Indocyanine green angiographic features of varix of the vortex vein ampulla

DYNAMIC ECHOGRAPHY OF VARIX OF THE VORTEX VEIN AMPULLA

PURPOSE

To describe four cases of varix of the vortex vein ampulla imaged with dynamic echography.

METHODS

Observational case series of four patients with varix of the vortex vein ampulla diagnosed with ocular examination maneuvers such as digital pressure or Valsalva. Dynamic echography was used to confirm the diagnosis.

RESULTS

Dynamic echography can quickly and noninvasively show the varix of the vortex vein ampulla disappear with external pressure, or engorge with a Valsalva maneuver or altered gaze directions.

CONCLUSION

Dynamic echography is very helpful in the establishment of the diagnosis of varix of the vortex vein ampulla and differentiating this benign condition from other retinal or choroidal abnormalities.

Vortex Vein Imaging: What Can It Tell Us?

This review article summarizes the patho-anatomy of the vortex veins, the major drainage channels for the choroid, and describes the various pathways of diseases associated with vortex vein abnormalities. This report also details the technical advancements to image the vortex veins, such as ultra-widefield indocyanine green angiography, which are critical to elucidate the importance of the vortices in various retino-choroidal disorders. Future applications of these advanced imaging systems to better understand the role of the vortex veins in health and disease are also discussed.

MULTIMODAL IMAGING IN VORTEX VEIN VARICES

PURPOSE

The aim of this study is to describe the clinical presentation of vortex vein varices with multimodal imaging.

METHODS

The authors carried out a retrospective case series of eight patients (7 female, 1 male) with an average age of 60.2 years (min 8, max 84, median 68.5) presenting with vortex vein varices. All patients were evaluated at the Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy and at Luigi Sacco Hospital, University of Milan, Milan, Italy. Patients underwent complete ophthalmologic examinations, including best corrected visual acuity, intraocular pressure, anterior segment, and fundus examination. Imaging studies, including fundus color photography, near-infrared reflectance imaging, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, and spectral-domain enhanced depth imaging optical coherence tomography were also performed. Ultra-widefield fluorescein angiography and ultra-widefield indocyanine angiography using the Heidelberg Retina Angiograph and the Staurenghi 230 SLO Retina Lens were used to demonstrate the disappearance of all retinal lesions when pressure was applied to the globe.

RESULTS

All eight cases initially presented to the emergency room. One patient presented secondary to trauma, two patients presented for suspected hemangioma, whereas the other five were referred to the authors' hospitals for suspected retinal lesions. On examination, retinal abnormalities were identified in all 8 patients, with 7 (87.5%) oculus dexter and 1 (12.5%) oculus sinister, and with 1 (12.5%) inferotemporally, 3 (37.5%) superonasally, 3 (37.5%) inferonasally, and 1 (12.5%) inferiorly. Fundus color photography showed an elevated lesion in seven patients and a nonelevated red lesion in one patient. In all patients, near-infrared reflectance imaging showed a hyporeflective lesion in the periphery of the retina. Fundus autofluorescence identified round hypofluorescent rings surrounding weakly hyperfluorescent lesions in all patients. On fluorescein angiography, all lesions were initially hyperfluorescent with a hypofluorescent ring, with the lesion becoming hyperfluorescent after injection of dye. Indocyanine green angiography demonstrated dilation of the vortex vein ampullae in all patients. Spectral-domain enhanced depth imaging optical coherence tomography demonstrated dilated choroidal vessels and a hyporeflective cavity without subretinal fluid in all patients. Ultra-widefield fluorescein angiography and ultra-widefield indocyanine angiography demonstrated disappearance of all retinal lesions when pressure was applied to the globe. Findings are consistent with the diagnosis of vortex vein varix in all eight patients, with six patients (75%) exhibiting a single varix and two patients (25%) exhibiting a double varix.

CONCLUSION

The diagnosis of vortex vein varices can be confirmed through clinical examination through the use of digital pressure to the globe during ophthalmoscopic examination. Adjunctive multimodal imaging (fundus color photography, near-infrared reflectance imaging, fundus autofluorescence, fluorescein angiography, indocyanine angiography, and spectral-domain enhanced depth imaging optical coherence tomography) was useful in the diagnosis of vortex vein varices in the authors' clinical cases. However, in more challenging clinical cases, the authors' novel use of the ultra-widefield contact lens for application of ocular pressure with a resulting resolution of the varix proved to be a useful and easy diagnostic imaging method for confirming the presence of vortex vein varices.

Varix of the Vortex Vein Ampulla: A Small Case Series

PURPOSE

To report three cases of varix of the vortex vein ampulla.

METHODS

Observational small case series. During 2002, three patients were examined for suspected choroidal melanoma. In all cases, the lesions were located at the equator or the periphery.

RESULTS

The lesions became more prominent when the eyes were positioned in the direction of the lesion, and disappeared when firm pressure by ultrasound probe was applied on the globe, while the eye was in primary position, or fundus was examined with a three-mirror Goldmann contact lens. These dynamic characteristics were also demonstrated by color Doppler imaging.

CONCLUSIONS

Varix of the vortex vein ampulla is an extremely rare condition. This diagnosis should be considered when an elevated choroidal lesion disappears when the fundus is examined with contact lens.

Submacular choroidal varix simulating chorioretinal folds with metamorphopsia

A novel case description of an isolated unilateral submacular choroidal varix simulating chorioretinal folds and inducing metamorphopsia in a 74-year-old phakic Caucasian man. Posterior segment examination revealed focal choroidal elevations corresponding to a deep, large choroidal vessel in the inferotemporal subparafoveal region. Fundus photography demonstrated a pigment epithelial detachment-like elevation inferior to the fovea, continuous with the course of a large choroidal vessel. Angiographic, indocyanine green (ICG), and spectral-domain optical coherence tomography (SD-OCT) imaging revealed an isolated unilateral submacular choroidal varix with direct connection to an inferior vortex vein. The diagnosis of submacular choroidal varix should be considered when the presence of metamorphopsia and corresponding choroidal elevations that remain unchanged through gaze direction or contact lens ophthalmoscopy occur. If present, angiographic, ICG, and SD-OCT imaging are recommended for proper evaluation of submacular choroidal varix that may enhance the characteristics of this lesion.