MULTIMODAL IMAGING IN VORTEX VEIN VARICES

Different Vortex Vein Anomalies Observed in a Single Case: Macular Vortex Vein in One Eye and Varix of Vortex Vein Ampulla in the Other Eye

We present a 56-year-old female with a macular vortex vein in her right eye and a varix of vortex vein ampulla in the inferior nasal fundus of her left eye. The choroidal lesions were evaluated by multimodal imaging including fundoscopy with contact lens, ultra-widefield fundus photography, swept-souse optical coherence tomography (SS-OCT), enface image of widefield optical coherence tomography (widefield enface-OCT), and ultra-widefield fundus angiography. Widefield enface-OCT revealed submacular large choroidal vessels in the right eye. Ultra-widefield indocyanine green fluorescence angiography (UWICGA) of the right eye showed the dye of those submacular choroidal vessels drained from the ampullae beneath the macula. Fundoscopy revealed an elevated lesion with crescent shadows in the inferior nasal fundus of the left eye. Dynamic fundoscopy with compression of the left eye resulted in a diminishing of the elevation and release of the compression resulted in an enlargement of the elevation. Ultra-widefield fundus photography of the left eye in the right inferior gaze revealed an elevated lesion with a crescent shadow in the inferior nasal fundus, while it is not prominent in the primary gaze. The B-scan of SS-OCT revealed a hyporeflective lesion in the choroid beneath the elevated lesion of the left eye. The elevated lesion was consistent with the vortex vein ampulla on UWICGA. This is the first case where two different choroidal vascular anomalies, macular vortex vein and varix of vortex ampulla, coexist in a single patient. Multimodal imaging is useful to visualize and diagnose choroidal vascular anomalies.

Acute spontaneous vortex vein occlusion: clinical features, multimodal imaging and natural course

AIMS

To describe the clinical features, multimodal imaging, treatments and natural course of acute spontaneous vortex vein occlusion.

METHODS

Clinical data were collected on nine patients with acute vortex vein occlusion. The symptoms and signs, multimodal imaging, treatments and follow-up results were summarised.

RESULTS

Six patients (66.7%) were men and three (33.3%) were women. The mean age was 47.8±15.4 years. Patients were initially misdiagnosed as having choroidal tumour (66.7%), scleritis (22.2%) and peripheral exudative haemorrhagic chorioretinopathy (11.1%). The related clinical characteristics included choroidal pseudo-tumour (100%), anterior segment injection (88.9%), acute ocular pain (77.8%), transient blurred vision (66.7%) and subsequent scleral icterus (66.7%). Six patients (66.7%) experienced a definite Valsalva manoeuvre prior to the onset. In acute phase, ultrasonography showed a low-to-medium reflective lesion without inside blood flow signal (mean thickness, 2.7±0.6 mm). Swept-source optical coherence tomography angiography (SS-OCTA) demonstrated the dilated vortex veins and ampulla with suprachoroidal haemorrhage and exudation. Indocyanine green angiography (ICGA) demonstrated choroidal circulation abnormalities in the affected quadrant. MRI showed a well-defined mass with enhancement. The main treatment was medical observation (44.5%). The choroidal pseudo-tumour spontaneously resolved with a mean course of 4.1±1.9 weeks.

CONCLUSIONS

Acute vortex vein occlusion is a rare condition and initial misdiagnosis is not uncommon. It is mainly identified as an evanescent choroidal pseudo-tumour with acute pain, red eye and blurred vision. Widefield ICGA and SS-OCTA can offer valuable diagnostic clues. Medical observation may be a treatment option.

The role of near-infrared reflectance imaging in retinal disease: A systematic review

Near-infrared reflectance (NIR) retinal imaging aids in a better visualization of structures at the level of outer retina, retinal pigment epithelium, and choroid. It has multiple advantages, including easy acquisition in association with structural spectral domain optical coherence tomography, more comfort for patients, and enhanced contrast and spatial resolution. It helps in the diagnosis of chorioretinal diseases that present with minimal funduscopic findings and can be used to follow up many chorioretinal conditions. We describe the chorioretinal NIR imaging appearance and the clinical role of NIR imaging in ocular inflammatory disease, vascular and acquired disease, degenerative disease, tumors, associated systemic condition, toxic and traumatic disease, optic nerve head conditions, and physiological findings.

VARIX OF A VORTEX VEIN AMPULLA INDUCED BY NODULAR SCLERITIS

PURPOSE

To describe a patient with a painful red-eye syndrome and a choroidal mass lesion that was diagnosed after multimodal imaging with a vortex vein ampulla varix induced by a nodular posterior scleritis.

METHODS

Retrospective case report documented with fluorescein angiography, indocyanine green angiography, b-mode ultrasound, fundus imaging, and swept-source optical coherence tomography.

RESULTS

A 24-year-old man presented with a painful red eye and sudden onset blurred vision. Fundus exam disclosed macular choroidal folds and a nonpigmented mass lesion at the inferior equator. Swept-source optical coherence tomography showed enlarged choroidal vessels with fluid in the suprachoroidal space under the central macula and a hyporeflective lobulated choroidal cavity in the inferior temporal retina. Multimodal imaging with contrast dyes showed a dilated vortex vein ampulla with early hyperfluorescence and a complete washout in late acquisitions on indocyanine green. The patient recovered uneventfully after a short-course administration of oral nonsteroidal anti-inflammatory drugs, disclosing irregular scleral nodules on swept-source optical coherence tomography that remained stable over a twelve-month follow-up.

CONCLUSION

This report suggests that nodular posterior scleritis can induce a vortex vein ampulla varix and contributes to a better understanding of the pathophysiology of this entity. We further suggest that in a diagnostic puzzling scenario the inflammatory syndrome should be treated before attempting to perform a chorioretinal biopsy.

[Vortex vein varix (clinical observations)]

Varix of the vortex vein ampulla is a rare benign condition that has clinical similarities to more concerning choroidal lesions that pose a threat to vision, in particular choroidal melanoma. The article describes two clinical cases, one of which is unique due to the combination of bilateral lesion and the presence of multiple varices in one eye. A brief review of the literature on this condition is also provided.

Suprachoroidal haemhorrage and vortex vein varix: A potential association

Purpose:

To report on the association between a vortex vein varix and suprachoroidal hemorrhage.

Case description:

A healthy 60 years-old man with high myopia (–10 diopters) was seen because of sudden paracentral metamorphopsias after emesis. Multimodal imaging included Spectral-Domain Optical Coherence Tomography (SD-OCT), ultrasonography and retinal angiography with fluorescein and indocyanine green. His vision was 20/20 but clinical assessment and imaging procedures evaluations showed a suprachoroidal hemorrhage in the temporal part of the para-macular area. The lesion corresponded to a mild hypo-fluorescence area on fluorescein angiography and to a massive detachment of the inner part of the choroid from the suprachoroidal space on SD-OCT. Indocyanine green angiography disclosed engorgement of a big choroidal vessel in the area of the lesion. An adjacent vortex vein varix was found on SD-OCT. A few weeks later the suprachoroidal hemorrhage resolved spontaneously, whereas the vortex vein varix persisted.

Conclusion:

We speculate that vortex vein varixes might represent a risk factor for the occurrence of suprachoroidal hemorrhage in high myopia and that this association may be worth investigating.

Summary statement:

In a high myopia suprachoroidal hemorrhage might be secondary to vortex vein varixes.

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.

Ultra-widefield retinal imaging: an update on recent advances

The development of ultra-widefield retinal imaging has accelerated our understanding of common retinal diseases. As we continue to validate the diagnostic and prognostic significance of pathology in the retinal periphery, the ability to visualize and evaluate these features in an efficient and patient-friendly manner will become more important. Current interest in ultra-widefield imaging includes the development of potential biomarkers of disease progression and indicators of preclinical disease development. This article reviews the current ultra-widefield imaging systems and recent advances in their applications to clinical practice with a focus on diabetic retinopathy, retinal vein occlusion, uveitis, and pediatric retina.

Distribution and Location of Vortex Vein Ampullae in Healthy Human Eyes as Assessed by Ultra-Widefield Indocyanine Green Angiography

PURPOSE

To study the number and distribution of vortex ampullae in healthy eyes using ultra-wide field (UWF) indocyanine green angiography (ICGA).

DESIGN

Prospective, observational study.

PARTICIPANTS

Thirty-six eyes of 36 healthy participants with no evidence of ocular or systemic disease.

METHODS

The UWF ICGA images (central and peripheral steered) were captured using the Optos California (Optos, Dunfermline, United Kingdom) instrument. The images were projected stereographically to correct for peripheral distortion and obtain accurate measurements. All images were graded and analyzed for number, location, and distance of the vortex vein ampullae from the center of optic nerve.

MAIN OUTCOME MEASURES

Mean number and the distance of ampullae from the center of optic nerve in all quadrants.

RESULTS

The mean number of ampullae observed by UWF ICGA was 8.0±2.1 (range, 5-13). The mean distance of a vortex vein ampulla from the optic nerve was 14.2±1.1 mm (range, 10.3-17.7 mm). The frequency of ampullae was higher in the superior and inferior quadrants than the nasal and temporal quadrants. Ampullae were never observed in the 3- or 9-o'clock meridians. Multiple regression analysis showed no relationship with age, gender, axial length, or ethnicity. Excellent intergrader reproducibility was found between graders with an intraclass correlation coefficient (distance measurements: intraclass correlation coefficient, 0.99; 95% CI, 0.979-0.999; P < 0.001; number of ampullae: intraclass correlation coefficient, 0.99; 95% CI, 0.988-0.999; P < 0.001).

CONCLUSIONS

The number of discrete vortex vein ampullae that can be discerned by UWF ICGA in healthy individuals is greater frequently and substantially than the 4 that are traditionally thought to drain the major quadrants. Considerable variability in the number and position of the ampullae may be apparent in healthy individuals.