|Year : 1982 | Volume
| Issue : 5 | Page : 491-496
Orbital venography in unilateral proptosis
MS Boparai, RC Sharma
Army Hospital Delhi Cantt, India
M S Boparai
Army Hospital Delhi Cantt
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Boparai M S, Sharma R C. Orbital venography in unilateral proptosis. Indian J Ophthalmol 1982;30:491-6
This presentation is based on an experiment orbital venography conducted on 50 cases.
| Material and methods|| |
50 cases have been subjected to orbital venography. 15 were unselected cases of random eye conditions and 35 were cases of unilateral proptosis. No sedation or preparation was done.
The patient lies supine on an examination table as for cerebral angiography. The veins of the forehead were made prominent by extending the neck and valsalva manouver. A tourniquet was placed around the head at the hair line to produce venous stasis and to stop dye from going backwards. A 10cc syringe filled with normal saline was attached to a 21-23 gauge disposable scalp vein needle with 10-15 cm tubing. The frontal/supra orbital vein was punctured in the directions of the vein. Slow infusion of saline was continued to keep the needle patent. Once the X-Ray tube was positioned another 10 ml syringe was filled with conray 420 (Meglumine and sodium lothalamate injection-May and Baker Ltd). 8-10ml of the dye was injected rapidly and an AP and lateral view films were taken in succession. If there was delay between the exposures, saline perfusion was carried on to keep the needle patient. As the dye was injected the patient was advised to grip the maxillary arch with the index fingers to prevent the dye from flowing into the facial veins. During AP view head was tilted backwards to avoid the petrous shadows coming into the orbits.
| Normal orbital venogram|| |
By frontal vein puncture superior ophthalmic veins on both sides get filled and comparison is possible. Radiologically the superior ophthalmic vein can be divided into 3 segments in the anterior posterior and basal views. These segments give the vein the form of a parallelogram [Figure - 1][Figure - 2].
The angle formed by the first two segments ranges from 50-60° and the angle formed by the second and the third segment is about 110° Lesions lying within the muscle cone cause opening up of the parallelogram depending on their size. Those lying outside the muscle cone cause closing up of the parallelogram depending on their situation.
| Observations|| |
Supraorbital/frontal vein was used in 40 cases and angular vein in 10 cases. Phlebography could successfully be performed in (78%) cases. The rest were technical failures as either the vein could not be found or could not be successfully punctured in three trials in single sitting. Angular vein puncture was painful and counter puncture and slipping of the vein was common. By frontal vein puncture, superior ophthalmic vein was visualised bilaterally making comparison possible. This is not the case with angular vein puncture.
Amongst 35 cases of orbital disease the failure was in 8 cases (22.8%). The diagnosis arrived at were as under : Venous occlusion-4, Orbital varix-2, Intraconal tumours-8, Extraconal tumours-13, Failure-8.
No complication of any consequence was encountered. Patients complained of a feeling of fullness in the forehead and eye balls which disappeared in a few minutes after stoppage of injection. Extravasation of eye was found in some cases. It caused mild irritation and haematoma formation for a few days. There was no hypersensitivity reaction in any case.
| Illustrated cases|| |
Case I, OS, 28 years male had been having a reducible swelling below the right lower lid of 8 years duration. The swelling had been gradually increasing. It used to become more prominent on bending down and eye used to get proptosed : A clinical diagnosis i of orbital varix was confirmed by direct injection into the varix the injection through the frontal vein had shown a normal superior ophthalmic vein. The varix evidently was in connection with the Inferior Ophthalmic vein. A cosmetic correction was carried out by ligation and excision of the anterior end of the varix.
Case 2. KS, 40 years male had a slow growing proptosis on the right side of 3 years duration. Eye was proptosed by 12 mm and was pushed down and forwards [Figure - 3]. Orbital venogram showed an extra conal tumour pressing on the first and second segment of the Rt superior ophthalmic vein [Figure - 4]. A lateral orbitotomy was undertaken and a pleomorphic adenoma of the lacrimal gland was removed.
Case No 3. A young male had proptosis of only 4 months duration. Eye was pushed forwards and downwards. Orbital Venogram showed an extra canal lesion pressing on all the three segments of the superior ophthalmic vein thereby showing extension right upto the apex of the orbit [Figure - 5]. A lateral orbitotomy was undertaken and the mass turned out to be a pseudo tumour.
Case No 4. HS, a 35 years male had a gradually increasing protusion of the right eye of 4 years duration. The eye ball was pushed down and forwards by 10 mm. Orbital venography showed convolation and dilatation of the first segment, opening up of the parallelogram and an abnormal draining vein in the orbit [Figure - 6]. The haemangioma was removed by an anteromedial approach in preference to a lateral approach as it was felt that the tumour had extended medially. This was based on the fact that opening of the parallelogram was not consistent with 9 mm proptosis -which this patient had. The tortuous first segment and abnormal draining veins were the result of the haemangioma.
Case No 5. MST, 46 years noticed protusion of the right eye which kept on gradually increasing for 4 years. Eye showed a straight forward proptosis of 7 mm. Orbital venography showed opening up of the parallelogram by an intraconal tumour similar to the previous case [Figure - 7]. A lateral orbitotomy was undertaken and a lymphomatous mass was removed.
| Discussion|| |
Orbital venography seems to be the most important single radiological investigation when it comes to obtaining information on nature, site and size of orbital space occupying lesions. Success rate of 78- in getting a good angiogram in this series compares well with Lloyd's rate of 80% through the frontal vein. Conray 420 has been used for the first time and appears to be very satisfactory.
2 cases of orbital varix were diagnosed which otherwise would not have been possible. Orbital varies may show pooling, phleboliths and abnormal connections. Case No. I showed normal superior ophthalmic vein but in direct injection into the swelling the venous lakes in connection with the inferior ophthalmic veins could be demonstrated. Only cosmetic correction need be undertaken in these cases and attempts at complete removal can prove disastrous. 4 cases showed venous occlusion which in 2 cases was due to pressure of the tumour and in 2 more due to possible thrombosis and closure of the vein by pyocoele of the frontal sinus.
Intra conal tumours were found in 8 cases. Location of the tumour helps in planning approach to the tumour which may be by lateral anterior or antero-medial orbitotomy. In case No 4 the mass was intra conal. The first segment showed dilatation and tortousity and the third segment was pushed laterally. There was also an abnormal draining vein in the orbit.
Extraconal lesions were found in 13 cases giving a good indication of the placement of the tumour in the orbit depending on whether the first, second or third part or all parts of the superior ophthalmic vein were displaced. In case No 2, the first and the segment of the parallelogram were pressed by a pleomorphic adenoma of the lacrimal gland indicating extension backwards. In case No 3 however all the three segments were pushed inwards indicating extension of the tumour mass upto nearl y the apex of orbit. The approach in the case of pressure in second and third part will preferably be lateral and in the first part only, anterior.
It can be concluded (i) that Orbit venography helps find the venous nature of a tumoureg varices. (ii) It helps find the situation of the tumour whether within or outside the muscle cone. (iii) It helps in planning surgical approach to an orbital space occupying lesion. (iv) It is of help in diagnosing a haemangionatous tumour. (v) May help in finding an arterio venous connection.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]