Orbital varices

From EyeWiki



Axial MRI of orbital varice in the left orbit. Courtesy of Michael Migliori, MD

Etiology

Orbital varices are venous malformations of the orbit, vascular hamartomas. [1][2] They consist of a plexus of thin-walled distensible low flow vein-like vessels that are commonly intrinsic to the normal circulation.[3]

Epidemiology

Orbital varices commonly present from early childhood to late middle age.[2] Most varices are unilateral and located superonasally.

Physical examination, Signs/Symptoms

Proptosis is a common presenting sign. Proptosis is the result of engorgement of varices and is typically intermittent and slowly progressive.[1] This clinical sign is elicited by increasing the orbital venous pressure through coughing, straining, Valsalva maneuver, bending of the head down.[1] [2][3] Complications associated with varices include acute orbital hemorrhage, thrombosis (often with sudden pain, proptosis, decreased vision) and optic nerve compression. Patients with long-standing lesions may develop enophthalmos from atrophy of surrounding fat, although correction of exophthalmos is expected with valsalva manoeuvres to reduce venous return.[2]

Diagnosis

The diagnosis can be confirmed with imaging (i.e. MRI, MRV, CT, ultrasound) and shows a lobulated mass with variable contrast enhancement. Phleboliths may be visible on imaging[1][2]

Management

Treatment is usually conservative. Incisional biopsy should be avoided because of the risk of hemorrhage. Surgery is reserved for relief of significant pain or in cases of vision threatening compressive optic neuropathy. Indications for surgical intervention include: nonresolving episodes of thrombosis, severe disfiguring proptosis or displacement of the globe and optic nerve compression. Specialized techniques such as coil embolization and carbon dioxide laser surgery have also been reported to reduce symptoms.[1] [2][3]


References

  1. 1.0 1.1 1.2 1.3 1.4 Skuta GL, et al. Basic and Clinical Science Course: Section 7. 2013-2014. American Academy of Ophthalmology.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Bowling, B, et al. Kanski’s Clinical Ophthalmology, 8th Ed. 2016. Elsevier Limited. Ch 3: 77-117.
  3. 3.0 3.1 3.2 Islam N, Mireskandari K, Rose GE. Orbital Varices and Orbital Wall Defects. Br J Ophthalmol 2004. 88: 1092-1103
  1. Dutton, JJ. Radiology of the Orbit and Visual Pathways. 2010. Elsevier, Inc. Ch 6:121-385.