Ocular Anatomy and

Cross-Sectional Imaging of the Eye

Ajay Malhotra, MD,* Frank J. Minja, MD,* Alison Crum, MD,† and Delilah Burrowes, MD‡

Ocular cross-sectional imaging is usually obtained as an adjunct to clinical ophthalmologic

examination and ocular ultrasound. Computed tomography/magnetic resonance imaging (CT/
MRI) are complimentary for ocular imaging and are performed for evaluation of the vitreous
cavity, choroid, retina, sclera, and potential spaces and for the assessment of extension of
disease beyond the globe into the orbit or brain. CT has superior spatial resolution aided by the
natural contrast between bone, soft tissues, air, and fat. The short scanning time is advanta-
geous to reduce motion effects and the need for sedation. CT is also the modality of choice for
evaluation of traumatic injury and for visualization of foreign bodies. Potential clinical indica-
tions for MRI include staging of retinoblastoma and other causes of leukocoria, assessment of
retinal or choroidal detachments for underlying retinal mass or hemorrhage, uveal melanoma,
ocular metastases, choroidal hemangioma, and buphthalmus, staphyloma, and coloboma. Last,
but not least, MRI has the advantage of no ionizing radiation.
Semin Ultrasound CT MRI 32:2-13 © 2011 Published by Elsevier Inc.

Ocular Anatomy
The globe occupies approximately one-third (or less) of the
volume of the orbit, with the other two-thirds of the volume
composed of fat, muscles, nerves, and vasculature (Fig. 1).
The wall of the eyeball (globe) consists of 3 primary layers:
● The sclera, or outer layer, is the fibrous protective layer
with the transparent cornea anteriorly;
● The uvea (uveal tract), or middle layer, having vascular
and nutritive function, contains pigmented tissue con-
sisting of the choroid, ciliary body, and iris;
● The retina, or inner layer, which is the neural, sensory
stratum of the eye.
Tenon’s capsule, also called the “fascia bulbi,” is a fascial
sheath that envelops the globe, forming a socket for the eye-
ball and separating it from the adjacent extraconal orbital fat.
Anteriorly, it blends with the sclera 3 mm from the sclero-
corneal junction and fuses with the bulbar conjunctiva. Pos-
teriorly the sclera is fused with the dural and arachnoid
*Section of Neuroradiology, Department of Radiology, Yale University, New
Haven, CT.
†Department of Ophthalmology, Yale University School of Medicine, New
Haven, CT.
‡Department of Medical Imaging, Children’s Memorial Hospital, Chicago, IL.
Address reprint requests to Delilah M. Burrowes, MD, Interim Division Head
of Neuroradiology, Department of Medical Imaging, Box 9, Children’s
Memorial Hospital, 2300 Children’s Plaza, Chicago, IL 60614. E-mail:
dburrowes@childrensmemorial.org
sheaths of the optic nerve. The lamina cribrosa is where the
optic nerve fibers pierce the sclera. Tenon’s capsule is also
perforated by the ciliary nerves and vessels and by the vortex
veins, the draining veins of the choroid and sclera.1,2
There is a potential space between the outer aspect of the
sclera and inner aspect of Tenon’s capsule—the episcleral
(Tenon’s) space, where inflammatory and neoplastic pro-
cesses can invade. The Tenon’s capsule is pierced by tendons
of the extraocular muscles and is reflected back along these
muscle sheaths to form a tubular sleeve at the site of perfora-
tion. The point where these two fuse is very resilient. There-
fore, the muscles retain their attachment to the capsule and
do not retract extensively after enucleation (tenotomy).3 Al-
though the normal layers of the globe wall may be difficult to
discern on cross-sectional imaging, particularly computed
tomography (CT), knowledge of ocular anatomy may facili-
tate accurate localization of pathology involving the globe (Figs.
2 and 3).
Sclera
The sclera is the outer supporting layer of the globe and
extends from the limbus at the margin of the cornea anteri-
orly to the optic nerve posteriorly, where it is contiguous with
the dural sheath of the optic nerve.1 The sclera acts as a
protective layer, maintains intraocular pressure and serves as
the attachment site for the extraocular muscles.4 The shape
and thickness of the sclera changes throughout life. It is thick
in early childhood, stretching with increased intraocular

2 0887-2171/$-see front matter © 2011 Published by Elsevier Inc.

doi:10.1053/j.sult.2010.10.009
Ocular anatomy and cross-sectional imaging of the eye
Figure 1 Diagramatic representation of the gross anatomy of the globe at the level of the optic nerve in midsagittal
section, important for an understanding of ocular pathology. (Diagram courtesy of Geri Mancini.) (Color version of
figure is available online.)
pressure, and becomes more rigid as one ages. Focal thinning
of the sclera with ectasia results in formation of a staphyloma
(Fig. 4). Scleral calcifications can occur, commonly at sites of
insertion of rectus muscles (Figs. 5 and 6).4 There is a poten-
tial space called the suprachoroidal space that lies between
the inner aspect of the sclera and the outer aspect of the
choroid.
Uvea (Choroid,
Ciliary Body, and Iris)
The uveal tract is a pigmented vascular layer that lies between
the sclera and the retina (Fig. 1). It consists of the ciliary
body, choroid, and the iris, and it is supplied by the ophthal-
mic artery as are the remainder of the orbital contents.
Iris
The iris is a thin, contractile, pigmented diaphragm that di-
vides the anterior ocular compartment (segment) into ante-
rior and posterior chambers, with a central aperture, the pu-
pil. The peripheral part of the iris attaches to the ciliary body.
It is suspended within the aqueous humor between the cor-
nea and the lens. The aqueous humor, formed by the ciliary
processes in the posterior chamber, circulates through the
pupil into the anterior chamber and exits into the Canal of
Schlemm at the iridocorneal angle.5
Ciliary Body
The ciliary body extends from the posterior insertion of the
iris to merge with the choroid at the ora serrata, which is also
the site of fusion of the retinal sensory and pigment epithe-
lium. The ciliary body forms a complete ring that runs
3
around the inside of the anterior sclera. It connects to the lens
via the zonules, also known as the suspensory ligaments (Fig. 3).
Choroid
The choroid extends from the optic nerve to the ora serrata
(where the sensory retina ends) and is the major vascular and
pigmented tissue of the middle layer of the globe.1 The inner
surface of the choroid is smooth and firmly attached to the
retinal pigment epithelium (RPE). Its outer surface is rough-
ened and is firmly attached to the sclera in the region of the
optic nerve and where the posterior ciliary arteries and ciliary
nerve enter the eye. It is also tethered to the sclera where the
vortex veins exit the globe. This accounts for the character-
istic biconvex shape of choroidal detachment, due to tether-
ing at the site of the vortex veins and posterior ciliary arteries
and ciliary nerves (Fig. 7). Bruch’s membrane is an acellular,
amorphous structure that is situated between the retina and
the rest of the choroid. When a choroidal malignant mela-
noma penetrates through Bruch’s membrane, it results in a
characteristic mushroom-shaped (collar button) growth con-
figuration.
Retina
The retina is the sensory inner layer of the globe. The inner
surface of the retina is in contact with the vitreous body and
its external surface is in contact with the choroid.
Grossly, the retina has 2 layers:
● the inner sensory layer (ie, photoreceptors) with the
first- and second-order neurons (ganglion cells) and
neuroglial elements of the retina
4 A. Malhotra et al

Figure 2 Normal, CT of the globe. Axial noncontrast CT images demonstrate the normal appearance of the globe at the
level of the optic nerve head (A), lens (B), and the superior globe (C). Coronal noncontrast images demonstrate the
normal appearance of the globe at the level of the lens (D), and the mid (E) and posterior (F) globe. (G) Oblique sagittal
reconstruction image demonstrates the continuity of the optic nerve head with the globe.
Ocular anatomy and cross-sectional imaging of the eye 5

Figure 3 Normal MRI of the globe. Axial T1-weighted with fat saturation (A) and T2-weighted (B) images of the globe
show the normal appearance of the lens, vitreous, and uveal structures. (C-D) Oblique sagittal T2-weighted images
through the globe and optic nerve head are useful for interrogating the posterior uveal structures.

● thin outer RPE layer, consisting of a single layer of cells cones thus it is insensitive to light and referred to as the “blind
with nuclei adjacent to the basal lamina (Bruch’s mem- spot.”
brane) of the choroid. The blood supply to the retina is from 2 sources:

The RPE cells are joined to each other by tight junctions. This
arrangement forms a barrier, the so-called “retinal blood bar-
rier.” The two retinal layers are bound tightly only at the ora
serrata anteriorly and the optic disk posteriorly.6 The intra-
ocular pressure and weak contact points maintain them in
close apposition. Retinal detachment along with retinal hem-
orrhage are characterized as corregated retinal folds. The de-
tached retina is limited posteriorly at the optic disk and an-
teriorly at the ora serrata (Fig. 8).
The macula, the center of the retina, lies 3.5 mm temporal
to the optic disk. The retina is thinnest at the fovea of the
macula. The optic disk is pierced by the central retinal artery
and vein. At the disk, there is complete absence of rods and
● the choroidal capillaries which supply the rods and
cones (the vessels do not enter the tissues, but tissue
fluid exudes between these cells);
● the central retinal artery supplying the inner structures
of the retina.
The central retinal artery is a branch of the ophthalmic artery,
and supplies the “internal layers” of the retina. The ophthal-
mic artery also supplies the choroid, and the cilioretinal ar-
tery is an arterial branch of the ophthalmic artery supplied
from the choroidal circulation. The interdependence be-
tween these two arterial branches are nicely demonstrated
clinically when some vision is preserved following central
6 A. Malhotra et al

Figure 4 Staphyloma. MRI demonstrating ocular deformity with uniform intraocular signal intensity of the right globe,
consistent with staphyloma, in axial T1 (A), sagittal fluid attenuation inversion recovery (B), axial T2 (C), and axial T1
postcontrast sequences (D). (Case courtesy of Ron Swanger, MD.)

retinal artery occlusion. In these patients with a cilioretinal Vitreous

artery (20% of the population), one can still perfuse the mac-
ula and still maintain minimal vision even though the rest of the
retina is dead/infarcted. The central retinal vein leaves the
globe through the lamina cribrosa and crosses the subarach-
noid space with two drainage pathways into the cavernous
sinus and into the superior ophthalmic vein. The retina con-
tains no lymphatic vessels.
The vitreous body occupies the space between the lens and
retina and represents two-thirds of the volume of the eye,
approximately 4 ml.7 The vitreous is 98%-99% water, bound
to a meshwork of collagen fibrils, a small amount of soluble
proteins, some salts, and hyaluronic acid (Figs. 1-3). The
vitreous body transmits light and supports the posterior sur-

Figure 5 Muscle insertion calcifications: Noncontrast axial (A) and coronal (B) CT demonstrates calcifications at the
ocular muscle tendonous insertions bilaterally.
Ocular anatomy and cross-sectional imaging of the eye 7

Figure 6 Drusen. Noncontrast CT demonstrates punctuate calcifications at the optic nerve heads bilaterally, typical of
drusen.

face of the lens. The vitreous body is attached to the sensory
retina at the ora serrata and the margin of the optic disk. It
also attaches to the ciliary epithelium in the region of the pars
plana. The attachment of the vitreous to the lens is firm in
young people and weakens with age. The vitreous is thick
and is composed of a well-balanced collagen network in
childhood. With aging, the vitreous attachments degrade,
and the vitreous becomes more “liquid”. Any insult to the
vitreous body may result in a fibroproliferative reaction that
may subsequently result in a tractional retinal detachment.6
Lens
The lens is a normally transparent, biconvex crystalline struc-
ture that transmits light and separates the aqueous from the
vitreous. It consists of multiple layers of cells arranged in a
concentric pattern.8 It contains approximately two-thirds
water and one-third structural protein. The conformational
changes in protein structure lead to lens opacities. The
zonules are suspensory ligaments that connect to the circular
and longitudinal fibers of the ciliary muscle, together referred
to as the ciliary body, and hold the lens in place (Figs. 1-3 and 9).
Cross-Sectional
Imaging of the Globe
Ocular cross-sectional imaging is usually obtained as an ad-
junct to clinical examination and often previous imaging with
ultrasound. This diagnostic strategy makes intuitive sense if
one considers a simplistic concept of the globe as a structure
composed of fluid-filled chambers (anterior, posterior, and
vitreous), the surrounding layer (retina, choroid, and sclera),
and potential spaces between the layers (suprachoroidal and
subretinal spaces). The anterior and posterior chambers are
best evaluated with ophthalmologic examination and ad-
junctive ultrasound, given the limited resolution of these
structures with computed tomography/magnetic resonance
imaging (CT/MRI). Most ocular CT/MRI is performed for
evaluation of the vitreous cavity, choroid, retina, sclera, and

Figure 7 Hemorrhagic choroidal detachment. (A-B) Axial CT images demonstrate hemorrhagic choroidal detachment
involving both the nasal and temporal aspects with the detached choroid restricted at the level of vortex veins and
posterior ciliary artery. Anteriorly the detachment extends to the ciliary body.
8 A. Malhotra et al

CT Technique
The standard technique for evaluation of ocular lesions is to
obtain thin section axial helical scanning (0.625 mm) with cor-
onal and sagittal reformats. The reformats are performed per-
pendicular to the hard palate. Modern multidetector row CT
scanners provide isotropic resolution and provide high quality
image reconstruction. Parameters should be appropriately se-
lected for adult (Table 1) and pediatric (Table 2) imaging of the
globe to keep the radiation dose to a minimum. Intravenous
contrast administration is usually reserved for evaluation of in-
traocular masses and inflammatory lesions and is not required
for trauma or foreign body screening (Fig. 10).
Figure 8 Retinal detachment. T1-weighted MRI demonstrates char-
acteristic corrugated retinal folds with subretinal hemorrhage. The Radiation in Globe Imaging
detached retina is limited posteriorly at the optic disk and anteriorly
at the ora serrata. The lens of the eye is one of the most radiosensitive tissues,
and the lens of a child is even more sensitive than that of an
adult. It is important to reduce the radiation dose when one
uses CT for globe imaging (ie, as low as reasonably achievable
potential spaces, and for extension of disease beyond the [ALARA]). The need for high spatial resolution in orbital and
globe into the orbit or brain (Figs. 2 and 3).9,10 CT and MRI ocular imaging dictates use of thin collimation (0.625-1.25
are often complimentary techniques in the imaging evalua- mm) with reconstruction interval of 1 mm. Because tube
tion of the globe. CT has superior spatial resolution with current is directly proportional to the radiation dose, if lesser
excellent evaluation of the orbital structures aided by the contrast is required and greater noise can be tolerated, a
natural contrast between bone, soft tissues, air, and fat. The lower tube current (mAs) should be used. A high kilovoltage
short scanning time makes motion less of a concern and
sedation can be avoided, particularly in pediatric patients. CT
is also the modality of choice for evaluation of traumatic
injury and for visualization of foreign bodies, especially me-
tallic or paramagnetic substances, where MRI is contraindi-
cated (Fig. 9). Potential clinical indications for MRI include
leukocoria (staging retinoblastoma, persistent hyperplastic
primary vitreous, retinopathy of infancy), retinal or choroidal
detachments—to exclude underlying retinal mass or hemor-
rhage, uveal melanoma (T1 shortening and MR susceptibility
artifacts indicate melanin and/or hemorrhage), ocular metas-
tases (for staging), choroidal hemangioma (with brisk en-
hancement post Gado), staphyloma-coloboma, or other al-
terations of size or shape. For retinoblastoma, although CT is
more sensitive for identifying the presence of calcifications,
MRI better demonstrates the extent of extraocular disease.
This is a critical point for prognosis because there is 90%
survival if the retinoblastoma is limited to the globe, whereas
mortality is ⬎90% if there is extraocular extension of dis-
ease.9,10 Last, but not least, MRI has the advantage of no
ionizing radiation.

CT Pitfalls
CT has limited soft-tissue contrast resolution compared with
MRI. Orbital evaluation on CT is sometimes limited by streak
artifacts from metallic hardware.11 CT is also limited in the
evaluation of intracranial extension of ocular disease and, is
often coupled with MRI for its improved contrast and spatial
resolution when orbital or intracranial extension is sus- Figure 9 Axial (A) and coronal (B) noncontrast CT shows the lens
pected. dislocated posteriorly, inferiorly and medially.
Ocular anatomy and cross-sectional imaging of the eye 9

Table 1 CT Technique for Adult Orbital/Globe Imaging single brief exposure for detectable opacities and visual im-
Scan Type Helical pairment (cataract) are 0.5-2.0 and 5.0 Sv, respectively.15
However, some authors have suggested lower thresholds for
Detector 64 ⴛ 0.625
radiation-induced lens injuries and further suggest that the
configuration
Position Supine head or feet first zero at risk of cataract increases with increased radiation dose with-
outer canthus of eye out a threshold.16
Topogram direction Craniocaudal In follow-up CT scans for patients without lesions in the
Scan start 1 cm inferior from hard palate posterior cranial fossa, exclusion of the posterior cranial fossa
End location 1 cm superior to the orbits from the scanning range results in reduced lens dose if the
Kilovoltage (kVp) 120 kV orbitomeatal line is used as a baseline.14 The lens can be
Tube Current (mA) Smart mA 100-200 excluded from the scanning range by the use of a more an-
Rotation time (in 0.8 gulated baseline than the orbitomeatal line, even when the
seconds) posterior cranial fossa is scanned.13 With automatic tube-
Pitch/ Speed of 0.984:1, 49.21
current modulation in the x-y plane, decreased anteroposte-
rotation
Field of view (FOV) 18 (Decrease appropriately)
rior exposure reduces the lens dose, while maintaining the
in cm image quality.17 Eye masks, such as a bismuth-coated latex
Noise Index 12 shield, are also useful to reduce the lens exposure when the
Helical set recons Recon/thickness and spacing/ orbital and ocular structures are not the focus of imaging.18
algorithm
1 thins (for MPR)/0.625 ⴛ
0.625 mm/bone plus Orbital and Ocular MRI
2 orbits (Bone)/2.5 ⴛ 2.5 mm/
Orbital MRI protocols often provide sufficient ocular imaging
bone plus
detail thus the critical aspects of orbital MRI protocols will be
3 orbits (standard)/2.5 ⴛ 2.5
mm/standard discussed first; to be followed by additional tips for obtaining
Intravenous contrast 70 mL of Ominpaque 350 at 2 high resolution ocular images. Typical MRI orbit protocols
mL per second use T2-weighted and T1-weighted postgadolinium fat satu-
Scan delay for 45 s ration images as the critical sequences for defining pathology.
contrast T2-weighted sequences have great sensitivity for edema
Reformats Coronal reformats 3 ⴛ 3 mm within the optic nerve, whereas the T1-weighted fat-satu-
perpendicular to the hard rated postgadolinium images allow demonstration of abnor-
palate mal enhancement within the orbit by subtracting out the
intraorbital fat (Fig. 3). T2-weighted sequences are acquired
in the axial plane, angled parallel to the optic nerves, which
peak (kVp) of 120 and a pitch of just less than 1 is used. The run in a slightly oblique axial plane towards the optic canals,
“acquire thin and view thick” strategy is helpful for dose resulting in the display of the entire optic nerve to the optic
reduction with thicker reconstruction (2.5 mm) thinner sec- chiasm on a single axial slice.10,19 Post gadolinium/fat satura-
tion thickness can be used for higher spatial resolution al- tion sequences are acquired in the same oblique axial plane,
though this often produces grainy images.12 often with the addition of coronal and sagittal oblique T1-
Whole-brain CT with the orbitomeatal line as the baseline weighted fat-saturated images. The coronal plane like the
routinely includes the orbits in the scanning range.13 The lens axial plane, allows for side to side comparison of orbital pa-
dose during brain CT is affected by the type of CT scanner thology, whereas the sagittal oblique plane is angled for op-
and the scanning settings. The lens dose can be estimated timal evaluation of a unilateral orbital segment of the optic
approximately by the CT dose index vol, with the lens dose nerve. T1-weighted sagittal images are obtained before con-
being roughly 20% lower than CT dose index vol for both trast administration for scouting purposes in order to define
axial and helical scanning.14 the axial oblique plane of the optic nerves. Clinicians often
According to 1990 recommendations of the International wish to evaluate the visual pathway from the optic nerves to
Commission on Radiological Protection, the thresholds in a the occipital lobes on MRI, thus the field of view commonly

Table 2 Pediatric Ct protocols 64-slice.xlsx

Protocol Scan Scan Rotation Feed Start Table
64 slice Mode type KV MA eff mAs CTDI Time Collimation Slice AQ Pitch Scan Delay Direction

Orbits
<1 year Spiral 120 150 150 23.46 1.0 0.6 3.0 64 ⴛ 0.6 0.55 Ca-Cr
1-4 year Spiral 120 170 170 26.59 1.0 0.6 3.0 64 ⴛ 0.6 0.55 Ca-Cr
5-9 year Spiral 120 190 190 29.71 1.0 0.6 3.0 64 ⴛ 0.6 0.55 Ca-Cr
10-14 year Spiral 120 200 200 31.24 1.0 0.6 3.0 64 ⴛ 0.6 0.55 Ca-Cr
(adult)
>15 year Spiral 120 200 200 31.24 1.0 0.6 3.0 64 ⴛ 0.6 0.55 Ca-Cr
10 A. Malhotra et al

Figure 10 BB pellet to the orbit. Anteroposterior (A) and lateral (B) CT scout views demonstrate a BB pellet within the right orbit. (C)
Axial CT at the level of the lens (C) and at the level of the orbital apex (D) demonstrate a ruptured right globe with intraocular air and
vitreous hemorrhage and the BB pellet with streak artifact close to the apex of the orbit. (E) Coronal CT confirms the apical location
of the BB. (F) Color fundus photograph of the right eye of a patient who was shot with a BB gun demonstrates the globe rupture and
intraocular air and hemorrhage. (Case courtesy of John Huang, MD.) (Color version of figure is available online.)
Ocular anatomy and cross-sectional imaging of the eye
extends beyond the orbital apex to include the canalicular
segment of the optic nerve, optic chiasm, proximal optic
tracts, and the optic radiations. This relatively large field of
view, 14-18 cm is easily obtained with a head coil.10,20 The
use of a head coil also allows for additional sequences
through the entire brain to further elucidate the remainder of
the visual pathway to the occipital lobes. A slice thickness of
3 mm with or without a gap provides sufficient orbital and
ocular detail. It is also possible to acquire isotropic voxels at
1 mm per slice in one plane then reformat the images in any
desired plane thus avoiding the need for additional scan time.
Ocular MRI
Ocular imaging requires high spatial resolution MRI with
adequate signal to noise. This is can be achieved with con-
ventional head coils and may be enhanced with surface coils.
The predominant MR signal from the globe is from the aque-
ous and vitreous humor, which have a ⬎98% water content;
giving them the expected bright T2 signal and low T1 signal
relative to the extraocular muscles. The uveal tract (choroid
layer, ciliary body and iris) have a slightly hyperintense T1
signal, and demonstrate enhancement with contrast. On T2-
weighted images, the uveal tract is largely obscured by the
bright T2 signal of the aqueous and viterous humor. There-
fore, abnormalities of the uveal tract, in particular focal thick-
ening of the choroid layer, are best seen on T1-weighted
images, preferably with contrast. The scleral layer demon-
strates low T1 signal and is readily apparent external to the
choroid layer. The lens is dark on T2-weighted images and
bright on T1- weighted images, presumably secondary to a
higher structural protein content relative to the adjacent hu-
mors.8
Exquisite anatomical detail is possible with high resolution
MR imaging using specialized surface coils dedicated to oc-
ular imaging. Fine anatomic structures of the eye globe have
been demonstrated in vivo, including the Tarsal plate, ciliary
body and Tenon’s capsule.21 These coils are able to perform
selective ocular imaging with smaller voxel sizes while main-
taining an adequate signal to noise ratio.10 The use of surface
coils however precludes simultaneous evaluation of the orbit,
orbital apex and the remainder of the visual pathway because
of the precipitous signal drop off beyond the smaller field of
view. Therefore, high spatial resolution ocular imaging
should be reserved for those cases where more information is
needed than can be provided by the routine orbit protocol to
meet clinical diagnostic or therapeutic planning needs.9
Surface coils can be applied directly on top of the patient’s
eye to obtain high resolution ocular images. Proximity of the
coil to the globe improves both signal-to-noise ratio and im-
age spatial resolution. Signal-to-noise ratio improves because
surface coils obtain better signal from proximity effects, with
limited noise from surrounding tissues beyond the small field
of view. The smaller field of view typically 3-6 cm, compares
with 14-18 cm with a head coil and translates into smaller
pixel size and higher spatial resolution at a given imaging
matrix. The high spatial resolution images afforded by sur-
face coils are ideal for staging of ocular malignancies to de-
11
termine involvement of the optic nerve or define extraocular
extension of tumor. The challenges of using surface coils
include increased sensitivity to eye motion artifacts, suscep-
tibility artifact at the eye surface-air interface, and chemical
shift artifacts at the sclera-orbital fat interface.21-24
Eye Movement
The eye has frequent voluntary and involuntary movements,
both of which can seriously degrade the MR images. Despite
voluntary attempts to keep the eyes open, spontaneous
blinking occurs every 10-15 seconds.25 Several methods have
been tried to minimize eye movement during the ocular MR
examination, some investigators have trained patients to re-
lax and look straight ahead, only closing their eyes just before
the measurements.23 Bert et al25 systematically evaluated
methods for limiting both voluntary and involuntary eye
movements, and found that imaging the eye closed with con-
tralateral fixation of gaze resulted in the least artifact prone
images. The closed eye had limited involuntary movements,
while contralateral fixation of gaze limited voluntary eye
movement in both eyes because of conjugate gaze. A water-
soaked gauze placed between the surface coil and the eye
being imaged taped shut, minimized magnetic field distor-
tion at the air-eye surface interface.26
Berkowitz et al27 demonstrated the feasibility of obtaining
blinking artifact-free images by alternating periods of no-
blinking with brief periods of blinking, especially when ac-
quiring data on oxygenation of the retina, where such motion
would substantially confound measurement of relatively
small signal intensity changes. Other authors advocate the
use of moderate sedation, general anesthesia, or local retro-
bulbar anesthesia depending on the patient population. Pe-
diatric and claustrophobic patients, for example, would best
tolerate an ocular MR examination under moderate sedation
or general anesthesia, whereas patients undergoing localiza-
tion for radiation therapy, retrobulbar anesthesia is preferred
to reduce involuntary eye movements.23,28,29 The optimal ap-
proach for minimization of eye motion will depend upon the
patient characteristics and the specific imaging question to be
answered. Imaging time is another important consideration
since surface coil imaging, with sequences lasting longer than
4 minutes are often severely degraded by motion artifacts.10
3 T Versus 1.5 T
Theoretically, the signal-to-noise ratio doubles when increas-
ing the magnetic strength from 1.5 to 3 T.20,23 Thus, we
would expect better images at 3 T compared with 1.5 T.
Interestingly, initial experience in ocular MRI at 3 T has not
demonstrated the expected gain in imaging quality over 1.5 T
imaging (Fig. 11). Lemke et al demonstrated statistically sig-
nificant higher signal to noise and contrast with noise ratio
for ocular images obtained at 3 T compared with 1.5 T;
however, these gains did not translate into the expected bet-
ter image quality. Imaging at 3 T is known to be extremely
sensitive to motion artifacts, and can be problematic even
12 A. Malhotra et al

Figure 11 Intraocular foreign body. This unfortunate patient was hammering metal without eye protection and expe-
rienced a sharp foreign body sensation in the left eye. (A) CT Scout/plain film view demonstrates a tiny metal fragment
within the left orbit. (B) Coronal CT reformat confirms metallic foreign body within globe. (C) Axial view of the inferior
globe demonstrates the metallic fragment and a vitreous hemorrhage which could be mistaken for lens dislocation,
however, view though the lens (D) shows its normal position. Fundus photo (E) demonstrates the intraocular foreign
body and striae of the retina pointing towards the site of impact. (Case courtesy of John Huang, MD.) (Color version of
figure is available online.)

while under retrobulbar anesthesia. Imaging at 3 T also am-
plifies the effects of an inhomogenous magnetic field at inter-
faces; with image distortion at the cornea-air interface and
chemical shift artifact at the eye globe-orbital fat interface.
Magnetic susceptibility effects are also greatly amplified at
3 T, which may be advantageous in the evaluation of hemor-
rhage or calcifications; but deleterious in patients with para-
magnetic eye liner or metallic fragments in the eye. The mag-
netic susceptibility effects are further amplified when using
gradient echo or echo planar sequences, as opposed to spin
echo sequences which employ a 180 degree refocused radio-
frequency pulse (Appendix).
Specific absorption rate varies proportional to the square
of the magnetic field strength; therefore significantly more
heat is deposited on the eye globe when imaging at 3T com-
pared with 1.5 T. This does not appear to be important at
these field strength levels but may become more important at
the 4-7 Tesla level.
MRI Safety Screening
Patients to be imaged with MRI should be carefully screened
for potential contraindications, for example pacemakers,
neural stimulators, history of previous welding or metal-
work, gunshot, coronary, or intracranial stents, especially
when imaged at greater field strengths. There is also in-
creased susceptibility artifact at greater magnet strength. In-
creased need for safety screening—as MRI examinations be-
come more widely available (Fig. 11). When imaging the
globe with a surface coil, it is important to screen the patient
for eye liner which often contains metallic pigments that may
render the images nondiagnostic.
Future Directions in Ocular MRI
Although high spatial resolution ocular MRI has its limita-
tions, physiological ocular MRI holds promise for future use.
fMRI and MRI-oxygenation techniques are being developed
to study retina and optic nerve head physiology at spatial
resolution high enough to depict the 3 layers of the retina.30
MRI has the potential for providing noninvasive evaluation of
early changes of diabetic retinopathy, as well as assessment of
response to antiangiogenic and vision sparing therapies. Ex-
perimental animal models for both diabetic retinopathy and
retinopathy of prematurity have already been developed and
high resolution images of the 3 retinal layers obtained.27
Ocular anatomy and cross-sectional imaging of the eye 13

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Appendix MR Protocols for Orbital/Globe Imaging at 1.5 T and 3T

Matrix,
Thk/Gap, FOV, Frequency ⴛ
Plane/Sequence mm cm Phase Nex TR, ms TE, ms TI, ms
At 1.5 T
Sagittal T1 5/1 23 256 ⴛ 256 1 500 10 NA
Sagittal FLAIR 3D 1 isotropic 25 256 ⴛ 256 1 5000 375 1800
Coronal IRFSE (cover chiasm through 0.9 isotropic 22 256 ⴛ 218 1 3800 210 160
globes)
Coronal T1 precontrast 3/0 18 256 ⴛ 192 1 475 7 NA
Axial T2 fat saturated 3/0 22 256 ⴛ 256 1 5500 110 NA
Coronal T1 post-fat saturated 3/0 16 256 ⴛ 192 1 500 10 NA
At 3 T
Sagittal T1 FLAIR 5/1 23 320 ⴛ 288 1 2000 10 860
Sagittal FLAIR 3D 1 isotropic 25 256 ⴛ 256 1 5000 375 1800
Coronal IRFSE (cover chiasm through 0.9 isotropic 22 256 ⴛ 218 1 3800 190 160
globes)
Coronal T1 precontrast 3/0 16 256 ⴛ 192 1 900 10 NA
Axial T2 fat saturated 3/0 22 320 ⴛ 288 1 5500 110 NA
Coronal T1 post fat saturated 3/0 16 256 ⴛ 192 1 500 10 NA
Axial T1 post fat saturated 3/0 16 256 ⴛ 192 1 500 10 NA
FOV, field of view; MR, magnetic resonance; NA, not available; TE, echo time; TI, time intensity; TR, repetition time.