Vortex Vein Varices
Case Report
I.
Case History
a. Patient demographics: 60 year-old Caucasian male
b. Chief complaint: wants new glasses
c. Ocular, medical history:
i. Cataract OU, no DR on previous 3 exams
ii. Type 2 diabetes mellitus x 2 years, hypertension, hyperlipidemia,
and obesity; stopped smoking 4 months prior
d. Medications: Clotrimazole cream, Metformin, HCTZ; stopped Lisinopril
and Rosuvastatin due to leg pain
e. Other salient information: none
II.
Pertinent findings
a. Clinical:
i. BCVA: 20/20 OD, OS
ii. Cover Test / Motilities / Confrontation fields / Pupils: normal
iii. Slit Lamp Exam: non-contributory
iv. IOP: 15 OD, 14 OS
v. DFE:
1. Nuclear sclerotic cataract OU and Cortical cataract OS not
affecting VAs
2. Lattice degeneration without holes (superior) OS
3. New (not seen on last 2 exams) 3DD dark gray domeshaped lesion superior-nasal OD without drusen or
lipofuscin; 1.5DD dark gray slightly elevated round lesion
superior-nasal OS without drusen or lipofuscin
b. Physical:
i. Vitals: BP: 144/89, Pulse: 90, Respiration: 18, Temperature 96.8°
F, Pain: 0
ii. Weight: 290 lbs., Height: 70 inches
iii. Normal physical exam
c. Laboratory studies:
i. HbA1C: 7.5 H, FBG: 155 H
ii. CBC / Chem 7 / TSH / PSA / Liver panel: normal
iii. Lipid panel: triglycerides 330 H, other components close to normal
iv. Urinalysis: microalbumin/creatinine ratio 327.13 H, microalbumin
30.40 H, other components normal
d. Radiology studies: ophthalmic ultrasound
i. OD: thickness 0.87 – 1.1mm, 4 – 5mm long, higher reflectivity by Ascan, no posterior extension
ii. OS: 0.67mm at thickest point, 3.5 – 4.4mm long, no posterior
extension
III.
Differential diagnosis
a. Primary/leading: Vortex vein varix
i. Size: 1-3DD at base; 2DD in height
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IV.
V.
ii. Color: grey-green to venous-colored
iii. Location: usually nasally at equator
iv. Red-free filter: black and larger
v. FA: no leakage; no secondary vascular supply
vi. B-scan: dynamic
b. Other: Choroidal melanoma
i. Size: 2-10DD
ii. Color: grey-green with possibly subretinal fluid or orange
pigmentation
iii. Location: anywhere
iv. Red-free filter: no color change
v. FA: pinpoint leakage; secondary vascular supply
vi. B-scan: stable; elevated
Diagnosis and discussion
a. Elaborate on the condition:
i. First described by Rutnin in 1967
ii. First reported cases by Osher in 1981
iii. Unilateral or bilateral, either eye, single or double, equatorial
location, usually nasal fundus
iv. Benign, asymptomatic
v. No predilection for age or gender
vi. Unrelated to systemic disease
vii. Rare; <1% (Osher), 0.052% (Lopez)
b. Expound on the unique features:
i. Color: grey-green, dark red-brown, dark red to burgundy, venouscolored
ii. Shape: smooth, ,elevated, dome-shaped, round
iii. Size: 1-3 DD, up to 6mm in diameter, up to 3mm thick
iv. Noted on sustained gaze; may require extended duration of gaze (5
seconds) for ampulla to fill
v. Lesion expands when choroidal venous pressure exceeds IOP
(congestion at ampulla)
1. Extreme gaze in direction of lesion
2. Head below heart (e.g., reclined)
3. Valsalva maneuver (reclined or sitting)
vi. Lesion flattens when IOP exceeds choroidal venous pressure
(congestion at ampulla relieved)
1. Gaze directed elsewhere (e.g., primary gaze)
2. Head elevated
3. Digital pressure (e.g., ophthalmodynamometry, ultrasound
probe, scleral depression, contact fundus lens) regardless of
gaze or head position
Treatment, management
a. Treatment and response to treatment: no treatment necessary
b. Summary of cases in the literature:
i. 22 cases reported (33 lesions)
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ii. Ages: 23-71
iii. Male: 42%, Female: 58%
iv. OD: 50%, OS: 50%
v. Superior nasal: 61%, Inferior nasal: 39%
vi. Bilateral: 14%
vii. Multiple: 27%
viii. Maximum diameter: 6mm
ix. Maximum height: 2DD, 2.6mm
x. One report of not seeing on prior exam
c. Bibliography:
Buettner H. Varix of the vortex vein ampulla simulating choroidal
melanoma. Am J Ophthalmol 1990; 109(5): 607-8.
Da Cruz L, James B, et al. Multiple vortex vein varices masquerading
as choroidal secondaries. Br J Ophthalmol 1994; 78: 800-1.
Gunduz K, Shields CL, Shields JA. Varix of the vortex vein ampulla
simulating choroidal melanoma – report of four cases. Retina
1998; 18(4): 343-7.
Hunter JE. Vortex vein varix. Am J Optom Physiol Opt 1983; 60(12):
995-6.
Kang HK, Beaumont PE, Chang AA. Indocyanine green angiographic
features of varix of the vortex vein ampulla. Clin Exper
Ophthalmol 2000; 28(4): 321-3.
Khan J, Damato BE. Accuracy of choroidal melanoma diagnosis by
general ophthalmologists: a prospective study. Eye 2007; 21:
595-7.
Lopez P. Varix of the vortex vein ampulla. J Am Optom Assoc 1986;
57(2): 104-8.
Levy J, Yagev R, et al. Varix of the vortex vein ampulla: a small case
series. Euro J Ophthalmol 2005; 15(3): 424-7.
Osher RH, Abrams GW, et al. Varix of the vortex ampulla. Am J
Ophthalmol 1981; 92(6): 653-60.
Potter JW, Vandervort RS, Thallemer JM. The clinical significance of
the vortex veins. J Am Optom Assoc 1984; 55(11): 822-4.
Rutnin U. Fundus appearance in normal eyes. Am J Ophthalmol 1967;
64(5): 821-39.
Seregard S, Daunius C, et al. Two cases of primary bilateral malignant
melanoma of the choroid. Br J Ophthalmol 1988; 72: 244-5.
Shields CL, Shields JA, De Potter P. Patterns of Indocyanine green
videoangiography of choroidal tumors. Br J Ophthalmol 1995; 79:
237-45.
Singh AD, De Potter P, et al. Indocyanine green angiography and
ultrasonography of a varix of vortex vein. Arch Ophthalmol 1993;
111: 1283-4.
The Collaborative Ocular Melanoma Study Group. Accuracy of
diagnosis of choroidal melanomas in the collaborative ocular
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VI.
melanoma study. COMS report number 1. Arch Ophthalmol 1990;
108: 1268-73.
Tomasini DN. Varix of the vortex ampulla: a dynamic phenomenon.
Clin Eye Vis Care 2000; 12(3-4): 151-4.
Wolfensberger TJ. Varix der vortex ampulla: ungewohnliche
differentialdiagnose bei aderhauttumoren (Varix of the vortex vein
as a differential diagnosis in tumors of the choroid). Klin Monatsbl
Augenheilkd 1997; 210(5): 334-6.
Conclusion
a. Clinical pearls, take away points
i. Usually found on routine DFE with BIO
ii. Unknown etiology; no treatment required
iii. 3-mirror contact fundus lens provides quick, easy, and inexpensive
method to verify disappearance (i.e., flattening)
iv. Fluctuating dynamic nature is characteristic and diagnostic
v. Misdiagnosis of vortex vein varix for choroidal melanoma: 0.036%
(Khan), 0.020% (C Shields)
vi. Misdiagnosis of retinal lesion for choroidal melanoma: 30% (Khan),
0.48% (COMS)
vii. Primary bilateral choroidal melanoma: 1 case every 18 years in US
viii. If in doubt, refer for ultrasound
ix. If still in doubt, refer to retinal specialist
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