J Korean Ophthalmol Soc.  2015 Oct;56(10):1640-1645. 10.3341/jkos.2015.56.10.1640.

A Case of Surgical Management for Orbital Organizing Hematoma from Orbital Varix

• Kim JW
• Lee KH
• Park CK
• Yoon JS

• KMID: 2214428
• DOI: http://doi.org/10.3341/jkos.2015.56.10.1640

Abstract

PURPOSE
Orbital varices, which can lead to proptosis or globe displacement, are caused by Valsalva's maneuver or bending forward. Most of the orbital varices are treated conservatively, but surgical treatment is necessary for severe cosmetic or functional problems. We report a case of orbital organizing hematoma accompanied by an orbital varix which was successfully removed surgically without complications such as intraoperative bleeding.
CASE SUMMARY
A 78-year-old female presented with the complaint of 4 mm proptosis and hyperglobus of left eye. Orbit magnetic resonance imaging (MRI) showed a well demarcated extraconal mass in the inferior orbit which appeared to be an orbital varix. Initially, we decided to monitor the patient without surgery because proptosis was reduced to 1 mm within a week. However, after 5 months, the symptoms suddenly worsened, specifically, 4 mm of proptosis with severe hyperglobus and pain. MRI showed a 29.7 x 21.2 x 23.7 mm mass compressing the globe upward. Six weeks of conservative care did not improve the symptoms and we eventually performed an anterior orbitotomy through the inferior conjunctiva. There was a minor bleeding during the surgery. Based on the histological test, the mass was determined to be an organizing hematoma covered by a membrane. At 8 months postoperatively, symptoms had not recurred.
CONCLUSIONS
Orbital varices are usually treated conservatively since its surgical removal is known to have risks. Nonetheless, if an MRI shows an orbital organizing hematoma, it can be surgically debulked successfully without complications when a chronic hemorrhage from orbital varix causes serious proptosis and globe deviation.

Keyword

Organizing hematoma; Varix

MeSH Terms

Aged
Conjunctiva
Exophthalmos
Female
Hematoma*
Hemorrhage
Humans
Magnetic Resonance Imaging
Membranes
Orbit*
Valsalva Maneuver
Varicose Veins*

Figure

• 

  Figure 1. Patient photographs at initial visit and 5 months after. (A, B) External photograph shows left exophthalmos and upward displacement of the left eye at initial visit. (C, D) 5 months later, aggravation of the left exophthalmos and hyperglobus was noted.

• 

  Figure 2. Orbital magnetic resonance imaging (MRI) at initial visit and 5 months after T1 and T2 weighted gadolinium enhanced orbital MRI. Initial visit, 25.5 × 13.7 × 21.1 mm sized enhancing tubular lesion with non-enhancing lesion showing T1 high signal intensity (A, B), T2 heteroge-neous signal intensity (C, D) was found at inferior orbit. 5 months later, increased size of the lesion to 29.7 × 21.2 × 23.7 mm, showing decreased T1 signal intensity (E, F), heterogenous T2 signal intensity, and newly appearing heterogenous enhancement with capsule of high signal intensity (G, H) was seen. Inferior rectus muscle and left globe was deviated without adjacent structure invasion.

• 

  Figure 3. Surgical photograph of anterior orbitotomy and pathologic findings of excised orbital organized hematoma. (A) Hard, whitish orbital mass (arrowhead) surrounded by capsules was found via anterior orbitotomy. (B) Gross finding of mass after anterior orbitotomy. (C, D) Histologically, the peripheral portion of tumor was composed of thick capsule (asterisk) with fibrosis and scattered red blood cells (white arrows) (Hematoxylin and eosin stain [H&E] stain, ×40 [C] and ×200 [D]). (E, F) Capillary (black arrows) was formed inside the thrombus (H&E, ×40 [E] and ×200 [F]).

Reference

References

1. Shields JA, Dolinskas C, Augsburger JJ. . Demonstration of orbital varix with computed tomography and valsalva maneuver. Am J Ophthalmol. 1984; 97:108–10.

2. Cohen JA, Char DH, Norman D. Bilateral orbital varices asso-ciated with habitual bending. Arch Ophthalmol. 1995; 113:1360–2.

3. Islam N, Mireskandari K, Rose GE. Orbital varices and orbital wall defects. Br J Ophthalmol. 2004; 88:1092–3.

4. Goldberg SH, Sassani JW, Parnes RE. Traumatic intraconal hem-atic cyst of the orbit. Arch Ophthalmol. 1992; 110:378–80.

5. McNab AA. Nontraumatic orbital hemorrhage. Surv Ophthalmol. 2014; 59:166–84.

6. Trope GD, Steel CM, Bowers JR. . Distensible superficial ve-nous orbital malformations involving the lower eyelid in two horses. J Am Vet Med Assoc. 2010; 237:943–8.

7. Bullock JD, Goldberg SH, Connelly PJ. Orbital varix thrombosis. Ophthalmology. 1990; 97:251–6.

8. Wright JE, Sullivan TJ, Garner A. . Orbital venous anomalies. Ophthalmology. 1997; 104:905–13.

9. Kim YJ, Kim YD. Orbital venous anomaly presenting with orbital hemorrhage. Jpn J Ophthalmol. 2009; 53:408–13.

10. Srinivasan S, Gaskell A, McWhinnie H. . Conservative man-agement of globe luxation associated with congenital orbital ve-nous anomaly. J Pediatr Ophthalmol Strabismus. 2003; 40:170–1.

11. Wade RG, Maddock TB, Ananth S. Orbital varix thrombosis: a rare cause of unilateral proptosis. BMJ Case Rep. 2013;Jan; 2013.

12. Foroozan R, Shields CL, Shields JA. . Congenital orbital vari-ces causing extreme neonatal proptosis. Am J Ophthalmol. 2000; 129:693–4.

13. Lacey B, Rootman J, Marotta TR. Distensible venous malforma-tions of the orbit: clinical and hemodynamic features and a new technique of management. Ophthalmology. 1999; 106:1197–209.

14. Tsai AS, Fong KS, Lim W. . Bilateral orbital varices: an ap-proach to management. Ophthal Plast Reconstr Surg. 2008; 24:486–8.

15. Couch SM, Garrity JA, Cameron JD, Cloft HJ. Embolization of or-bital varices with N-butyl cyanoacrylate as an aid in surgical ex-cision: results of 4 cases with histopathologic examination. Am J Ophthalmol. 2009; 148:614–8.e1.

16. Mokhtarzadeh A, Garrity JA, Cloft HJ. Recurrent orbital varices after surgical excision with and without prior embolization with n-butyl cyanoacrylate. Am J Ophthalmol. 2014; 157:447–50.e1.

17. Shapiro A, Tso MO, Putterman AM, Goldberg MF. A clinicopatho-logic study of hematic cysts of the orbit. Am J Ophthalmol. 1986; 102:237–41.

18. Yoshikawa K, Fujisawa H, Kajiwara K. . Cause of hematic cysts of the orbit: increased fibrinolysis and immunohistologic ex-pression of tissue plasminogen activator. Ophthalmology. 2009; 116:130–4.

19. Dobben GD, Philip B, Mafee MF. . Orbital subperiosteal hem-atoma, cholesterol granuloma, and infection. Evaluation with MR imaging and CT. Radiol Clin North Am. 1998; 36:1185–200.