Multiple vortex vein ampulla varicosities

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.

DIAGNOSIS OF VORTEX VARIX USING OPTICAL COHERENCE TOMOGRAPHY AND SCLERAL INDENTATION

PURPOSE

We report a case of a vortex vein varix diagnosed with optical coherence tomography under globe compression.

METHODS

To illustrate the dynamical behavior of a vortex vein varix, optical coherence tomography was performed with and without gentle globe indentation with a cotton swab.

RESULTS

A 51-year-old woman was referred by her optician for an incidental finding of a nonpigmented choroidal mass in the right eye. The patient was asymptomatic with a best-corrected visual acuity of 20/16 in both eyes. On fundoscopy, a prominent smooth pink lesion at the level of the superonasal equatorial retina could be observed in the right eye. Peripheral optical coherence tomography over the area revealed dilated choroidal vessels with an overlying healthy retina. Optical coherence tomography scan was repeated applying gentle globe indentation under which the lesion completely collapsed.

CONCLUSION

This case illustrates that the diagnosis of a vortex vein varix can be made in clinics using noninvasive tools such as optical coherence tomography. The anatomical localization of the lesion and the pressure-evoked fluctuation of size and shape are important clues which lead to the diagnosis.

[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.

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.

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.