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Normal CT Orbits Report Template
Normal CT orbits report template: globes, optic nerve-sheath complexes, extraocular muscles, orbital apex, bony walls, lacrimal glands and paranasal sinuses with and without contrast, with notes on proptosis measurement, thyroid eye disease, post-septal cellulitis and the apex.
EXAMINATION: CT of the orbits [with / without] intravenous contrast. CLINICAL HISTORY: [indication, e.g. “Left periorbital swelling and erythema, evaluate for orbital cellulitis” / “Proptosis” / “Suspected intraocular foreign body”] COMPARISON: None available. TECHNIQUE: Helical CT of the orbits from the frontal sinuses through the maxillary sinuses [following the administration of x mL of intravenous iodinated contrast], with thin-section axial images reconstructed in soft tissue and bone algorithms and coronal and sagittal reformats. Dose reduction techniques were used. FINDINGS: Globes: Both globes are normal in size, contour and position. Normal attenuation of the lens, anterior chamber and vitreous bilaterally. No intraocular foreign body, calcification or hemorrhage. No retinal or choroidal detachment. Optic nerve-sheath complexes: Normal in caliber and course bilaterally without thickening, enhancement or tortuosity. Extraocular muscles: Normal in size, attenuation and symmetry, including the tendinous insertions. No muscle enlargement. Intraconal and extraconal spaces: Normal orbital fat. No mass, hematoma, abscess or fat stranding. No post-septal inflammatory change. Orbital apex and superior orbital fissure: Patent and symmetric. Normal cavernous sinuses on the included images. Lacrimal glands and nasolacrimal ducts: Normal in size and symmetric. No obstruction. Bony orbits: The orbital walls are intact. No fracture, erosion or hyperostosis. The lamina papyracea is intact bilaterally. Paranasal sinuses: Clear. [Mild mucosal thickening of the x.] No subperiosteal collection adjacent to the medial orbital walls. Preseptal soft tissues: [Unremarkable. / Mild preseptal soft tissue swelling of the left eyelid without post-septal extension.] Visualized intracranial contents: Unremarkable. No epidural collection along the frontal convexities. IMPRESSION: 1. Normal CT of the orbits. No orbital mass, inflammatory process, fracture or foreign body. 2. [Left preseptal soft tissue swelling without post-septal (orbital) involvement.]
Dictation notes
- The orbital septum is the line the report is organised around: preseptal cellulitis is eyelid disease treated with antibiotics; post-septal (orbital) cellulitis — fat stranding, muscle enlargement, proptosis or a subperiosteal abscess along the lamina papyracea — is an admission and possible drainage.
- Measure proptosis on the axial image through the lenses: a line between the anterior zygomatic margins to the anterior cornea, with more than 21 mm or a 2 mm asymmetry considered abnormal; give the number rather than “mild proptosis”.
- Thyroid eye disease enlarges the muscle bellies with tendon sparing (inferior, medial, superior, lateral, in that order); myositis involves the tendon too, and a single enlarged lateral rectus in isolation deserves a second look for a mass or lymphoma.
- Report the orbital apex separately: a mass, inflammation or fracture at the apex threatens the optic nerve and the contents of the superior orbital fissure, and the window for vision salvage is hours, not days.
- For foreign body searches, state the material and location in relation to the globe wall and whether the globe is ruptured (flattened posterior sclera, deep anterior chamber, intraocular air or lens dislocation) — a metallic fragment also contraindicates MRI and the report should say so.
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