American College of Radiology
ACR Appropriateness Criteria®

Orbits, Vision and Visual Loss

Variant 1: Traumatic visual defect. Suspect orbital injury. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT orbits without IV contrast Usually appropriate ☢☢☢ 1-10 mSv 9 9 0 0 0 1 0 0 0 2 14
CT head without IV contrast Usually appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 7 7 0 1 0 0 3 3 10 2 0
MRI orbits without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 0 5 2 8 2 2 0
MRI head without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 1 3 1 2 12 0 0 0
MRI orbits without and with IV contrast May be appropriate (Disagreement) O 0 mSv O 0 mSv [ped] 5 5 2 0 1 3 4 5 4 0 0
CT orbits with IV contrast May be appropriate (Disagreement) ☢☢☢ 1-10 mSv 5 5 2 0 5 2 2 6 1 1 0
MRI head without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 5 2 1 4 1 10 1 0 0 0
CTA head and neck with IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 2 2 5 8 1 0 0
MRA head and neck without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 4 4 2 0 5 5 6 1 0 0 0
MRA head and neck without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 4 4 2 0 5 3 8 1 0 0 0
CT head with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 3 2 11 2 0 1 0 0 0
Arteriography cervicocerebral Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 8 1 9 0 1 0 0 0 0
Radiography orbit Usually not appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 10 3 2 0 1 0 1 0 0
CT orbits without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 10 1 6 2 0 0 0 0 0
CT head without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 3 6 0 0 0 0 0 0
Variant 2: Nontraumatic orbital asymmetry, exophthalmos, or enophthalmos. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI orbits without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 6 11
CT orbits with IV contrast Usually appropriate ☢☢☢ 1-10 mSv 8 8 0 0 0 0 0 1 6 5 5
CT orbits without IV contrast May be appropriate ☢☢☢ 1-10 mSv 6 6 0 0 0 1 2 6 1 3 4
CTA head and neck with IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 2 3 9 2 1 0
MRA head and neck without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 5 5 3 2 0
MRI head without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 1 0 1 6 11 0 0 0
MRI orbits without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 4 11 2 0 0
MRA head and neck without IV contrast May be appropriate (Disagreement) O 0 mSv O 0 mSv [ped] 5 5 0 4 1 3 7 4 0 0 0
MRI head without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 5 2 0 0 6 6 5 0 0 0
Arteriography cervicocerebral May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 4 5 8 2 0 0 0 0
CT head with IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 0 3 0 10 5 1 0 0 0
CT head without IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 1 3 1 7 6 1 0 0 0
CT head without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 4 3 4 1 1 0 0 0
Radiography orbit Usually not appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 16 0 0 0 1 0 0 0 0
CT orbits without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 9 6 2 0 0 0 0 0 0
Variant 3: Suspected orbital cellulitis, uveitis, or scleritis. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT orbits with IV contrast Usually appropriate ☢☢☢ 1-10 mSv 9 9 0 0 0 0 0 1 4 0 12
MRI orbits without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 2 10 5
CT orbits without IV contrast May be appropriate ☢☢☢ 1-10 mSv 6 6 0 0 0 3 5 10 1 0 0
MRI head without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 1 1 0 7 9 1 0 0
MRI orbits without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 5 9 4 0 0
CTA head and neck with IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 2 3 3 9 1 0 0 0
MRA head and neck without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 5 0 2 3 3 10 1 0 0 0
MRI head without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 5 0 1 1 6 8 3 0 0 0
CT head with IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 0 2 3 8 5 1 0 0 0
MRA head and neck without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 4 4 0 5 2 9 3 0 0 0 0
Arteriography cervicocerebral Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 4 7 1 2 0 0 0 0
CT head without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 2 3 7 5 1 1 0 0 0
CT orbits without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 3 3 7 2 3 1 5 1 0 0 0
CT head without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 5 6 1 0 0 0 0 0
Radiography orbit Usually not appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 16 0 1 0 0 0 0 0 0
Variant 4: Suspected optic neuritis. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI orbits without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 2 15
MRI head without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 3 5 8
MRI orbits without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 3 4 6 3 0
MRI head without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 1 0 0 0 4 4 6 2 0
CT orbits with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 3 3 6 2 2 3 2 2 0 0 0
CT head with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 6 3 2 3 1 2 0 0 0
CT head without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 3 3 2 1 1 0 0 0
CT orbits without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 2 2 7 2 3 3 1 1 0 0 0
CT orbits without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 2 2 6 4 3 3 0 0 1 0 0
CTA head and neck with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 5 3 1 0 0 0 0 0
MRA head and neck without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 2 8 5 3 1 0 0 0 0 0
MRA head and neck without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 2 8 6 2 1 0 0 0 0 0
CT head without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 6 5 3 4 1 0 0 0 0
Arteriography cervicocerebral Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 0 1 0 0 0 0 0
Radiography orbit Usually not appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 16 0 1 0 0 0 0 0 0
Variant 5: Visual loss. Etiology identified on ophthalmologic examination or laboratory tests.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI orbits without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 3 3 7 0 2 2 5 0 1 0 0
CT head without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 8 2 2 2 2 0 0 1 0
CT orbits without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 2 2 8 1 3 2 2 0 0 1 0
MRI head without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 2 7 2 0 3 3 1 1 0 0
MRI orbits without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 2 8 5 4 1 1 0 0 0 0
Arteriography cervicocerebral Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 2 1 1 0 0 0 0 0
CT head with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 9 2 2 2 1 0 1 0 0
CT head without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 3 3 0 1 1 0 0 0
CT orbits without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 9 2 1 1 3 1 0 0 0
CTA head and neck with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 5 2 0 0 0 1 0 0
MRA head and neck without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 9 5 2 0 0 0 1 0 0
MRA head and neck without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 9 6 1 0 0 0 1 0 0
Radiography orbit Usually not appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 16 0 0 1 0 0 0 0 0
CT orbits with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 11 3 4 1 0 0 0 0 0
MRI head without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 1 11 6 2 0 0 0 0 0 0
Variant 6: Visual loss. Intraocular mass,optic nerve, or pre-chiasm symptoms. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI orbits without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 0 1 17
CT orbits with IV contrast Usually appropriate ☢☢☢ 1-10 mSv 7 7 0 0 0 0 2 4 5 5 3
MRI orbits without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 0 4 12 2 0
CT orbits without IV contrast May be appropriate ☢☢☢ 1-10 mSv 6 6 0 0 0 3 1 12 3 0 0
MRI head without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 1 0 0 2 2 12 1 0 1
MRI head without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 5 1 0 1 5 9 2 1 0 0
CT head with IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 1 1 3 11 1 0 0 0
CT head without IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 0 1 3 7 6 2 0 0 0
CTA head and neck with IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 0 4 5 7 1 1 0 0
MRA head and neck without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 4 4 1 1 5 6 1 4 1 0 0
MRA head and neck without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 4 4 1 3 2 9 3 1 0 0 0
Arteriography cervicocerebral Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 5 5 1 1 0 0 0 0
CT head without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 3 4 2 2 0 1 0 0
Radiography orbit Usually not appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 18 1 0 0 0 0 0 0 0
CT orbits without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 9 3 5 0 0 0 0 0 0
Variant 7: Nonischemic visual loss. Chiasm or post-chiasm symptoms. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI head without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 4 14
MRI head without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 4 10 4 0
CT head with IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 1 0 0 2 7 3 4 2 0
CT head without IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 1 0 0 5 4 3 5 1 0
CTA head and neck with IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 1 1 3 6 6 2 0 0
MRA head and neck without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 5 0 0 0 6 5 6 1 0 1
CT head without and with IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 2 3 11 0 0 0 0
CT venography head with IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 2 3 5 3 6 0 0 0
MR venography head without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 4 4 1 4 1 7 4 2 0 0 0
MR venography head without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 4 4 0 3 3 3 8 0 0 0 0
MRA head and neck without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 4 4 0 3 2 5 7 0 0 0 0
CT orbits with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 3 3 5 3 4 4 1 1 0 0 1
CT orbits without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 3 3 7 2 5 2 2 0 1 0 0
MRI orbits without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 3 3 4 2 10 0 1 0 0 0 0
MRI orbits without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 3 3 5 1 10 1 0 0 0 0 0
Arteriography cervicocerebral Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 4 4 2 2 0 0 0 0
CT orbits without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 2 2 8 3 6 1 0 1 0 0 0
Radiography orbit Usually not appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 18 1 0 0 0 0 0 0 0
Variant 8: Ophthalmoplegia or diplopia. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI head without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 3 4 10
MRI orbits without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 3 13
CT orbits with IV contrast Usually appropriate ☢☢☢ 1-10 mSv 7 7 0 0 0 0 2 3 4 3 5
MRI orbits without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 1 6 7 2 0
MRI head without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 2 0 1 6 7 1 0
CT orbits without IV contrast May be appropriate ☢☢☢ 1-10 mSv 6 6 0 0 1 2 4 11 1 0 0
CTA head and neck with IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 1 4 13 0 0 0
MRA head and neck without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 4 13 0 0 0
MRA head and neck without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 1 2 4 12 0 0 0
CT head with IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 0 1 4 12 2 0 0 0
CT head without IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 0 0 6 12 1 0 0 0
Arteriography cervicocerebral Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 1 5 4 3 1 0 0 0
CT head without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 7 2 7 2 1 0 0 0 0
Radiography orbit Usually not appropriate ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 16 0 1 0 0 0 0 0 0
CT orbits without and with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 1 9 3 4 1 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.