Clinical History
A 84-year-old man presents to our institution to perform a neck CT.
Imaging Findings
A 84 year-old man with tonsil carcinoma previously treated by chemotherapy presents to our institution to perform a neck CT checking. An axial CT neck scan shows a slight soft-tissue density lesion
in right orbital apex. Because of the findings orbital CT in axial and coronal sections were performed. The non-enhanced orbital CT in axial sections shows no obvious lesion. After administration of
gadolinium axial CT shows a lobulated, well-defined mass in right orbital apex which enhances homogeneously, and occupies the superior orbit, located inferolateral to the superior rectus muscle and
superomedial to lateral rectus muscle and displaces the optic nerve medially. Coronal CT scans demonstrate an increase in size of the lesion due to prone position. Orbital CT in axial sections after
Valsalva maneuver was performed later, showing an enlargement of the lesion with regard to supine position. Given the radiological features and the size variations of the lesion after Valsalva
maneuver and prone position, the findings are suggestive of right orbital varix.
Discussion
Orbital Varices are vascular lesions of the orbit and represent the most common cause of spontaneous orbital hemorrhage. These vascular malformations are characterized by proliferation of venous
elements and dilation of one or more orbital veins associated with congenital weakness in the venous wall. Orbital varices are usually in direct communication with the native venous system, so the
increase in venous pressure caused by a Valsalva maneuver will produce an increase in size of the lesion. Orbital varices may be primary or secondary. Primary orbital varices are congenital venous
malformations, but may also be secondary to intracranial vascular malformations, particularly arteriovenous shunts. The most common location for these masses is the superior position in the orbit,
which tend to parallel the normal orbital vasculature. Typically occupy the superior or superomedial orbit, in the area of the superior ophthalmic vein. Clinically proptosis or globe displacement
increases during a Valsalva maneuver, reflecting the varix' connection to the venous system. Axial CT scans or supine position may be normal because the varix is completely collapsed. In coronal CT
sections (prone position) because increased venous pressure, the mass expands significantly. May also be seen as several round or tubular structures with associated calcifications (phleboliths). MR
imaging shows a varix to be hyperintense on T1-weighted, proton density, and T2-weighted images and enhances homogeneously on postcontrast T1- weighted. Most orbital varices do not require aggresive
treatment. The only two indications for intervention are functional deficit or intractable pain due to extreme orbital pressure (with hemorrhage or thrombosis), and cosmetic disfigurement. There are
many methods of treatment including surgical excision, electrothrombosis, injection of sclerosing agents, and venous embolization with microcoils. In case of acute thrombosis or hemorrhage, surgery
may be required. If there is cosmetic disfigurement, treatment by venous embolization after surgical exposure is a sure procedure.
Differential Diagnosis List
