The Utility of Dynamic CT Imaging With Pre- and Post-Valsalva Maneuvers for Confirmation of Suspected Orbital Varices

A 71-year-old female presented with a singular episode of bilateral transient vision loss after bending at the waist. The examination noted 20/20 vision bilaterally (OU), normal intraocular pressures, full extraocular movements, and full visual fields OU. There was no diplopia or proptosis. Initial CT identified a left intraconal mass (13 × 8 × 8 mm) between the left optic nerve and inferior rectus, with subsequent MRI showing decreased interval size. For further evaluation, the patient underwent a thin-cut CT of the orbits with and without the Valsalva maneuver to evaluate for dynamic change in the size of the lesion. Panel A demonstrates an axial view of the orbit just below the level of the optic nerve obtained in the patient’s usual resting state. A small ovoid structure is seen immediately subjacent to the optic nerve (black arrow), extending posteriorly toward the apex. Panel B demonstrates postcontrast CT image at the same level as the patient performing the Valsalva maneuver. The marked increase in the size of the contrast-enhancing structure (black arrowhead) confirms suspicion of an orbital varix. Note that the patient’s left globe becomes proptotic due to retrobulbar venous distension. Panel C and D show pre- and post-Valsalva maneuver images in the coronal plane, demonstrating the lesion’s orientation in relation to adjacent intraorbital structures (white arrow and white arrowhead, respectively). This case illustrates the utility of CT imaging with dynamic Valsalva maneuver for definitive evaluation of suspected orbital varix, as a change in size distinguishes this entity from other orbital pathology, enhancing diagnostic capabilities in clinical practice.FIG.