REVIEW ARTICLE

Neuroimaging in Neuro-Ophthalmology

(Systematic Review)

Tayyaba Gul Malik¹, Khalid Farooq²

¹Department of Ophthalmology, Rashid Latif Medical College/Arif Memorial Teaching Hospital, Lahore

²Department of Radiology, Lahore Medical and Dental College/Ghurki Trust Teaching Hospital, Lahore

ABSTRACT

There are quite a number of neurological diseases, which initially present to the ophthalmologists. Based on the

proper history and clinical findings ophthalmologists have to suggest the ancillary neuro-imaging to support their

provisional diagnosis and reach the site of lesion. Unless the ophthalmologists are aware of the right imaging at

right time and at right area to focus, there are many pitfalls. MRI and CT of the brain and orbit are important

investigations in neuro-ophthalmology which if intelligently ordered can add to the diagnostic and management

process. In general, MRI is the most commonly ordered investigation in neuro-ophthalmology with so many

additional sequences as FLAIR, GRE, diffusion weighted imaging, spectroscopy, in addition to T1 and T2

weighted imaging. Having said that CT scan has its advantages in cases of bony pathologies and acute brain

hemorrhages. This article reviews the indications and importance of different neuro-imaging techniques, based on

the previous studies from 1997 to 2019.

Key Words: Neuro-ophthalmology, Magnetic Resonance imaging, Optic neuritis, Papilledema, Visual Pathway,

Optic tract, Optic nerve, Meningioma, Glioma.

How to Cite this Article: Malik TG, Farooq K. Neuroimaging in Neuro-Ophthalmology (Systematic Review). Pak

J Ophthalmol. 2020, 36 (2): 180-189.

Doi: 10.36351/pjo.v36i2.1026

area of interest in neuro-imaging is also a mandatory

part of neuro-imaging, failing which can lead to

INTRODUCTION

Neuro-imaging is an important part of neuro-

pitfalls in diagnosis. At times, the definite clinical

ophthalmology but it cannot replace a thorough

findings are not supported by neuro-imaging, in which

clinical examination. Rather ordering a relevant neuro-

case it is important to have a detailed discussion of the

imaging test depends upon a detailed history and

case with the radiologist. Sometimes very thin slices of

thorough evaluation in the clinics. Suggesting a right

a particular area of interest are required and which are

investigation at a right time can save time as well as

missed in general thick slice scans. At other times,

money. It is very important for the ophthalmologists to

some additional investigation is needed to prove a

have sufficient knowledge about which investigation is

required in a particular case, when to use contrast,

definite clinical diagnosis.

The purpose of this review article was to find out

which neuro-imaging tests are commonly used in

neuro-ophthalmology and what were the presenting

complaints of the patients for which these

investigations were suggested. Keeping in view the

published data an exercise is done to make clear when

to order which of the neuro-imaging test to save time

and money by avoiding wrong investigation or right

investigation in wrong time and area.

which views (coronal, axial, sagittal) are important in

which case and which sequence is necessary. Keeping

a radiologist fully informed about the positive clinical

findings and the provisional diagnosis along with the

Correspondence to: Professor Tayyaba Gul Malik

Department of Ophthalmology, Rashid Latif Medical

College/Arif Memorial Teaching Hospital, Lahore

Pakistan Journal of Ophthalmology, 2020, Vol. 36 (2): 180-189

180

Tayyaba Gul Malik, et al

Neuro-imaging was done for complaints of

diplopia, decreased vision, visual field defects, swollen

optic discs, headache, pulsatile tinnitis, nausea,

vomiting associated with headache, ocular motor nerve

palsies, Horner syndrome, nystagmus, presumed

cortical blindness, supranuclear gaze palsy, ptosis and

as part of investigation in cases of neurofibromatosis.

The final diagnoses included idiopathic intracranial

hypertension, meningioma, glioma of visual pathway,

multiple sclerosis, trochlear headache, Pituitary

adenoma, Craniopharyngioma, ischemic strokes,

hemorrhages, aneurysms, herpes simplex encephalitis,

Stenosis of dural sinuses and cerebral venous sinus

thrombosis. Diagnoses of case reports and series

included; Hair dresser syndrome, Pseudotumor

Cerebri, Horner Syndrome, Tolosa-Hunt Syndrome,

Sixth Nerve Palsy, Migraine, Amyloidosis,

Encephalopathy Syndrome, Orbital Apex Syndrome,

Behr Syndrome, Optic Nerve Hypoplasia, 4th Nerve

Palsy, Pituitary Apoplexy, Eight and a half syndrome,

Cholesterol Granuloma of the Sphenoidal sinus,

Craniopharyngioma and Alzheimers Disease. Other

neuro-imaging results included Arnold Chiari

MATERIAL AND METHODS

PRISMA guidelines were followed for this systematic

review. A literature search was conducted on the 11^th

November 2019. NCBI Pubmed database was used

with search terms „neuroimaging‟ and „neuro-

ophthalmology‟ (1997 to 2019). One hundred and

eighteen results were found. Articles with un-

accessible full articles, duplicates and irrelevant

articles were excluded. We were left with 70 items.

This produced a list of 19 review articles, 19 original

articles and 29 case reports or case series. Review

articles were not included in this review. Studies,

which did not use neuro-imaging in diagnosis of

neuro-ophthalmology cases, were excluded from our

study. We also excluded articles, which were

published only as abstracts or were presented only in

conferences without publication. One of the study was

also removed because it did not mention the type of

imaging used in the study. The flow chart for data

retrieval is shown below.

Medline search was done on 11^thNovember 2019

with words „Neuro-Imaging‟ and „Neuro-

Ophthalmology‟ (data between 1997 to 2019).

Malformation,

Carotico-Cavernous

Fistula,

Vertebrobasilar ischemia, cerebral edema, non-

Hodgkin's Lymphoma, ectopic posterior pituitary

gland, Rathke's cleft cyst, carcinomatous meningitis

secondary

to

metastatic

breast

cancer,

neurosarcoidosis and Carotid artery dissection.

118 articles found.

MRI scan was the most commonly ordered

investigation followed by CT scan. Other ancillary

sequences were done when initial MRI and CT were

normal. The investigations, which were done in

decreasing order of frequency, were as follows:

Articles with un-accessible full articles, duplicates

and irrelevant articles were excluded.

1. MRI.

After excluding review articles, we were left with

19 original articles and 29 case reports/ case series.

2. CT.

3. MRV.

4. CT Angiography.

5. MRA.

RESULTS

In 19 original articles, total number of patients were

1350 (858 females and 492 males), with age ranging

from 1 year to 81 years. There were 14 retrospective

studies, 2 case control studies, 2 cross sectional studies

and 1 interventional study. There were 29 case

reports/case series, which included 72 patients (45

females and 27 males) with age ranging from 3 months

to 89 years.

6. FLAIR.

7. PET.

8. DTI and Diffusion Tensor Tractography.

9. Arteriography.

181

Pakistan Journal of Ophthalmology, 2020, Vol. 36 (2): 180-189

Neuroimaging in Neuro-Ophthalmology (Systematic Review)

Table 1: Details of original articles (neuro-imaging in neuro-ophthalmology from 1997 to 2019).

Sample Provisional

Author

Study Design

Neuroimaging

Findings

Size

Diagnosis

IIH (Idiopathic

intracranial

hypertension)

Ocular motor nerve

palsies

Empty sella, globe flattening,

prominent perioptic cerebrospinal

fluid, venous sinus stenosis

Gondi KT,

Case control study

53

MRI, CT, MRV

et al,¹³2019

Park KA,

Retrospective

127

35

MRI

Inflammatory lesions and neoplasms

et al,¹⁴2019

Koytak PK,

et al,¹⁵2018

Bursztyn LLCD,

et al,¹⁶2018

Optic nerve sheath

meningioma

Diagnosis of Optic nerve sheath

meningioma was confirmed

92

Optic Neuritis

83.7% positive results for on MRI

Isolated optic nerve enhancement,

demyelinating foci in frontal lobe and

parieto-occipital lobe

Ischemic strokes, tumors,

hemorrhages, vascular malformation,

demyelination, encephalitis

Khadse R

Retrospective

40

24

Optic Neuritis

MRI

et al,¹⁷2017

Kowal

Optic tract lesions

MRI, FLAIR

et al,¹⁸2017

Aguilar-Pérez M

et al,¹⁹2017

Chang RO,

et al,²⁰2016

Ming Ge,

Retrospective

interventional

Retrospective

51

12

11

25

IIH

MRI, MRV

MRI

Empty sella, Stenotic dural sinuses

Empty sella

Optic pathway

gliomas

Trochlear

headaches

Diffusion Tensor

Tractography

Diagnosis of Optic nerve Gioma was

confirmed

et al,²¹2015

J. H. Smith,

et al,²²2014

MRI and CT

MRI, FLAIR, DTI

MRI /DTI

Normal imaging

Integrity of the optic radiations (FA)

was significantly impaired in patients

with MS. Atrophy of the visual

cortex, grey and white matter.

Optic nerve axons and myelin sheath

integrity was disturbed

Balk LJ,

case control study

Retrospective

222

MS

et al,²³2014

Kennedy de Blank

PM, et al, ²⁴2013

Optic pathway

gliomas

50

Optic neuropathy

and cranial nerve

palsies.

28.9% of neuroimaging tests

requested by neuro-ophthalmologists

resulted in an abnormal finding

25 normal, others had empty sella

and stenotic dural sinus

CT, CTA, MRI,

MRA, MRV

Mehta et al,²⁵2012 Retrospective

157

S. Ambika,

Retrospective

et al,²⁶2010

50

308

125

91

IIH

CT, MRI, MRV

MRI, MRV

MRI, CT

CTA

Agarwal P,

35 patients had cerebral venous sinus

thrombosis

Retrospective

et al,²⁷2010

Wolfe S,

Miscellaneous

conditions

Cross sectional

et al,²⁸2008

.18% Positive imaging

Lee AG,

Retrospective

et al,²⁹2005

Optic tract lesions

93 normal, lesions found in 18 cases

Mcfadzean R,

Cross sectional

et al,³⁰1998

Isolated 3rd nerve

palsy

Parieto occipital

lobe lesions

72 were normal, aneurysm in 18 and

10 had other abnormalities

Parieto occipital lobe lesions

confirmed

100

71

Jacobson DM,³¹

Retrospective

1997

MRI

Table 2: Details of case reports/case series (neuro-imaging in neuro-ophthalmology; 1997 to2019).

No. of

Cases

Authors

Diagnosis

Neuroimaging Findings

Jonathan A,

CT/CTA or

MRI/MRA)

3

1

Hair dresser syndrome

IIH

Vertebrobasilar ischemia

et al,³²2019

Tommy L.H.

et al,³³2018

Karti DT,

MRI, MRV

Bilateral Dural Venous Sinus Stenosis

CT, MRI

(cervical)

MRI/Cerebral

Angiogram

Horner syndrome

Tolosa–Hunt Syndrome

Multiple spinal root cysts between C7 and T1 segments

et al,⁴2018

Ravindran K,

et al,³⁵2017

Inflammatory stranding of the right orbital apex and

extension into the lateral wall of the right cavernous sinus

Pakistan Journal of Ophthalmology, 2020, Vol. 36 (2): 180-189

182

Tayyaba Gul Malik, et al

No. of

Cases

Authors

Diagnosis

Neuroimaging Findings

Brandon J,

et al,³⁶2017

Nadha A,

1

Sixth Nerve Palsy

Migraine

MRI and MRA Normal

1

MRI, CT

Normal

et al,³⁷2017

Multifocal patchy and confluent vasogenic edema in the

cerebral hemispheres, hemosiderin deposition from

microhemorrhages

Oana M,

CTA/MRA/

MRI

Amyloidosis

et al,³⁸2017

Hyperintense signal change at periventricular, parieto-

occipital, cerebellar, and brainstem areas visualised in

FLAIR

Chou MC,

Encephalopathy

Syndrome

MRI/MRA/CT/

FLAIR

1

et al,³⁹2017

Carlen A,

Retrro-orbital mass. Excision biopsy showed non-

Hodgkin's lymphoma

1

Orbital Apex syndrome

Sixth Nerve Palsy

CT

et al,⁴⁰2017

Hidehiro Oku,

et al,⁴¹2016

Raoof N,

MRI and MRA Aneurysm of intracavernous carotid artery

Sixth Nerve Palsy

MRI and CT

MRI

Skull base Endochondroma

et al,⁴²2015

Bilateral hypointense signals in the globus pallidus, the

putamen, and the substantia nigra as well as a cerebellar

atrophy

Kleffner I,

2

1

Behr syndrome

et al,⁴³2015

MRI/MRI

tractography/

(fMRI),

Vaphiades MS,

et al,⁴⁴2015

Progressive Supranuclear

Palsy-Like Syndrome

normal

Koukkoulli A,

et al,⁴⁵2015

Cheng HC,

et al,⁴⁶2015

Madgula,

Ophthalmoplegia with

lid SCC

1

5

1

MRI

Perineural Spread of Cutaneous Squamous Cell Carcinoma

Ectopic posterior pituitary gland, agenesis of septum

pellucidum, Rathke's cleft cyst

Optic nerve hypoplasia

4th nerve palsy

Metastatic breast cancer

et al,⁴⁷2014

Berkenstock M, et

al,⁴⁸2014

Pituitary Apoplexy

Third nerve palsy

MRI and MRA Pituitary adenoma with haemorrhage

Bansal S,

MRI

Neurosarcoidosis

et al,⁴⁹2014

8 ½ Syndrome with

Hemiparesis and

Hemihypesthesia:

The Nine Syndrome?

Cholesterol Granuloma

of the sphenoidal Sinus

Ischemia of right pons involving the abducens nucleus,

adjacent medial longitudinal fasciculus(MLF), and facial

colliculus, extending to the ipsilateral mediallemniscus and

corticospinal tract

A homogenous T1 and T2 hyperintense lesion causing

expansion of sphenoidal sinus

Rosini F,

1

et al,⁵⁰2013

Pehere N,

1

MRI

et al,⁵¹2011

Reyes KB,

Suprasellar cystic lesion compressing the chiasm,

flattening the pituitary gland

Craniopharyngioma

4th nerve palsy

MRI

et al,⁵²2011

Raghavendra S, et

al,⁵³2010

1

MRI

Mid brain hemorrhage

Sánchez VM,

et al,⁵⁴2006

Andrew GL,

et al,⁵⁵2004

Freedman KA,

et al,⁵⁶2004

Madhura A.

et al,⁵⁷2004

Parsa CF,

1

Alzheimer's Disease

PET scan

MRI AND PET

MRI

Parietal-occipital bilateral hypo-metabolism

Hypoperfusion in the parieto-occipital areas.MRI showed

pariet-occipital atrophy

8

Nonketotic

Hyperglycemic patient

1

Normal

Internal carotid artery aneurysm and arteriovenous fistula

arising

2

third nerve palsy

MRI and MRA

CT and MRI

MRI

13

8

Optic nerve gliomas

Acute optic neuropathy

Gliomas of optic nerve and chiasma

et al,⁵⁸2001

Andrew GL,

et al,⁵⁹2000

3 sarcoidosis, 4 meningioma, metastasis

Carotid artery dissection, pituitary tumour, ischemic

occipital lobe injury, Arnold Chiari Malformation, CCF,

Carotid stenosis, MS, optic nerve sheath meningioma

Mark L,

MRI, CT,

Arteriography

9

Miscellaneous

et al,⁶⁰1998

183

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Neuroimaging in Neuro-Ophthalmology (Systematic Review)

Fig. 1: Axial T2 images; 1) Eyeball, 2) Lateral Rectus, 3) Medial

Rectus 4) Optic Nerve.

Fig. 5: Gadolinium contrast with fat suppression showing

enhancement of optic nerve sheath.

Fig. 2: Coronal T1 images through orbit; 1) Optic nerve 2) Medial

Rectus 3) Superior Rectus 4) Lateral Rectus 5) Inferior

Rectus 6) Optic chiasm.

Fig. 6: Axial Flair images; 1) Eyeball, 2) Optic nerve, 3) Medial

Fig. 3: Coronal T2 images; 1) Eyeball, 2) Optic nerve, 3) Medial

Rectus, 4) Inferior Rectus, 5) Lateral Rectus, 6) Superior

Rectus 7) Superior Oblique 8) Optic chiasm.

Rectus 4) Lateral Rectus, 5) Optic Chiasma.

DISCUSSION

In this systematic review only NCBI Pubmed database

was used with search terms neuroimaging AND neuro-

ophthalmology (1997 to 2019). The details of the

studies and case reports are depicted in table 1 and 2.

When we searched Pakistan Journal of Ophthalmology

website from 2006 to 2019, only 14 articles were

found related to neuro-ophthalmology. After excluding

the articles, which did not include neuro-imaging, we

were left with 5 case reports and 5 original articles.

Case reports included CSF rhinorrhea¹, Ewing

Sarcoma², Optic disc drusen³, traumatic optic

neuropathy⁴and tuberous sclerosis⁵. Original articles

Fig. 4: Sagittal T1 images; 1) Eyeball, 2) Superior Rectus, 3) Optic

Nerve, 4) Inferior Rectus.

Pakistan Journal of Ophthalmology, 2020, Vol. 36 (2): 180-189

184

Tayyaba Gul Malik, et al

included headache⁶, head trauma⁷, meningiomas of

visual pathway⁸, Retinoblastoma⁹and systemic

associations of optic nerve diseases¹⁰.

edema.

Fat-suppression techniques are used in various

conditions including orbital pathologies. Orbital fat on

conventional T1-weighted imaging makes it difficult

to differentiate from other normal tissues (optic nerve

and Extraocular muscles), tumors, inflammatory

lesions and vascular malformations. There are two

types of fat-suppression sequence used in neuro-

ophthalmology.

In the following paragraphs, the commonly used

neuro-imaging techniques and important sequences are

discussed based on the articles reviewed through

Pubmed search.

Magnetic Resonance Imaging (MRI)

1. T1 weighted images with gadolinium contrast and

fat suppression allows the optic nerve sheath

lesions to be enhanced¹².

The basic mechanism of MRI is the rearrangement of

charged hydrogen ions after exposure of a tissue to a

short electromagnetic pulse. Relaxation times of the

tissues depend upon their characteristics and a tissue

may be T1 weighted or T2 weighted. The magnetic

field in MRI is expressed in Tesla (T). The commonly

used field is 1.5T to 3.0T¹¹.

2. STIR (short T1 inversion recovery) is used

without contrast and is quite optimal sequence for

diagnosing intrinsic lesions of the intraorbital optic

nerve (e.g. optic neuritis).

In T1 weighted images, CSF and vitreous appear

dark and it is good for studying normal anatomy. In T2

weighted images, water appears hyperintense. Hence,

the edematous tissues will be differentiated from the

surrounding tissues as hyperintense. Optic nerve

gliomas can be seen as tubular or fusiform

enlargement of the nerve, which appear isointense to

hypointense when compared with the adjacent tissues

on T1-weighted MRI and enhance after gadolinium

injection¹². Optic nerve meningiomas appear separate

from the optic nerve on coronal views. It is visible in

the form of a concentric ring around the nerve.

Inflammation of the Optic nerve sheath is better

detected by gadolinium-enhanced fat-saturated T1-

weighted MRI, in which they appear as

circumferential optic nerve sheath enhancement and

on axial views these are seen as tram-track sign

(Figure 5). Fat suppression techniques are also useful

in confirming the fat-containing lesions, such as

Dermoid cysts and lipomas. Thus for optic nerve

sheath and optic nerve lesions, fat suppression is a

gold standard.

Diffusion-Weighted Imaging

In

patients

with

Idiopathic

Intracranial

Diffusion-weighted imaging (DWI) is a special MRI

technique that is based on the microscopic random

Brownian motion of water. It is useful in detecting

acute ischemic strokes. This technique is useful in very

early stage of ischemic stroke when the changes are

undetectable on T1 and T2 weighted MRI¹². As

different stages of infarction can also be identified by

DWI, this technique is helpful in distinguishing

vasogenic reversible ischemia from irreversible

ischemia in patients with cortical blindness and

brainstem ischemia.

Hypertension (IIH), T1-weighted images of the brain

may show an empty sella turcica while axial T2-

weighted MRI images of the orbit show distension and

tortuosity of the optic nerve sheaths. Flattening of the

posterior globe is also an MRI sign of IIH¹². Afferent

and efferent visual pathways are also best detected by

MRI studies (Figures 1, 2, 3, 4).

However, in the presence of acute hemorrhage and

bony abnormalities, CT is a better option.

Gadolinium contrast studies is a special contrast

medium, which shows up when placed in a magnetic

field. When given through intravenous route, it

remains inside the vessels unless there is a defect in

the blood brain barrier. It is used with T1 weighted

images. It helps in enhancing the brightness of tumour

images and inflammatory lesions. Sellar masses are

also best visualized with contrast enhanced T1

weighted images. PostcontrastT1-weighted images can

be helpful in diagnosing Giant cell arteritis¹², in which

case there is increased vessel wall thickness and

(FLAIR) Sequence

As CSF is bright onT2-weighted images, it becomes

difficult to differentiate periventricular lesions from

CSF signal. In fluid-attenuated inversion recovery, a

T2-weighted image of CSF signal is suppressed to

allow better detection of adjacent pathology. FLAIR

sequences also help to highlight inflammatory

changes¹²(Figure 6).

185

Pakistan Journal of Ophthalmology, 2020, Vol. 36 (2): 180-189

Neuroimaging in Neuro-Ophthalmology (Systematic Review)

Gradient Recalled Echo (GRE) or susceptibility-

weighted imaging (SWI) is helpful in diagnosing

micro hemorrhages (within the first few hours)

(Figure 2).

acute hemorrhage, bony injury and in case of foreign

bodies, can mask the visibility.

Optic nerve head drusen and tumours that show

calcification e.g., Craniopharyngiomas, Meningiomas

and Retinoblastomas can be detected with CT scan.

Especially in cases of optic nerve sheath meningioma,

CT shows perineural calcification in the form of

“tram-tracking”. Hyperostosis of the neighboring

bones is also a diagnostic sign¹².

FIESTA and CISS (fast imaging employing

steady-state acquisition and constructive interference

in steady-state). The structures surrounded by CSF and

isodense to CSF in T1 and T2 weighted images are

better visualized by this technique. Orbital masses,

which arise from the orbital nerves can be better

detected with this technique.

In cases of traumatic optic neuropathy, CT scan

can help in detecting the optic canal fracture, edema

(or blood) within the optic canal (or optic nerve

sheath), intraconal hematoma, or foreign body/fracture

fragments causing impingement on the optic nerve.

Magnetic Resonance Venography (MRV)

and Magnetic Resonance Arteriography

(MRA)

Fludeoxy

Glucose

(FDG)–PET: Positron

MRA is a very good technique, which has reduced

dependency on Conventional invasive angiography.

MRA relies on blood flow within the vessels and

hence contrast is not required. However, the

thrombosed aneurysm and small aneurysms are

missed. MRV is used to detect venous sinus

thrombosis or venous stenosis¹¹.

emission tomography (PET) is a sequence, which is

used in diagnosing inflammatory and/or neoplastic

processes. Fluorodeoxy glucose (FDG) is a metabolic

marker. Greater uptake of glucose by the inflammatory

and neoplastic lesions can be helpful in diagnosis.

Large vessel vasculitis in GCA and extraocular muscle

inflammation in Graves disease is detected by this

technique¹².

Diffusion Tensor Imaging and Diffusion

Tensor Tractography

DTI and DTT can be helpful in visualizing the axon

and myelin integrity. Data from DTI is used to

reconstruct a 3D images in DTT.

Computed Tomographic Angiography and

Venography (CTA, CTV): Extremely thin slices of

brain are taken to investigate intracranial aneurysms.

CTV is a good diagnostic technique for cerebral

venous sinus thrombosis. Contrast is injected and the

patient is exposed to radiations.

Magnetic Resonance Spectroscopyis capable of

detecting brain metabolites and hence help in

distinguishing between neoplasms, demyelinating

lesions, radiation necrosis, inflammatory lesions and

mitochondrial disorders that can affect the visual

pathways.

Conventional catheter angiography was once

the only diagnostic test for intracranial aneurysm but

now CTA and MRA have surpassed its use and it is

only reserved for the patients in which the CTA and

MRA are not diagnostic¹².

Limitations of MRI include bony defects and acute

haemorrhages, which are not detected on MRI.

Magnetic foreign bodies, cardiac pace markers,

ferromagnetic aneurysm clips are contraindications for

MRI. The test is also not suitable for claustrophobic

patients.

Limitation of this systematic review is the use of

only one database (Pubmed). Other databases and gray

literature/unpublished data were also not included.

CONCLUSION

Relevant history with detailed clinical examination

along with the provisional diagnosis and the area of

interest for neuro-imaging must be included in the

investigation form. In case of any confusion, it is

better to consult a radiologist, for the best interest of

the patient, before filling the investigation form rather

than writing a wrong investigation.

Computed Tomography (CT) uses X-rays to

obtain images, which are then computed to form cross-

sectional images. White is the maximum density of the

tissue as in bones and black is the minimum density as

in air. Iodinated contrast is used to improve the

visualization of structures but allergy to iodine and

renal failure are contraindications. Use of contrast in

Pakistan Journal of Ophthalmology, 2020, Vol. 36 (2): 180-189

186

Tayyaba Gul Malik, et al

Biousse V. Diagnostic Errors in Initial Misdiagnosis of

Optic Nerve Sheath Meningiomas. JAMA Neurol.

Doi:10.1001/jamaneurol.2018.3989

Authors’ Designation and Contribution

Tayyaba Gul Malik; Professor: Study design, literature

search, data acquisition, data analysis, manuscript

writing, final review.

16. Bursztyn LLCD, De Lott LB, Petrou M, Cornblath

WT. Sensitivity of orbital magnetic resonance imaging

in acute demyelinating optic neuritis. Can

Ophthalmol. 2019: 54 (2): 242-246.

Doi: 10.1016/j.jcjo.2018.05.013.

J

Khalid Farooq; Professor: Study design, data

acquisition, final review.

17. Khadse R, Ravindran M, Pawar N, Maharajan P,

Rengappa R. Clinical profile and neuroimaging in

pediatric optic neuritis in Indian population: A case

series. Indian J Ophthalmol. 2017; 65: 242-5.

18. Kowal KM, Rodriguez FFR, Srinivasan A. Trobe

JD. Spectrum of Magnetic Resonance Imaging Features

in Unilateral Optic Tract Dysfunction. J Neuro-

Ophthalmol. 2017; 37: 17-23.

19. Aguilar-Perez M, Martinez-Moreno R, Kurre W,

Wendl C, Bazner H, Ganslandt O, Unsold R,

Henkes H. Endovascular treatment of idiopathic

intracranial hypertension: retrospective analysis of

immediate and long-term results in 51 patients.

Neuroradiology, 2017 Mar; 59 (3): 277-287.

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