Venous malformations in the orbit

Thrombosed orbital varix of the inferior ophthalmic vein: A rare cause of acute unilateral proptosis

Background

Orbital varices are rare, accounting for only 0-1.3% of orbital masses. They can be found incidentally or cause mild to serious sequelae, including hemorrhage and optic nerve compression.

Case Description

We report a case of a 74-year-old male with progressively painful unilateral proptosis. Imaging revealed the presence of an orbital mass compatible with a thrombosed orbital varix of the inferior ophthalmic vein in the left inferior intraconal space. The patient was medically managed. On a follow-up outpatient clinic visit, he demonstrated remarkable clinical recovery and denied experiencing any symptoms. Follow-up computed tomography scan showed a stable mass with decreased proptosis in the left orbit consistent with the previously diagnosed orbital varix. One-year follow-up orbital magnetic resonance imaging without contrast showed slight increase in the intraconal mass.

Conclusion

An orbital varix may present with mild to severe symptoms and management, depending on case severity, ranges from medical treatment to escalated surgical innervation. Our case is one of few progressive unilateral proptosis caused by a thrombosed varix of the inferior ophthalmic vein described in the literature. We encourage further investigation into the causes and epidemiology of orbital varices.

[Orbital venous varices: modern diagnostic methods and differential diagnosis]

OBJECTIVE

To study the possibility of the modern CT and MRI methods in diagnostics of the orbital venous varices (OVV), discover the special characteristics of these lesions concerning their hemodynamic and differential diagnosis with other orbital lesions.

MATERIAL AND METHODS

In the period from 2012 to 2019 ten patients with OVV were evaluated. Four of them were men, three - women and three - children (boys aged 7, 10, and 12 years). Age of the patients varied from 7 to 75 years old (mediana - 34).

CT was performed on 9 patients using low dose protocol with injecting the contrast in standard position (supine) and in the prone position. CT-angiography was performed on 3 patients and CT-perfusion - 5 patients which allowed the assessment of the blood supply and quantitative lesions hemodynamic by calculating blood flow (BF_OVV), blood volume (BV_OVV) and mean transit time (MTT_OVV).

MRI with contrast injection and Fat Sat technology was performed on 9 patients, 3 of them were both in the supine and prone positions. 4 patients were evaluated by bolus MR-angiography (TRICKS).

RESULTS

The majority of the OVV was localized in the medial compartments and apex of the orbit. Left sided lesions were found in 6 cases, right - 3. One patient had both sided OVV. In one of the cases in 10-year-old child, we revealed malformation of the Galen vein associated with bilateral varicose enlargement of the intraorbital veins (secondary OVV).

In CT studies all of the lesions enhanced after the contrast injection. When the patients were study in the prone position, all lesions were enlarging; which lead to the diagnosis of OVV. CT-angiography (venous blood flow) proved vascular nature of the lesions. While studying the quantitative lesion hemodynamic by the CT perfusion technology, it was discovered, that OVV tend to have high blood volume (BV_OVV=19.61±3.23(ml/100g) and high blood flow (BF_OVV= 60.87±8.11) and the prolongation of mean transit time (MTT_OVV=19.23±3.07). Normal parameters measured in white matter were CBV_N=1.37±0.69(ml/100g), CBF_N=38.4±4.31(ml/100g/min), MTT_N=2.89±0.44s.

In MRI studies all the lesions had iso-hypointense MR-signal on T1- and hyperintense on T2-images. The pattern of contrast enhancement was inhomogeneous, however reaching homogeneity after some time. TRICKS MR-angiography was more sensitive than CT-angiography (venous phase). Moreover, the absence of radiation exposition was an additional advantage of the MR-venography.

CONCLUSION

Diagnosis of orbital vascular pathology requires an understanding of the classification of vascular lesions, the integration of the patient's medical history with epidemiological data, as well as a through analysis of the results of instrumental diagnostic methods. CT or MRI, including scanning in the prone position, as well as minimally invasive CT- and MR-TRICKS-angiography and ophthalmological studies of the patient, determine a comprehensive approach to the diagnosis and selection of adequate treatment for orbital venous varices.

In the differential diagnosis of OVV with other neoplasms of the orbit, we recommend CT-perfusion study with determine the quantitative characteristics of its hemodynamics.

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.

[Vascular tumors of the orbit]

Vascular tumors of the orbit include capillary hemangioma, cavernous hemangioma, hemolymphangioma, hemangiopericytoma and a few rare tumors. Capillary hemangioma and hemolymphangioma, occurring mainly in children, are covered in the chapter devoted to childhood tumors. In this chapter, cavernous hemangioma and hemangiopericytoma are discussed as well as rare vascular tumors. Although orbital varix is not a tumor, it is also considered because of the diagnostic problems and the close correlation of orbital varix with a true tumor: hemolymphangioma.

Embolization of orbital varices with N-butyl cyanoacrylate as an aid in surgical excision: results of 4 cases with histopathologic examination

PURPOSE

To report the results of intervention with percutaneously injected n-butyl cyanoacrylate (NBCA) to embolize orbital varices followed by surgical resection.

DESIGN

Retrospective case series.

METHODS

Four patients with symptomatic orbital varices were treated with percutaneous injection of NBCA to embolize the varicosity before surgical resection. Intervention was indicated because of progressive orbital pain attributed to orbital varices. Three of the 4 described cases were associated with severe episodic proptosis. The vision was not affected by the orbital varix in any of the cases before intervention. Radiographic guidance was used during injection of the NBCA. Surgical resection was undertaken via orbitotomy immediately after embolization. The resected tissue was submitted for histopathologic evaluation.

RESULTS

Follow-up after surgery ranged from 7 to 19 months. All of the patients experienced relief of orbital pain. All patients noted transient binocular diplopia in extremes of gaze after the procedure, which resolved spontaneously. No patients had diplopia in primary gaze. No patient lost vision as a result of the procedure. There was no difficulty with procedure-related hemostasis in any of the cases.

CONCLUSIONS

Percutaneously injected NBCA seems to be useful and safe as an aid in visualization and hemorrhage prevention during surgical resection of symptomatic orbital varices.

Les lésions vasculaires de l’orbite

Vascular diseases are an important part of orbital pathology. We describe vascular tumours of the orbit and vascular diseases with repercussion on the orbit, from intra or extra orbital origin. The classification of these abnormalities is difficult and several terms are used to describe the same histological entity. The objective of this work is, using the current classification, to illustrate the different imaging aspects of the most frequent vascular diseases of the orbit.

Vascular Lesions of the Orbit in Children

Hemangioma and venous lymphatic malformation are the two most common orbital vascular lesions occurring in the pediatric patient. MR imaging precisely delineates and characterizes these lesions and thus plays an important role in their diagnosis and management. This article discusses the characteristic clinical and imaging findings of hemangiomas and venous lymphatic malformations and the controversies regarding the origin and nomenclature of vascular lesions.

Orbital varix rupture during cataract surgery

We report a case of orbital varix rupture during cataract surgery with retrobulbar anesthesia. No remarkable changes were observed 10 minutes after retrobulbar anesthesia was administered, but a rise in intraocular and intraorbital pressure was noted about 10 minutes after phacoemulsification began. The eyelid could not be closed at the end of surgery because of severe proptosis. Follow-up by magnetic resonance imaging and color Doppler imaging revealed orbital hemorrhage and varix. Based on the time of its appearance, the hemorrhage was thought to be the result of venous congestion caused by anesthetic agent in the muscle cone. Although intermittent exophthalmos is a symptom of orbital varix, silent orbital varix should be considered when selecting the method of anesthesia for ocular surgery.

Orbital vascular lesions. Role of imaging

Vascular lesions represent an important subgroup of orbital abnormalities; however, there is much controversy regarding their pathophysiology and nomenclature. Attempts at resolution of some of the issues have resulted in changes of names of some of the lesions (e.g., lymphangioma to venolymphatic malformation). Imaging plays an important role in delineation and characterization of these lesions. A radiologist informed about the pathophysiology and attentive to the internal architecture of the lesions shown on images, particularly MR images, often can predict the histologic diagnosis. Imaging information helps clarify some of the controversies surrounding these lesions.

Orbital masses

The "space approach" will be introduced as a means of analyzing orbital masses on imaging studies. Determination in which space an orbital mass resides, the character of its margin, the presence or absence of bony changes, and evidence of extension of the mass beyond the orbit often allows the radiologist to narrow the differential diagnosis and provides essential information to the ophthalmologist for definitive diagnosis and treatment planning.

Orbital venous anomalies demonstrated by spiral computed tomography

OBJECTIVE

To describe the radiographic appearance of acute hemorrhage in orbital venous malformations and how spiral computed tomography (CT) can aid in the diagnosis of these lesions in patients with atypical presentations.

DESIGN

Case series from the Eye Plastics and Orbital Service of Massachusetts Eye and Ear Infirmary. PARTICIPANTS/INTERVENTION/MAIN OUTCOME MEASURES: Three patients who initially presented with signs and symptoms of orbital hemorrhage are presented. Their initial clinical and radiologic imaging, follow-up examination, and results of the spiral CT are summarized.

RESULTS

The initial CT in each case showed a well-localized homogeneous mass in the posterior/inferior orbit. In the two cases without antecedent trauma, it was difficult to distinguish these localized hemorrhages from possible intraorbital neoplasm. On resolution of the hemorrhage, these three patients had different presentations. The first patient had intermittent proptosis that was documented by increase in exophthalmometry measurement before and after Valsalva maneuver (symptomatic and with clinical signs). The second patient had a subjective orbital pressure sensation, but no visible change by examination (symptomatic but without clinical signs). The third patient was not symptomatic and had no significant clinical findings (asymptomatic and without clinical signs). Spiral CT showed the presence of an enlarging inferior orbital mass during Valsalva maneuver, which was not apparent pre-Valsalva in all these patients.

CONCLUSIONS

Localized hemorrhages easily may be mistaken for solid intraorbital masses: therefore, accurate determination can avoid unnecessary surgical intervention. Patients with orbital venous malformation may or may not have symptoms and clinical signs of intermittent proptosis. After the resolution of the initial hemorrhage, spiral CT during Valsalva maneuver using a single breath hold technique is useful in showing the presence of this venous anomaly when suspicious of this entity, even in patients who are asymptomatic.

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.

Orbital varix in Grönblad-Strandberg syndrome

Images

Embolisation of orbital varix

A 34-year-old man with intermittent exophthalmos, found to have a large varix in the right orbit, was treated by endovascular surgery. Percutaneous transfemoral venous catheterisation and embolisation of the orbital varix was performed on two occasions. A Tracker 18 microcatheter was introduced through the right inferior petrosal sinus, cavernous sinus, superior ophthalmic vein and then into the varix, following a guidewire. Superselective venography of the right ophthalmic vein showed the varix. A total of 204 platinum microcoils was used to pack the varix. At the time of discharge, the exophthalmos had largely resolved. As this technique is much less invasive than surgical resection, we recommend an attempt at endovascular embolisation of orbital varices prior to surgical removal.

The differential diagnosis of orbital calcification as detected on computed tomographic scans

We reviewed 350 orbital computed tomographic scans to determine the frequency, significance, and differential diagnosis of calcified lesions. Of 171 suitable scans that fulfilled the study criteria, 37 (22%) showed calcific densities. The most common intraocular lesion that contained calcium was retinoblastoma, and the most frequently calcified extraocular masses were vascular lesions (hemangioma, lymphangioma, and varix). We describe two orbital tumors--metastatic colonic carcinoma and primary orbital malignant melanoma--that previously have not been reported as having calcification. The presence of calcification within lesions of the lacrimal gland fossa usually, but not always, portends malignant disease.

Colour Doppler imaging in the demonstration of an orbital varix

Colour Doppler imaging (CDI) is a recent development in ultrasonography. It allows simultaneous two-dimensional structural imaging and Doppler evaluation of blood flow. Quantitative information on flow velocity is obtained by pulsed Doppler spectral analysis, the colour information being used to choose the vessel of interest. Using this technique the authors examined a patient with an orbital varix previously diagnosed by clinical findings and computed tomography. Dynamic evaluation with real-time direct imaging of flow facilitated the diagnosis of this orbital disorder without the need for any contrast material. This technique may prove to be a useful adjunct to computed tomography for the evaluation of suspected vascular lesions of the orbit.

Congenital orbital vascular malformation complicated by massive retrobulbar hemorrhage

A 2-year-old female infant with a presumed diagnosis of infantile hemangioma of the left eyebrow developed acute proptosis of the left eye several days after a mild orbital trauma. Computerized axial tomography (CAT) and carotid angiography confirmed the presence of a vascularized mass in the retrobulbar space, spreading anteriorly to the orbital rim and the frontal area. Due to progression of the proptosis and the development of exposure keratitis, surgical intervention was necessary. A large vascular tumor and a massive hemorrhage occupying the orbit were removed. The pathological examination confirmed the diagnosis of a vascular malformation of the orbit, most probably orbital varices. A relatively good visual acuity was achieved after surgery by occlusion therapy.

Periodic exophthalmos associated with the blue rubber bleb naevus syndrome: a case report

A 71-year-old woman with the blue rubber bleb naevus syndrome experienced 4 episodes of self-limiting unilateral exophthalmos. Is is suggested that a vascular malformation in the orbit is responsible for this phenomenon. A biopsy sample was taken of one of the cutaneous lesions and studied by light and transmission electron microscopy. The histological appearances are discussed in relation to possible mechanisms causing this periodic exophthalmos.

Intermittent exophthalmos studied with computerized tomography. Report of two cases

Two cases of intermittent exophthalmos are reported. In both instances, cerebral angiography and orbital venography failed to outline the lesion, which was clearly demonstrated with the aid of computerized tomography. An orbital varix was seen to be the cause of proptosis in one surgically verified case, whereas in the other this same diagnosis was suspected on the basis of the clinicoradiological findings. The etiology, clinical manifestations, and management of orbital varix are briefly discussed.

Vascular problems of the orbit

Vascular neoplasms and malformations of the orbit are unusual and fascinating problems. The benign capillary and cavernous hemangiomas are the most common vascular tumors and are classified separately because of distinct clinical and pathologic differences. The capillary hemangiomas progress rapidly in early childhood but have a tendency to regress. The cavernous hemangiomas occur later in life, progress slowly, and often require surgical excision. The orbital aneurysm, venous malformation, arteriovenous malformation, and carotid-cavernous fistula all may cause exophthalmos, visual loss, and other ocular abnormalities. They can be differentiated clinically; however, recent advances in ultrasonography, venography, and arteriography usually permit an exaxt diagnosis. They may be treated surgically, but the mortality and morbidity associated with such surgery must be balanced against the threat of loss of vision.

Sudden visual loss secondary to an orbital varix

A 45-year-old man presented with precipitous loss of vision and rapidly changing field defects in one eye. Computerized tomography and B-scan ultrasonography revealed a small orbital mass adjacent to the optic nerve. This was removed via lateral orbitotomy. On pathologic examination it was diagnosed as a small orbital varix. Drs. Frederick C. Blodi and Stephen Trokel comment on the case.