The choroidal veins in each quadrant converge into vortex veins through a wide ampulla.1 2
Usually there is one vortex vein per quadrant of the eye, but accessory veins may also coexist.
The ampullae of the vortex veins are located in the oblique meridians at 1:30, 4:30, 7:30 and
10:30 o'clock position although the location may vary. The veins exit the globe obliquely through the scleral canal midway between the limbus and optic nerve before draining into the superior and inferior ophthalmic veins.
Lim et al3
have shown that up to 70% of eyes may have more than four vortex veins. Further, the number of a second or third vortex veins found in nasal quadrant is significantly higher than in the temporal quadrant; thus, increasing the possibility of a dilated ampulla occurring in the nasal quadrant.
Vortex veins can be easily visualised in patients with lightly pigmented fundus and in myopic subjects who have thin retina.
A marked dilatation of the ampulla is referred to as a varix or varicosity of the vortex vein ampulla. The appearance can often be confused with a choroidal melanoma, naevus or even metastases.4 5
This can lead to a series of investigations, which may be unnecessary.
In most cases, a single varix is found in one eye but it may be bilateral.6
However, having two varices in the same quadrant is extremely rare and has only been reported once.7
Clinically, the vortex vein varices may appear as an elevated mass, which is ill-defined and dark red in colour (). The size and shape of the varices may vary with the direction of gaze—that is, it can become more prominent when the eye gazes in the direction of the lesion.6
Pressure over the globe drains the blood out of the varix causing the lesion to disappear (). Hence, indentation of the globe while performing indirect ophthalmoscopy or applying gentle pressure with a Goldman 3 mirror contact lens may be a simple and effective way of diagnosing varices of the vortex vein ampulla.
A dark red elevated ill-defined choroidal mass.
Note complete disappearance of the lesion on gentle pressure over the globe.
Various other investigations have also been used to establish the diagnosis.4
‘B’ scan ultrasonography may show acoustic solidity and gaze-evoked dynamic enlargement of the lesion. Indocyanine green angiography demonstrates early hyperfluorescence with gradual pooling of dye and gaze-evoked fluctuation of the hyperfluorescence in the lesion. Colour doppler imaging can also be performed.
In summary, we have reported the second case in literature of two vortex vein varices involving one quadrant of the retina. We also believe that diagnosis of vortex vein varicosity can be mostly established by clinical examination and ancillary investigation will be rarely required.
- Varicosity of the vortex vein is not uncommon and you can see it if you look for it. This can be easily seen in myope and patients with lightly pigmented retina.
- Gentle pressure on the globe with a scleral depressor, three mirror or even a cotton bud while examining with a +78 /+90 dioptre lens will lead to obliteration of the lesion.
- Investigation may be needed only if the above is negative or if there is a coexisting lesion.