Orbital Varices

Background Varices are dilatation of congenital venous structures involving the wall or valves of the vein. Although likely present from birth, venous anomalies present between the third and fourth decades of life, though presentation either in childhood or late adulthood is possible. They grow over time and may occur anywhere in the body. Varices have been associated with other vascular malformations including the blue rubber bleb nevus syndrome. Involvement of the orbit is uncommon and most present incidentally when imaging studies are done for other reasons. Recently, endovascular surgery has provided additional options in terms of surgical intervention.

Methods A retrospective review of 15 patients coded as possible orbital varix seen through the University of Virginia Ophthalmology/Orbital Surgery service. The majority of these patients presented with imaging done for other reasons.

Results Many of these patients had Valsalva or positionally induced proptosis. Most patients were asymptomatic, but acute hemorrhage into presumed varix was seen dramatically in one case.

Conclusion Orbital varices are an uncommon cause of orbital pathology. A majority of these are asymptomatic but can cause both proptosis and enophthalmos. Most cases remain stable and no intervention is required. Recently, endovascular surgery has been used with both coil embolization and obliteration with sclerosing agents such as bleomycin, or occlusion with n-butyl cyanoacrylate glue. These offer potential treatment in symptomatic patients, but they should be reserved for the rare patients who are symptomatic. Imaging remains a critical means of diagnosis with CT and MRI with contrast. Valsalva maneuver should be performed during imaging to adequately visualize the varix, and change in lesion size observed with and without Valsalva may assist in lesion characterization if the varix has not spontaneously thrombosed. Additional imaging studies include Doppler ultrasonography, and TWIST sequence on MRI. Unusual orbital occurrences of varices have included bloody tears from lacrimal sac involvement and choroidal vortex vein varix resembling melanoma.