial resection of large cervical meningioma. Posterior Ischemic Optic Neuropathy Rarer than AION Associated with prolonged surgeries (CABG) Prolonged hypotension Cardiac risk factors 4

Posterior Ischemic Optic Neuropathy Anterior optic nerve Short posterior ciliary arteries Posterior optic nerve Circumferential branches of

St Louis, Mosby, 2004 Posterior Ischemic Optic Neuropathy Findings High diffusion signal of the retrobulbar optic nerve and/or chiasm ADC maps may be

nerve Case courtesy of Dr. Karen Salzman MD.

Mikulis DJ. Diffusion MR imaging in a case of acute ischemic optic neuropathy. AJNR 27(2):255-257.

5 Posterior Ischemic Optic Neuropathy Anterior optic nerve Short posterior ciliary arteries Posterior optic nerve Circumferential branches of ophthalmic/retinal arteries Sadun AA: Anatomy and physiology. In: Yanoff M, Duker JS (eds) Ophthalmology, 2nd edn. St Louis, Mosby, 2004 Posterior Ischemic Optic Neuropathy Findings High diffusion signal of the retrobulbar optic nerve and/or chiasm ADC maps may be difficult to interpret T2/STIR signal may be normal Enhancement may occur in subacute/late stages Case # 3 Restricted diffusion of left anterior optic nerve Case courtesy of Dr. Karen Salzman MD. 45 year old female with slowly progressive painless proptosis and now with right visual field loss Anterior Ischemic Optic Neuropathy Al-Shafai LS, Mikulis DJ. Diffusion MR imaging in a case of acute ischemic optic neuropathy. AJNR 27(2): Displaces ophthalmic vein Low signal intensity rim Cor performed after Axial, progressive Soft tissue attenuation Mass at orbital apex, eccentric Axial CTA and T1 FS post STIR hyperintense with low intensity septae Coronal STIR and T1 FS post Intraconal Circumscribed/Non-aggressive Low signal intensity capsule/septae Conal/Extraconal tissues normal Progressive, centripetal 5

Schwannoma Cavernous malformation Orbital apex

malformation/varix Homogenously enhancing,

symptomatic when small Homogenous, non-progressive

attenuation/intensity, non-enhancing Superficial

6 Schwannoma Cavernous malformation Orbital apex meningioma Dermoid/Epidermoid Venolymphatic malformation/varix Homogenously enhancing, symptomatic when small Oculomotor Schwannoma Schwannoma Cavernous malformation Orbital apex meningioma Dermoid/Epidermoid Venolymphatic malformation/varix Homogenously enhancing, symptomatic when small Homogenous, non-progressive Orbital Apex Meningioma Schwannoma Cavernous malformation Orbital apex meningioma Dermoid/Epidermoid Venolymphatic malformation/varix Homogenously enhancing, symptomatic when small Homogenous, non-progressive Fat attenuation/intensity, non-enhancing Superficial Angular Dermoid 6

Schwannoma Cavernous malformation Orbital apex meningioma Dermoid/Epidermoid Venolymphatic malformation/varix Homogenously enhancing, symptomatic when small

Valsalva Smoker WRK, et al. Vascular lesions of the orbit: more than meets the eye. Radiographics 2008 28:1 185-204.

septae No dominant arterial supply F>M, average age 40 Cavernous Malformation Presentation Slowly progressive painless proptosis Diplopia may occur from EOM

mass T1 isointense, T2/STIR hyperintense T2 hypointense capsule and septae Progressive irregular centripetal May have areas of T1 hyperintense thrombus CentriFUGAL

7 Schwannoma Cavernous malformation Orbital apex meningioma Dermoid/Epidermoid Venolymphatic malformation/varix Homogenously enhancing, symptomatic when small Fluid-fluid levels, transspatial, follows course of vein Homogenous, non-progressive Fat attenuation/intensity, non-enhancing Orbital varix T1 FS with and without Valsalva Smoker WRK, et al. Vascular lesions of the orbit: more than meets the eye. Radiographics : Case # 3: Cavernous Malformation Most common vascular orbital lesion ISSVA Slow flow venous/vascular malformation Dilated vascular spaces with fibrous capsule and septae No dominant arterial supply F>M, average age 40 Cavernous Malformation Presentation Slowly progressive painless proptosis Diplopia may occur from EOM compression or CN compression Visual field deficits may occur from compression of ON if near orbital apex Cavernous Malformation Findings Non-aggressive intraconal mass T1 isointense, T2/STIR hyperintense T2 hypointense capsule and septae Progressive irregular centripetal May have areas of T1 hyperintense thrombus CentriFUGAL Sequential axial T1 sequences obtained before contrast and at 60, 100, and 300 seconds after contrast administration. Tanaka A, et al. Differentiation of cavernous hemangioma from schwannoma of the orbit: a dynamic MRI study. AJR :

Case # 4 72 year old male with fuzzy vision on the left Patient unable to clarify further Lesion within the posterior globe Homogenously enhancing Adjacent nonenhancing lesion Axial T1 pre and T1 FS

8 Case # 4 72 year old male with fuzzy vision on the left Patient unable to clarify further Lesion within the posterior globe Homogenously enhancing Adjacent nonenhancing lesion Axial T1 pre and T1 FS post Mass-like heterogenous high T2 signal Contained mass-like Globe Enhancing mass Intrinsic T1 hyperintensity Adjacent distinct non-enhancing component Choroidal/Retinal detachment Uveal nerve sheath tumor Uveal melanoma Uveal metastases Retinoblastoma Possibly but? Very rare, high T2 signal Main differential, lesion has T1 hyperintensity Coronal STIR and T1 FS post Choroidal/Retinal detachment Uveal nerve sheath tumor Uveal melanoma Uveal metastases Retinoblastoma Possibly but? Very rare, high T2 signal Main differential, lesions has T1 hyperintensity Disease of the young Metastatic prostate adenocarcinoma to the globe with associated retinal detachment 8

Case # 4: Uveal Melanoma Most common primary intra-ocular malignancy White population Incidence increases with age, rarely seen before age 20

Guidelines for imaging retinoblastoma: imaging principles and MRI standardization.

apparent and diagnosed early Choroidal lesions found on fundoscopy, often after retinal detachment has occurred https://med.virginia.

Variable but robust Variable T2 signal Look for exudative retinal detachment T1 bright, T2 bright, non-enhancing Case # 5 Uveal melanoma: Rad-Path

9 Case # 4: Uveal Melanoma Most common primary intra-ocular malignancy White population Incidence increases with age, rarely seen before age 20 Retinoblastoma with retinal detachment Axial T2, T1 pre, and T1 post contrast sequences in a 7 year old male. de Graaf P, et al. Guidelines for imaging retinoblastoma: imaging principles and MRI standardization. Pediatric Radiology : Uveal Melanoma Presentation Depends on location, can occur anywhere uveal tissue is present Iris lesions visually apparent and diagnosed early Choroidal lesions found on fundoscopy, often after retinal detachment has occurred services/gamma-knife/disorderstreated/uveal-melanoma/ Uveal Melanoma Findings Intrinsic T1 hyperintense mass Melanin and hemorrhage Variable but robust Variable T2 signal Look for exudative retinal detachment T1 bright, T2 bright, non-enhancing Case # 5 Uveal melanoma: Rad-Path correlation 76 year old male with dementia, family reports he s not seeing as well lately No other clinical information provided Patient could not get contrast due to ESRD Houle V, Bélair M, Allaire GS. AIRP best cases in radiologic-pathologic correlation: choroidal melanoma. Radiographics :

No extension past 2:00 or 10:00 Contained T1 hyperintensity of deep aspect V -shaped

Axial T2 and T2 FS Lines converge to optic disc High diffusion signal of deep aspect Axial

to optic disc No extension beyond 2:00 or 10:00 No definite mass Choroidal detachment

Amorphous, no linear filling defect Large Intra-Vitreous Hemorrhage Hematocrit effect

melanoma/metastasis Should be considered, no contrast enhanced images acquired Main

10 No extension past 2:00 or 10:00 Contained T1 hyperintensity of deep aspect V -shaped linear filling defect within the globe Circumferential, T2 hyperintense on both sides Axial T2 and T2 FS Lines converge to optic disc High diffusion signal of deep aspect Axial DWI and Sagittal T1 Globe Linear, circumferential vitreous filling defect Lines converge to optic disc No extension beyond 2:00 or 10:00 No definite mass Choroidal detachment Retinal detachment Intra-vitreous hemorrhage Ocular melanoma/metastasis Main differential Amorphous, no linear filling defect Large Intra-Vitreous Hemorrhage Hematocrit effect Choroidal detachment Retinal detachment Intra-vitreous hemorrhage Ocular melanoma/metastasis Should be considered, no contrast enhanced images acquired Main differential Amorphous, no linear filling defect Metastatic prostate adenocarcinoma to the globe with associated retinal detachment 10

Case # 5: Retinal Detachment Separation of the retina from the underlying choroid May occur due to: Trauma Exudative fluid accumulation Traction band

surgery) Myopic patients more at risk, longer globe Sudden onset vision loss if traumatic/hemorrhagic Senile patients or those with pre-existing

Limited anteriorly by ora serrata Lines do not extend beyond 2:00,10:00 Fluid in the subretinal space Simple fluid or blood products Ora serrata =

Nontraumatic orbital conditions: diagnosis with CT and MR imaging in the emergent setting.

11 Case # 5: Retinal Detachment Separation of the retina from the underlying choroid May occur due to: Trauma Exudative fluid accumulation Traction band formation Post-operative complications Retinal Detachment Presentation More commonly older patients with other ocular pathology (prior cataract surgery) Myopic patients more at risk, longer globe Sudden onset vision loss if traumatic/hemorrhagic Senile patients or those with pre-existing vision loss, may not be expected Retinal Detachment Findings Curvilinear defect Limited posteriorly by the optic disk Lines CONVERGE posteriorly Limited anteriorly by ora serrata Lines do not extend beyond 2:00,10:00 Fluid in the subretinal space Simple fluid or blood products Ora serrata = Junction between retina and ciliary body Subretinal hemorrhage (Left) Subchoroidal hemorrhage (Right) LeBedis CA, Sakai O. Nontraumatic orbital conditions: diagnosis with CT and MR imaging in the emergent setting. Radiographics 2008;28: Case # 6 47 year old female with progressive painless proptosis bilaterally, now with visual field loss Diffuse enlargement of the extra-ocular muscles Homogenous Lacrimal glands normal Coronal T1 FS and FS post 11

T2/STIR signal of muscles, mild proptosis Crowding at orbital apex Sparing of distal insertion sites Intraconal fat prominent but not involved Axial STIR and T1 FS post Conal Enlarged EOMs, proptosis

insertion Orbital pseudotumor Thyroid associated orbitopathy Sarcoidosis Lymphoma Erdheim-Chester Painful condition, involved tendinous insertion Almost always involves lacrimal gland, systemic

12 T2/STIR signal of muscles, mild proptosis Crowding at orbital apex Sparing of distal insertion sites Intraconal fat prominent but not involved Axial STIR and T1 FS post Conal Enlarged EOMs, proptosis Tendons spared Prominent but not inflamed intraconal fat Crowding of apex Orbital pseudotumor Thyroid associated orbitopathy Sarcoidosis Lymphoma Erdheim-Chester Painful condition, involved tendinous insertion Orbital pseudotumor Thyroid associated orbitopathy Sarcoidosis Lymphoma Erdheim-Chester Painful condition, involved tendinous insertion Almost always involves lacrimal gland, systemic process Myositic Orbital Pseudotumor Orbital Sarcoidoisis Causing Chronic Ptosis Patient with chronic ptosis and systemic sarcoidosis. Infiltrative enlargement and of superior rectus and LPS. Orbital pseudotumor Thyroid associated orbitopathy Sarcoidosis Lymphoma Erdheim-Chester Painful condition, involved tendinous insertion Almost always involves lacrimal gland, systemic process Infiltrative processes, T2 hypointense De Niro JE and Silkiss RZ. The drooping lid that wouldn t go away. EyeNet June 2014, Morning Rounds. 12

Case # 6: Thyroid Associated Orbitopathy Most common cause of painless proptosis Patients with Graves disease, rarely lymphocytic

lesions. Drier A, et al. Cerebral, facial, and orbital involvement in Erdheim-Chester disease: CT and MR imaging findings.

cross-reaction Thyroid Orbitopathy Presentation Patient with thyroid disease May be iatropic stimulus Painless proptosis,

Thyroid Orbitopathy Findings Bilateral symmetric muscle enlargement SPARING of anterior myotendinous junction IMSLO: Inferior

Inflammatory Process 17 year old male with history of horizontal diplopia and now with painless proptosis on the right Patient

13 Case # 6: Thyroid Associated Orbitopathy Most common cause of painless proptosis Patients with Graves disease, rarely lymphocytic thyroiditis (Hashimoto s) Women > Men by 5:1, middle-aged Orbital Erdheim-Chester Infiltrative enhancing low T2 signal intraconal lesions. Drier A, et al. Cerebral, facial, and orbital involvement in Erdheim-Chester disease: CT and MR imaging findings. Radiology : Mechanism still not fully understood Inflammatory cells in muscles ramped up by TSH antibody cross-reaction Thyroid Orbitopathy Presentation Patient with thyroid disease May be iatropic stimulus Painless proptosis, chemosis, corneal dryness Bilateral 75-90%, symmetric 60-80% Diplopia and vision loss when severe Compression of orbital apex Thyroid Orbitopathy Findings Bilateral symmetric muscle enlargement SPARING of anterior myotendinous junction IMSLO: Inferior Medial Superior Lateral Obliques Fatty infiltration of muscle Increased volume of intraconal fat Case # 7 Thyroid Orbitopathy = Inflammatory Process 17 year old male with history of horizontal diplopia and now with painless proptosis on the right Patient with Graves disease and painless proptosis. CT images before and after treatment with TNF-α inhibitors. Bahn RS. Graves ophthalmopathy. NEJM :

Medial rectus displaced, no fat stranding No significant diffusion signal

Non-dependent aspect saturates out on FS Axial T2 FS and DWI Extraconal

diffusion abnormality Cavernous malformation Orbital dermoid Orbital epidermoid

Malformation Cavernous malformation Orbital dermoid Orbital epidermoid

14 Medial rectus displaced, no fat stranding No significant diffusion signal Circumscribed mass, fluid-fluid level Faint peripheral Axial T1 pre and T1 FS post Non-dependent aspect saturates out on FS Axial T2 FS and DWI Extraconal Circumscribed/Non-aggressive mass Lipid/Fat containing Fluid-fluid level No diffusion abnormality Cavernous malformation Orbital dermoid Orbital epidermoid Venolymphatic malformation/varix Intraconal, progressive Orbital Cavernous Malformation Cavernous malformation Orbital dermoid Orbital epidermoid Venolymphatic malformation/varix Intraconal, progressive Main differential, no diffusion restriction External Angular Orbital Epidermoid 14

Cavernous malformation Orbital dermoid Orbital epidermoid Venolymphatic malformation/varix Fluid-fluid levels, trans-spatial, follows course of vein Intraconal, progressive Main differential, no

Case # 7: Deep Orbital Dermoid Congenital lesion, most common orbital tumor in children Abnormal ectodermal remnant lined by squamous epithelium Has epidermal components: hair, sweat, sebaceous

15 Cavernous malformation Orbital dermoid Orbital epidermoid Venolymphatic malformation/varix Fluid-fluid levels, trans-spatial, follows course of vein Intraconal, progressive Main differential, no diffusion restriction Orbital varix T1 FS with and without Valsalva Smoker WRK, et al. Vascular lesions of the orbit: more than meets the eye. Radiographics : Case # 7: Deep Orbital Dermoid Congenital lesion, most common orbital tumor in children Abnormal ectodermal remnant lined by squamous epithelium Has epidermal components: hair, sweat, sebaceous glands Has NO macroscopic fat, T1 signal from oily sebaceous material Fat = Mesoderm = Teratoma Orbital Dermoid Presentation Child/Adolescent Superficial dermoid more common External angular dermoid occurs at lacrimal fossa Slow growing, may be diagnosed later in life if deep Painless mass Painless proptosis, ophthalmoplegia Orbital Dermoid Findings Circumscribed mass Most commonly lacrimal fossa Non-enhancing Calcifications on CT rare Lipid signal characteristics Minimal to no diffusion abnormality Inflammatory changes if rupture occurs External Angular Dermoid Incidental finding on CT obtained for headache. Fat attenuation lesion of the lacrimal fossa. 15

Case # 8 58 year old male with slowly growing painless mass, now with painless proptosis and ptosis on the left Of note,

no of mass Superficial inflammatory changes Axial T1 FS pre and post Low ADC signal Low T2 signal Extraconal Lacrimal gland,

infectious markers, T2 bright, Infectious dacryoadenitis Sarcoidosis Orbital pseudotumor Sicca syndrome (Sjögren) Pleomorphic

progression, infectious markers, T2 bright, Enhancement, no systemic disease Sarcoidosis Orbital pseudotumor Sicca syndrome

16 Case # 8 58 year old male with slowly growing painless mass, now with painless proptosis and ptosis on the left Of note, patient admitted to picking at lesion for the last week Low T1 signal extraconal mass Localizes to lacrimal gland, minimal to no of mass Superficial inflammatory changes Axial T1 FS pre and post Low ADC signal Low T2 signal Extraconal Lacrimal gland, both lobes Low T1/T2, minimal Restricted diffusion Axial T2 and ADC No locally invasive features Painful, rapid progression, infectious markers, T2 bright, Infectious dacryoadenitis Sarcoidosis Orbital pseudotumor Sicca syndrome (Sjögren) Pleomorphic adenoma Malignant salivary gland neoplasm Lymphoma Infectious Dacryoadenitis Infectious dacryoadenitis Painful, rapid progression, infectious markers, T2 bright, Enhancement, no systemic disease Sarcoidosis Orbital pseudotumor Sicca syndrome (Sjögren) Pleomorphic adenoma Malignant salivary gland neoplasm Lymphoma Painful process, Typically bilateral, more common in women, enhances 16

Sicca Syndrome Infectious dacryoadenitis Sarcoidosis Orbital pseudotumor Sicca syndrome (Sjögren) Pleomorphic adenoma Painful, rapid

Lymphoma Typically bilateral and more common in women Enhancement, usually one lobe, invasive Case # 8: Lacrimal Gland Lymphoma

neoplasm ~1/3 Involvement of both orbital and palpebral lobes in inflammation/lymphoma MALT type most common, follicular next MALT =

Orbital and palpebral lobes involved Lobes separated by levator palpebrae superioris aponeurosis Unilateral disease Lacrimal Lymphoma

17 Sicca Syndrome Infectious dacryoadenitis Sarcoidosis Orbital pseudotumor Sicca syndrome (Sjögren) Pleomorphic adenoma Painful, rapid progression, infectious markers, T2 bright, Enhancement, no systemic disease Painful process, Malignant salivary gland neoplasm Lymphoma Typically bilateral and more common in women Enhancement, usually one lobe, invasive Case # 8: Lacrimal Gland Lymphoma Lacrimal Gland Adenoid Cystic Carcinoma Lacrimal gland masses, rule of thirds Inflammatory ~1/3 Lymphoproliferative ~1/3 Salivary type neoplasm ~1/3 Involvement of both orbital and palpebral lobes in inflammation/lymphoma MALT type most common, follicular next MALT = good prognosis Lacrimal Lymphoma Presentation Older patients, F>M May not have systemic disease Progressive painless proptosis Ptosis Orbital and palpebral lobes involved Lobes separated by levator palpebrae superioris aponeurosis Unilateral disease Lacrimal Lymphoma Findings Unilateral enlarged lacrimal gland Both lobes Low T1 and low T2 Minimal Diffusion restriction Cellularity Cannot differentiate lymphoma types 17

Closing Points Lymphoid Hyperplasia of Lacrimal Gland Essentially identical appearance to

Determine the location of the lesion in question. 2.

18 Closing Points Lymphoid Hyperplasia of Lacrimal Gland Essentially identical appearance to lymphoma. Gao Y, et al. Lacrimal gland masses. AJR : Determine the location of the lesion in question. 2. Know the chronicity of the problem and the presence/absence of pain. 3. Factor in demographics. 4. Knowledge of the most common at a given location gets you there most of the time. Case Studies In the Orbit Ethan Neufeld MD Department of Radiology and Imaging Sciences University of Utah Health Sciences Center Salt Lake City, Utah, USA 18

13/02/1440 بسم ا هلل ا لرحمن ا لر حيم

13/02/1440 بسم ا هلل ا لرحمن ا لر حيم بسم ا هلل ا لرحمن ا لر حيم 1 Slowly progressive versus rapidly progressive proptosis by Ali M ISMAIL professor of ophthalmology @SOHAG U H Occuloplastic fellow @NNUH Occuloplastic fellow @Cambridge UH