Bilateral partially thrombosed orbital varices: case report and literature review
Bilateral partially thrombosed orbital varices
A 76-year-old male presented to the emergency department with worsening bilateral eye pain for 2 days, with no history of eye or head trauma. On examination, the patient’s eyes were red and protruded, increasing the possibility of orbital bleeding. This patient’s past medical history included chronic obstructive pulmonary disease (COPD). Laboratory tests showed high activated partial thromboplastin time (APTT), high blood urea nitrogen (BUN), and low estimated creatinine clearance.
CT examination revealed tubular fusiform lesions in the superior aspect of the bilateral orbits, measuring 27 x 13 mm and 39 x 20 mm on the right and left, respectfully. On a non-contrast scan, the left orbital lesion showed increased density, concerning for blood clot. A few additional smaller lesions were also seen. Corresponding contrast enhanced MRI examination demonstrated homogeneous enhancement of the right orbital lesion whereas the left orbital structure showed low signal intensity with only peripheral enhancement with Gadolinium, again suggestive of a thrombosed vascular lesion. US examination of the left orbital lesion was performed with and without Valsalva maneuver. This illustrated increased venous flow with reflux at the proximal portion of the lesion, with the remaining distal portion showing no blood flow. The overall appearance favored bilateral orbital varices with a thrombosed left-sided varix.
An orbital venous varix is an uncommon condition that can occur both congenitally and due to an underlying pathology causing increased venous pressure within the orbit. In typical cases, patients with orbital varix present with proptosis and intermittent diplopia. Complications include intraorbital hemorrhage and thrombosis, which can be associated with acute onset of retro-orbital pain, progressive proptosis, and decreased visual acuity. Imaging plays a vital role in the diagnosis and differentiation of an orbital varix from other retroocular lesions. A multimodality imaging approach may be necessary to outline features of the lesion and reveal complicated cases, in order to provide appropriate and timely treatment.
Orbital varices represent a rare type of venous malformation composed of a single or multiple abnormally enlarged veins communicating to the systemic venous system. Clinical presentation is nonspecific. Potential complications including intraorbital bleed and venous thrombosis may lead to a permanent visual loss. Multimodality imaging is important for proper interpretation and accurate diagnosis as well as timely management of the lesion.