LL was a 56-year-old man with complaints of a deep aching around his right eye for several weeks. Examination found a firm, somewhat tender mass in the area of the lacrimal gland. A- and B-scan revealed a poorly defined lesion with high and low areas with the appearance of a cystic pattern in some parts of the tumor (Fig. 1).

Fig. 1
figure 00441

A-scan of adenocystic carcinoma of lacrimal gland (vertical arrows)

Full size image

Computed tomography scan showed bone destruction with extension of the lesion posteriorly into the orbit. Biopsy of the lacrimal gland confirmed an adenocystic carcinoma. He later underwent orbital exenteration.

The superior orbit is frequently a source of complaints of pain and tenderness. The patient is instructed to look as far inferiorly as possible, and the examiner carefully inspects the superior fornix for clinical findings such as conjunctival injection, lid edema, or other signs of inflammation. With the exception of disease of the lacrimal gland, echographic and radiologic studies are often unremarkable in the examination of this area, and the patient can be reassured that there is no significant disease process. The cause of the pain is usually nondetectable with current imaging techniques since ultrasound, CT, and MRI scans are also interpreted as unremarkable.

An exception to the low diagnostic yield in the superior orbit is the entity of trochleitis with superior oblique tendonitis, which can be readily detected on A-scan. The tendon is best imaged by placing the probe on the inferior temporal sclera and aiming towards the superior nasal orbit in a transocular approach. The probe should then be moved in small back-and-forth and side-to-side movements to maximally image the tendon. It runs along the medial wall of the orbit until it joins the superior oblique muscle and arches towards the orbital apex. It is thickened and lower reflective than the opposite superior oblique tendon when inflamed. The trochlea is best seen by imaging the superior oblique tendon in a transocular view and then looking at the orbital tissue just temporal to this area.