Embolization of Orbital Varices with N-Butyl Cyanoacrylate as an Aid in Surgical Excision: Results of 4 Cases with Histopathologic Examination STEVEN M. COUCH, JAMES A. GARRITY, J. DOUGLAS CAMERON, AND HARRY J. CLOFT ● PURPOSE: To report the results of intervention with percutaneously injected n-butyl cyanoacrylate (NBCA) to embolize orbital varices followed by surgical resection. ● DESIGN: Retrospective case series. ● METHODS: Four patients with symptomatic orbital varices were treated with percutaneous injection of NBCA to embolize the varicosity before surgical resec- tion. Intervention was indicated because of progressive orbital pain attributed to orbital varices. Three of the 4 described cases were associated with severe episodic proptosis. The vision was not affected by the orbital varix in any of the cases before intervention. Radiographic guidance was used during injection of the NBCA. Surgical resection was undertaken via orbitotomy immediately after embolization. The resected tissue was submitted for his- topathologic evaluation. ● RESULTS: Follow-up after surgery ranged from 7 to 19 months. All of the patients experienced relief of orbital pain. All patients noted transient binocular diplopia in extremes of gaze after the procedure, which resolved spontaneously. No patients had diplopia in primary gaze. No patient lost vision as a result of the procedure. There was no difficulty with procedure-related hemostasis in any of the cases. ● CONCLUSIONS: Percutaneously injected NBCA seems to be useful and safe as an aid in visualization and hemor- rhage prevention during surgical resection of symptomatic orbital varices. (Am J Ophthalmol 2009;148:614 – 618. © 2009 by Elsevier Inc. All rights reserved.) O RBITAL VARICES ARE VENOUS MALFORMATIONS composed of venous channels of abnormal cali- ber and distribution as either a single vessel with segmental outpouchings or multiple tangled venous chan- nels. 1 Orbital varices have been classified as either con- genital or acquired. 2,3 More recently, the classification has been modified using distensibility of the involved vessel as the primary variable. 4,5 Orbital varices are the most com- mon cause of episodic unilateral proptosis and spontaneous orbital hemorrhage. 6 The proptosis typically worsens after engorgement of the varix secondary to maneuvers that elevate venous pressure, including the Valsalva maneuver, bending posture, and coughing. 7,8 Patients with an orbital varix frequently report recurrent proptosis, orbital hemor- rhage, or deep orbital pain. Occasionally, patients can have enophthalmos after recurrent variceal engorgement. Surgical removal often is difficult because of indistinct surgical margins and the control of intraoperative hemor- rhage. Frequently reported indications for therapy include unfavorable cosmetic appearance, orbital pain, and vision loss. 9,10 Although no standard treatment has been devel- oped, previously reported options include electrothrombo- sis, injection of sclerosing agents, surgical resection, and, more recently, embolization with cyanoacrylate glue fol- lowed by excision. 11–14 We report results of 4 patients who underwent computed tomography-guided percutaneous embolization of orbital varices with n-butyl cyanoacrylate (NBCA) followed by immediate surgical resection. METHODS THE CHARTS OF 4 CONSECUTIVE PATIENTS WITH ORBITAL varices treated with NBCA embolization before surgical resection were reviewed (Table). There were 3 males and 1 female whose ages ranged from 30 to 56 years. All of the patients had orbital pain at presentation. Three of 4 patients had experienced episodic proptosis. One patient reported preoperative episodic diplopia that occurred in primary gaze during variceal engorgement but did not have any measurable strabismus without engorgement. The diagnosis of orbital varix was confirmed by computed tomographic imaging or magnetic resonance imaging (Fig- ure 1). The patient without episodic proptosis was found to have abnormal venous flow by Doppler ultrasound. None of the patients described had vision loss secondary to the varix. Orbital pain was the indication for surgical resection in all patients. ● DESCRIPTION OF PROCEDURE: All of the patients were administered general anesthesia and were placed in the prone position. The head then was tilted appropriately to place the varix in the dependent position to encourage variceal engorgement. Using fluoroscopy and DynaCT Accepted for publication Apr 27, 2009. From the Departments of Ophthalmology (S.M.C., J.A.G., J.D.C.); Pathology (J.D.C.); and Radiology (H.J.C.), Mayo Clinic, Rochester, Minnesota. Inquiries to James A. Garrity, Department of Ophthalmology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; e-mail: Garrity. James@mayo.edu © 2009 BY ELSEVIER INC.ALL RIGHTS RESERVED. 614 0002-9394/09/$36.00 doi:10.1016/j.ajo.2009.04.024