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.

Imaging of Painful Ophthalmologic Disorders

Cross-sectional imaging with computed tomography (CT) and MRI are diagnostic examinations useful in the diagnosis of painful ophthalmologic disorders and their potential complications. CT is a first-line imaging study for suspected orbital infections, particularly useful in differentiating preseptal cellulitis and orbital cellulitis and detecting complications such as orbital abscess. When compared with CT, MRI is better for orbital soft tissue evaluation, particularly useful for optic neuritis, ocular diseases such as endophthalmitis, and invasive fungal rhinosinusitis with orbital involvement. CT angiography is the preferred noninvasive imaging modality for the detection and classification of carotid cavernous fistula.

A periorbital pain with a specific diagnosis and treatment

Primary trochlear headache is a little-known cause of periorbital headache described in adults. It can involve very disabling pain. In addition, it can be associated with other types of headaches, making them even more difficult to identify. To diagnose this pathology, it is necessary that the examination of the trochlea be incorporated into the usual clinical practice of the patient with headache, which will allow the establishment of an adequate treatment. The case is presented of an adolescent patient with a diagnosis of migraine, who was admitted with a disabling headache secondary to a primary trochlear headache.

Strictly Limited Orbital Pain as Sentinel Headache of Subarachnoid Hemorrhage

BACKGROUND

The headache preceding an intracranial aneurysm rupture is called a sentinel headache (SH), and it is characterized by a sudden, intense, and persistent headache. As subarachnoid hemorrhage (SAH) often develops within several weeks of SH, its rapid diagnosis and treatment can improve the prognosis.

CASE DESCRIPTION

A 52-year-old woman with migraine in her medical history visited the outpatient clinic due to left orbital pain. There was no neurologic deficit. Although magnetic resonance imaging examination found no SAH, a left internal carotid artery-posterior communicating artery bifurcation aneurysm was detected by magnetic resonance angiography. Ten days after the onset of orbital pain, the patient consulted our hospital for a second opinion. We scheduled an elective clipping because the irregular shape of the aneurysm had a high risk of rupture. On the day before surgery, the aneurysm ruptured and led to SAH. Clipping was performed immediately. The patient was discharged with no neurologic deficit.

CONCLUSION

Clinicians must take into consideration that unilateral orbital pain, though atypical, may be a symptom of SH.

Acetazolamide and Thyroid-Associated Ophthalmopathy; a Preliminary Tested Hypothesis in a TertiaryReferral Center

This study evaluated the effect of acetazolamide on thyroid-associated ophthalmopathy (TAO). Patients with a VISA classification index equal to or more than four were enrolled in the study and were randomly assigned into two groups. In both groups, treatment was initiated using prednisolone. Patients in the case group received acetazolamide tablets 250 mg daily in addition to prednisolone. Three months later, the VISA inflammatory score of patients in both groups were determined. Subsequent to intervention with acetazolamide, the VISA inflammatory score of patients in the case group were reduced as follows; orbital pain (57.1% versus 41.7%, P=0.736), eyelid edema (42.8% versus 27.1%, P=0.67), chemosis (53.3% versus 33%, P=0.31), injection of the eyelids (60% versus 41.6%, P=0.342), and conjunctival injection (50% versus 46.13%, P=0.73). However, these reductions were not statistically significant when compared with those observed in the control group (P=0.246). In conclusion, the effect of acetazolamide on all the parameters of the VISA inflammatory score was examined independently. All patients in the case group revealed a reduction in VISA inflammatory score following intervention. However, these reductions were not statistically significant. Further studies with large sample sizes are required.