Embolisation of orbital varix

Intermittent Orbital Pain due to Hemodynamic Collapse of an Orbital Varix: A Case Report

Orbital varices typically present with symptoms related to dilation or thrombosis. We describe a rare presentation of an orbital varix with pain caused by hemodynamic collapse of the varix. A woman in the third decade presented with position-dependent orbital pain and enophthalmos. She was found to have an intraorbital varix and a separate pterygoid varix. The patient underwent endovascular treatment of the pterygoid varix using coils and sclerosing agents which altered the venous outflow from the orbital varix. The patient had immediate resolution of symptoms after the procedure. Our findings suggest that extraorbital venous outflow abnormalities may be the cause of symptoms in selected cases of orbital varices. By understanding the venous structures on cerebral angiography and treating the extraorbital component, orbital intervention may be avoided, reducing the risk of complications.

Dilated orbital vein causing Valsalva-induced proptosis

This case report highlights intermittent proptosis precipitated by exercise or Valsalva maneuvers. Conventional orbital computed tomography scan and catheter angiography did not disclose any orbital vascular lesion. Orbital B-scan ultrasonography, however, before and after a Valsalva maneuver demonstrated intermittent orbital vein dilation adjacent to the optic nerve of the left eye. Clinicians should be aware that anatomic venous variations and vascular malformations including orbital varices may produce a characteristic symptom of recurrent proptosis with Valsalva or head position. Conventional structural orbital imaging (e.g., computed tomography or magnetic resonance imaging) may not demonstrate a lesion.

Classification and treatment of orbital venous malformations: an updated review

Orbital venous malformation (OVM) is a congenital vascular disease. As a common type of vascular malformation in the orbit, OVM may result in vision deterioration and cosmetic defect. Classification of orbital vascular malformations, especially OVMs, is carried out on the basis of different categories, such as angiogenesis, hemodynamics, and locations. Management of OVM is complicated and challenging. Treatment approaches include sclerotherapy, laser therapy, embolization, surgical resection, and radiotherapy. A satisfactory outcome can be achieved only by selecting the appropriate treatment according to lesion characteristics and following the sequential multi-method treatment strategy. This article summarizes the current classification and treatment advances in OVM.

Inferior petrosal sinus route microcatheterization study and embolization for primary orbital varix

PURPOSE

Primary orbital varix is a rare lesion but difficult to treat. Our main aim was to demonstrate the varices and their central venous communication and to explore the feasibility of embolization of these lesions.

METHOD

In four patients with clinical suspicion of varix, in whom MRI showed retro-global vascular channels, microcatheter digital subtraction angiography (DSA) of the varices was performed using femoral venous access. Embolization was carried out in two patients.

RESULTS

In all four patients orbital varices could be accessed with a microcatheter through inferior petrosal sinus and ophthalmic vein (superior or inferior) route. Microcatheter angiography showed opacification of varices and demonstrated their central venous communication. Two patients were treated with coil embolization. Complete resolution of symptoms was seen in one patient and partial relief in the other.

CONCLUSION

The study presents microcatheterization of orbital varices via the inferior petrosal sinus-cavernous sinus-ophthalmic vein route with injections into distal ophthalmic veins for demonstration of these variceal sacs and their central venous connection. Coiling to disconnect the venous communication should be the primary goal of embolization.

Transvenous sclerotherapy of a large symptomatic orbital venous varix using a microcatheter balloon and bleomycin

An orbital venous varix is rare and can present with diplopia, proptosis, or hemorrhage. Treatment can be challenging, especially if the varix is in a posterior location within the orbit, since surgical exposure becomes difficult. A few case reports have been published describing transcatheter embolization of an orbital varix with coils, direct percutaneous injection of n-butyl cyanoacrylate glue, and the percutaneous injection of bleomycin. We present a case of a symptomatic orbital venous varix of the left inferior ophthalmic vein successfully treated with transvenous endovascular sclerotherapy using a microcatheter balloon and bleomycin.

Transvenous sclerotherapy of a large symptomatic orbital venous varix using a microcatheter balloon and bleomycin

An orbital venous varix is rare and can present with diplopia, proptosis, or hemorrhage. Treatment can be challenging, especially if the varix is in a posterior location within the orbit, since surgical exposure becomes difficult. A few case reports have been published describing transcatheter embolization of an orbital varix with coils, direct percutaneous injection of n-butyl cyanoacrylate glue, and the percutaneous injection of bleomycin. We present a case of a symptomatic orbital venous varix of the left inferior ophthalmic vein successfully treated with transvenous endovascular sclerotherapy using a microcatheter balloon and bleomycin.

Embolization of a deep orbital varix through endovascular route

We report a case of the primary deep orbital venous varix treated by endovascular coil embolization procedure by transfemoral catheterization. This method of treatment has the advantage of image-guided localization of the pathology, real-time management and confirmation of the success of the procedure in the sitting.

Optic neuropathy following endovascular coiling of an orbital varix

Orbital varices are vascular malformations consisting of abnormal venous channels. Indications for intervention include loss of vision, elevated orbital pressure with motility deficit, and intractable pain. We present a case of a 65-year-old woman with an orbital varix, who underwent embolization via endovascular coiling. This treatment resulted in an intralesional thrombosis with subsequent enlargement of the varix, leading to a compressive optic neuropathy and severe vision loss. If an intervention is to be contemplated, the possibility of this rare but serious complication should be carefully considered and patients appropriately counseled.

Combined endovascular and surgical approach for the treatment of palpebral arteriovenous malformations: experience of a single center

BACKGROUND AND PURPOSE

Palpebral AVMs (pAVMs) are rare vascular lesions for which the treatment is challenging. Our aim was to present the technical aspects of the presurgical treatment by interventional neuroradiology of pAVMs and to report the clinical and angiographic results of combined (interventional neuroradiology/surgery) treatment of these malformations.

MATERIALS AND METHODS

Nine patients (5 females, 4 males) with a mean age of 22 years (range, 12-35 years) were treated in our department from December 1992 to April 2007 for superficial pAVMs. Seven patients presented with isolated pAVMs, while 2 had hemifacial AVMs. Ten TAE procedures, by using a liquid embolic agent (glue or Onyx) or microparticles, were performed in 7 patients. Six patients underwent absolute alcohol, glue, or sclerotic agent injection by direct puncture in 8 procedures. Clinical and angiographic follow-up were performed with a mean delay of, respectively, 6.3 and 5 years.

RESULTS

Three patients had a single EVT. Iterative procedures were performed in 5 patients. In 1 patient, EVT was not performed because of the risk of occlusion of the central retinal artery. No complication occurred except 1 case of transient palpebral hematoma. No visual acuity loss related to an endovascular procedure was reported. Exclusion of the AVMs at the end of the procedure was >75% in all cases and total in 3/8 cases. All the patients except 2 underwent at least 1 surgical procedure after the embolization. Good clinical regression of the mass was obtained in all patients at long-term follow-up.

CONCLUSIONS

Combined endovascular and surgical treatment of pAVMs is an effective and safe technique with good clinical results at long-term follow-up.

[Orbital varix presenting with enophthalmos. A case report]

We report a 23-year-old patient, presenting with enophthalmos in the left eye. The ophthalmologic examination was normal, except a 3-mm enophthalmos measured using the Hertel's exophthalmometer and an intermittent proptosis observed through the Valsalva maneuver. Orbital imaging tests disclosed a retroocular vascular lesion. A carotis arteriography was performed, and it revealed a tumor with vascular elements presumed to be orbital varix. Ultrasound Doppler examination showed a nonechogenic lesion with an increasing volume during Valsalva. Based on these findings, the tumor was diagnosed as orbital varix. We decided to manage the patient conservatively, in the absence of complications such as proptosis with corneal exposure, optic nerve compression, or esthetically unacceptable appearance. Orbital varix is a vascular anomaly, accounting for 2 % of orbital tumors. It generally presents with an intermittent exophthalmos or orbital hemorrhages. The development of enophthalmos associated with varices, such as reported in our case, is rare.

Orbital venous malformation: percutaneous treatment using an electrolytically detachable fibred coil

PURPOSE

To report the efficacy of percutaneous treatment of an orbital venous malformation with an electrolytically detachable fibred coil.

METHODS

We report an instance of radiography-guided percutaneous treatment with an electrolytically detachable fibred coil in a 16-year-old boy with acute, spontaneous, painless proptosis on the left side, which progressed with time.

RESULTS

Magnetic resonance imaging, angiography and orbitophlebography revealed a low-flow, intraorbital venous malformation. Percutaneous puncture and drainage were followed by a short remission. Following an acute recurrence, a single detachable fibred coil was deployed via a percutaneous approach under angiographic guidance. No radiological or clinical recurrences were observed over 4 years.

CONCLUSIONS

Embolization of a deep orbital venous malformation with detachable fibred coils via a percutaneous approach can be highly effective, and may be considered before proceeding with open surgery.

Non-traumatic enophthalmos: a review

Enophthalmos can be defined as a relative, posterior displacement of a normal-sized globe in relation to the bony orbital margin. Non-traumatic enophthalmos has a wide variety of clinical presentations and may be the first manifestation of a number of local or systemic conditions. It may present with cosmetic problems such as deep superior sulcus, pseudoptosis or eyelid retraction; or functional problems such as diplopia or exposure keratopathy. There are three main pathogenic mechanisms: structural alterations in the bony orbit; orbital fat atrophy; and retraction. Evaluation of enophthalmos patients includes orbital imaging and a thorough ophthalmic and systemic examination. In this review, we discuss the presenting features of non-traumatic enophthalmos and include a brief description of the more important causes. An approach to the clinical evaluation of these patients is also discussed together with a brief overview of the principles of management.

Radiological pitfalls in patients with inducible dynamic proptosis

We report two patients presenting with marked clinical unilateral enophthalmos who had positional variability and dynamic proptosis on valsalva. On orbital imaging, enophthalmos was not documented and in fact, globe proptosis of the same side was reported for one of the patients. During CT and MRI scanning patients are often instructed to hold their breath to eliminate motion artefact. This may inadvertently induce dynamic proptosis. The radiological pitfalls of imaging patients with inducible dynamic proptosis and how to identify such patients are discussed.

Interventional neuroradiology for the ophthalmologist

The past two decades have witnessed major advances in diagnosing vascular conditions that affect blood supply and hemorrhagic risk to the brain and the eye. Technological improvements have resulted in the ability to better radiologically image the cerebrovascular system and to deliver pharmacological and embolic agents that have high specificity. Neuroradiological interventional therapy has become the preferred option in managing many conditions that were previously treated by standard neurosurgical procedures. Some of these conditions were considered either inoperable or treatable only with unacceptable neurosurgical risks. This article reviews the current state of the neuroradiological interventional management in conditions that may be encountered in ophthalmological practice.

Dynamic Exophthalmos Secondary to an Orbital Varix

We present a case of dynamic exophthalmos secondary to an orbital varix. Objectives of this paper are to describe this rare entity and review its etiology, diagnosis and treatment options. A 21-year-old woman presented complaining of exophthalmos in the right eye on bending forward. Neuroimaging studies revealed an irregularly shaped mass located in the posterior intra-extraconal region adjacent to the orbital roof. Surgical and interventional endovascular therapies were considered, but due to the complex nature of the lesion the patient was followed-up conservatively. Orbital varix may cause dynamic exophthalmos and most patients may be managed conservatively. Patients harboring non-treatable orbital varix should be advised to avoid any strenuous exercises and postures which may increase intraorbital pressure.

Coil embolization of a congenital orbital varix in a dog

A 10-week-old Labrador Retriever was examined because of a swelling above the left eye. Ophthalmic examination revealed a tubular, light-pink, slightly raised lesion of the left conjunctiva that extended from the limbus to the fornix and into the dorsal eyelid. The lesion affected the entire margin of the dorsal eyelid and extended 2 cm dorsal to the eyelid margin. With compression of the left jugular vein, the exophthalmos worsened immediately and the subconjunctival and eyelid lesion enlarged. Results of ultrasonography, computed tomography, and contrast venography were consistent with a diagnosis of an orbital varix. Coil embolization was elected for treatment of the varix to prevent the pain and morbidity associated with an orbitotomy. Coils were introduced through a 22-gauge IV catheter inserted through the upper eyelid into the varix. The only complication was moderately severe orbital swelling. The owners reported that the lesion had resolved by 2 weeks after coil embolization.

Orbital varices: imaging findings and the role of color Doppler sonography in the diagnosis

The orbital varices are infrequent intraorbital masses, which cause intermittent, positional exophthalmos. They have low venous pressure inside which causes difficulties in detection by routine protocols of nearly all imaging modalities. Color Doppler sonography is a simple procedure that can easily detect orbital varices which avoids further evaluation in non-complicated patients. We report the imaging findings of a case of orbital varix and discuss the role of color Doppler sonography in the diagnosis and follow-up.

Embolisation of Orbital Varix via the Superficial Temporal Vein

SUMMARY

A case of orbital varix is presented, in which the lesion was successfully treated by means of embolisation with Guglielmi detachable coils, via the superficial temporal vein. Reports of endovascular treatment via transvenous route of orbital varix are lacking, only one case having previously been presented in the literature.We stress endovascular management for such an entity.

Distensible venous malformations of the orbit: clinical and hemodynamic features and a new technique of management

OBJECTIVE

To investigate distensible venous malformations of the orbit (DVMO) as part of a spectrum of orbital vascular malformations, including some that involved periorbital skin, extraorbital sites (central nervous system or nasal sinuses), or combinations of these. The authors also investigated the effectiveness of a new technique of management for selected cases.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Thirty patients had distensible venous anomalies, of which four were combined distensible venous-lymphatic vascular malformations. Distensible lesions were defined as those showing clinical or radiographic expansion with Valsalva maneuver or when the head was placed in a dependent position. These lesions were then classified as superficial (anterior to the equator of the globe), deep (posterior to the globe's equator), combined (deep and superficial), or complex (with intracranial or major extraorbital involvement).

INTERVENTION

Surgery was performed on 15 patients (50%), mainly for pain or for cosmetic indications. Six patients underwent this new technique, which involved intraoperative direct venography with control of outflow via pressure at the superior or inferior orbital fissure. The venous malformation was then embolized (by use of cyanoacrylate glue) and excised.

RESULTS

The mean age at presentation was 28.2 years (range, 8 months to 75 years). Sixty-six percent of cases involved the left orbit. Superior and medial orbital involvement was most common. Three cases (10%) were classified as superficial, and 13 (43%) as deep. Six patients (20%) had combined superficial and deep components. Eight (27%) had major extraorbital involvement (4 intracranial, 2 facial, and 2 paranasal sinus). Direct venography demonstrated complex multichannel anomalies draining to various sites, including the face and pterygopalatine fossa, without necessarily having a direct connection to the major orbital venous circulation.

CONCLUSIONS

Distensible venous malformations of the orbit are part of a spectrum of developmental venous malformations that may be localized to the orbit or involve it as part of a more extensive lesion. The authors describe their clinical and radiologic features and report a new technique of management for selected cases. This method of vascular isolation and embolization of lesions may greatly facilitate excision.

Coexistent orbital and cerebellar venous anomalies in linear sebaceous naevus syndrome

BACKGROUND

Orbital venous anomalies can result in significant morbidity and have been reported in association with other venous anomalies, some with the potential for serious complication.

METHODS/RESULTS

We present a case of an orbital venous anomaly coexistent with a large cerebellar venous angioma and a linear sebaceous naevus. Clinical features, associations, complications and management principles are presented.

CONCLUSION

Upon clinical recognition of an orbital venous anomaly, brain imaging and appropriate clinical assessment should be considered in light of the possibility of coexistence of potentially life-threatening lesions.