Tumor or Inflammation? How Multi-Modality Image Fusion and Shear Wave Elastography Can Help Solve the Diagnostic Dilemma

Differentiating intraocular tumors from inflammatory conditions remains a major diagnostic challenge in ophthalmology, particularly in masquerade syndromes where clinical and imaging features overlap. Despite advances in ocular imaging, no single modality provides sufficient diagnostic specificity. This narrative review synthesizes current evidence on optical imaging modalities, ultrasonography, and elastography, focusing on their complementary roles in intraocular disease characterization, with emphasis on shear wave elastography (SWE) within a multimodal framework. Conventional imaging provides partial insights: OCT and ultrasonography define structural features, while angiographic techniques assess vascular behavior. Elastography adds a biomechanical dimension by enabling in vivo assessment of tissue stiffness. Malignant lesions typically exhibit increased stiffness and heterogeneity, whereas inflammatory processes show more variable profiles, yet overlap exists. Integrating structural, vascular, and biomechanical data improves pattern recognition and diagnostic confidence. A tri-axis fusion model and a practical diagnostic workflow are proposed to support clinical decision-making. Multi-modality image fusion represents a shift toward hybrid multi-dimensional tissue characterization in ophthalmology. The addition of elastography may assist in the differential diagnosis process between intraocular tumors and inflammatory conditions. Further standardization, validation, and integration with artificial intelligence are required for routine clinical implementation.