|Removal of a residual and retro-trochlear varix in the anterior orbit|
|Clinical evaluation with emphasis on identifying the character of filling (rapid-slow) and deflation of the lesion during and following a Valsalva maneuver|
|Diagnostic imaging requires dynamic arterial and Valsalva-augmented venous multidetector imaging (CT DP–MDCTA)|
Varices are a challenge surgically since they are thin walled, may be deflated (making them hard to find) and can be ruptured easily during surgery. Rupture can be avoided by mapping, which is facilitated percutaneously by inflating the lesion and placing a needle in the varix. Co-localization with CT scan in the radiology suite has added accurate visualization intraoperatively to facilitate this process. If this facility is not available, superficial lesions can be identified and cannulated. This process is easily aided by intraoperative inflation of the varix through raising the thoracic pressure in order to identify the lesion for placement of the cannula and for the mapping and gluing of the varix. Deeper lesions can also be identified by careful exposure using periodic Valsalva to recognize and isolate the anterior surface as shown in the following retro-trochlear varix.
Once cannulated, the lesion can be mapped to define its limits and to determine the outflow, which can be through single or multiple vessels. The strategy for gluing is to block the outflow carefully with the first injection of glue (either Onyx or N -butyl-cyanoacrylate) and then backfilling the lesion. This may require multiple injections through the same cannula.