Case report

Case one

A 59-year-old Caucasian woman was referred with a diagnosis of possible left lacrimal sac mucocoele. She gave a 6-month history of subcutaneous paranasal swelling overlying the left medial canthal tendon, but with no associated epiphora, discharge, pain, or headache. There had been no change in the mass and she was otherwise asymptomatic with no previous ocular history or past medical history.

Her Snellen visual acuities were 6/6 in each eye, with no intraocular disease. There was an uninflamed mass, measuring 4 mm 5 mm, overlying the left medial canthal tendon and although resembling a lacrimal mucocoele, it could be emptied by firm pressure and readily refilled (Figure 1); it did not increase in size with a Valsalva manoeuvre, although refilling was faster. There was no evidence of an orbital mass or restriction of eye movements. The dye disappearance test was normal and both canaliculi were freely patent to syringing. A clinical diagnosis of angular vein varix was made, with a recommendation of no active intervention.

Figure 1.

The paranasal mass (a) is easily compressible with a finger (b) and starts to refill rapidly even before capillary return is complete (c); this confirms the diagnosis of an angular vein varix, rather than a lacrimal sac mucocoele.

Full figure and legend (303K)

Case two

A 65-year-old Caucasian woman presented with a right paranasal lump, which had slowly increased in size over 4 years. Although she had childhood pulmonary tuberculosis, there was no previous ocular history.

The paranasal lump was nontender, purple, mobile in the subcutaneous space and found to lie in the line of the angular vein. There was a nearby scar where a previous removal had been attempted. As the lesion was not compressible, a diagnosis of thrombosed angular vein was made. It is possible that previous surgery had caused retrograde thrombosis of the angular vein up to the union of the frontal and superior ophthalmic veins. CT scan confirmed there was no associated intranasal or intraorbital anomaly and the patient elected for no treatment.

Case three

A 61-year-old Sri Lankan woman presented with a left paranasal lump that was initially painful. It had been present for several months. She had a history of blepharitis and keratoconjunctivitis sicca secondary to gluteraldehyde exposure. She had no history of trauma to the area. Her history was otherwise unremarkable. The paranasal lump was nontender, mobile in the subcutaneous space and found to lie in the line of the angular vein (Figure 2). The lesion was not compressible and a diagnosis of spontaneous thrombosis of an angular vein varix was made without further investigation. The patient elected for no treatment.

Figure 2.

Left thrombosed angular vein varix (arrow).

Full figure and legend (164K)

Comment

A lacrimal sac mucocoele typically presents as a paranasal swelling centred just below the medial canthal tendon and the patient will usually complain of epiphora. Pressure will deflate the sac if open to the canaliculi or nasolacrimal duct, but otherwise the sac may become distended with mucus and assume a blue appearance. Dacryocystorhinosotomy is to be recommended to prevent dacryocystitis and relieve epiphora.

A varix of the angular vein may simulate a lacrimal sac mucocoele, but tends to be anterior to the medial canthal tendon. The angular vein is formed by the junction of the supra-trochlear and supra-orbital veins that runs obliquely downwards on to the side of the root of the nose, to the level of the lower margin of the orbit where it becomes the anterior facial vein. It communicates with the cavernous sinus by draining into the superior ophthalmic vein.

The aetiology of the condition is unclear. Varices usually occur at other sites because of chronic obstruction to flow,¹ but could also be due to abnormalities of connective tissue,² following trauma³ or due to hereditary predispositions.⁴ There was no clear aetiology in any of our cases.

There has been one prior English language report of angular vein varix,⁵ where the lesion was excised for cosmetic reasons. The diagnosis is a clinical one, but could be confirmed by phlebography or Doppler ultrasonography. None of our cases justified surgical excision with the small, perhaps entirely theoretical, risk of intracranial air embolus via the superior ophthalmic vein. Sclerotherapy and ligation have been used with some success for oesophageal varices,⁶ but we have no experience of their use in this situation.

References

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