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Bilateral Atypical Eyelid Lesions in a 50-Year-Old Woman

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 50-year-old woman was referred to the oculoplastic clinic for evaluation of bilateral vascular lesions of the eye visible beneath the palpebral conjunctivae on the upper and lower eyelids. She denied any vision changes or pain but did report a sensation of pressure in the location of the lesions, which was relieved when prone. She had a 25-year history of bulimia and was purging almost daily. She reported an inability to go more than 3 days at a time without purging and noted a reduction in the pressure and size of her lesions with respite from these daily episodes. She had no history of eye surgery, hypertension, atherosclerotic disease, or other risk factors for vascular disease. The patient first noticed these lesions 15 years ago in association with a subconjunctival hemorrhage on the left side. An orbital magnetic resonance image obtained at the time of that episode demonstrated a 2 × 0.6-cm focus of enhancement along the inferior and inferolateral palpebral tissues anterior to the left globe, suggestive of lymphangioma, hemangioma, or vascular malformation without other focal abnormalities. The anterior segment examination showed bilateral superior (Figure, A) and inferior (Figure, B) large dilated blood vessels underlying the palpebral conjunctivae. Complete ophthalmic and orbital examinations revealed no other abnormalities.

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Bulimia-induced varices of the inferior and superior palpebral arcades

D. Observe periocular lesions while psychiatric treatment is continued

Magnetic resonance imaging of the orbits from 2 years before this patient’s presentation demonstrated enhancing vascular lesions within the palpebral tissue of the upper and lower eyelids bilaterally. On examination, the lesions were slightly smaller compared with previous findings on imaging. Although the differential diagnosis includes capillary hemangioma, arteriovenous hemangioma, and lymphangioma, the patient was clinically diagnosed with bilateral bulimia-induced varices of the palpebral arcades. We recommended observation, given her inability to stop purging, to address the origin of disease.

Sclerotherapy (choice A) is not the recommended next step because it is typically used for the treatment of orbital low-flow lymphovenous malformations, but it has not been studied for use in varicosities of the peripheral arcade.1 Moreover, sclerotherapy of orbital or facial lesions carries the risk of hemorrhage or embolic events in some cases.2,3 Surgical excision (choice B) is not preferred because the patient’s daily purging should be under better control before surgery is performed. Daily episodes of purging could result in postoperative preseptal or retrobulbar hemorrhage with significant risk of vision loss as well as recurrent varices. Systemic propranolol (choice C) is typically used as first-line treatment of capillary hemangiomas, with response rates reported as high as 60%.4 Its use in the treatment of peripheral arcade varices has not been reported. Moreover, the use of propranolol in a patient who is actively purging could exacerbate bulimia-associated physiological instability.5

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Article Information

Corresponding Author: Andrea L. Kossler, MD, Byers Eye Institute, Department of Ophthalmology, Stanford University School of Medicine, 2452 Watson Ct, Palo Alto, CA 94303 (akossler@stanford.edu).

Published Online: October 15, 2020. doi:10.1001/jamaophthalmol.2020.2090

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Arat  YO , Mawad  ME , Boniuk  M .  Orbital venous malformations: current multidisciplinary treatment approach.   Arch Ophthalmol. 2004;122(8):1151-1158. doi:10.1001/archopht.122.8.1151 PubMedGoogle ScholarCrossref
2.
Barnacle  AM , Theodorou  M , Maling  SJ , Abou-Rayyah  Y .  Sclerotherapy treatment of orbital lymphatic malformations: a large single-centre experience.   Br J Ophthalmol. 2016;100(2):204-208. doi:10.1136/bjophthalmol-2015-306657 PubMedGoogle ScholarCrossref
3.
Dehghani  A , Rezaei  L , Ghanbari  H , Nasrollahi  K , Tavakoli  M .  Ophthalmic artery occlusion following facial sclerosing therapy.   J Ophthalmic Vis Res. 2018;13(3):351-354. doi:10.4103/jovr.jovr_29_16 PubMedGoogle ScholarCrossref
4.
Léauté-Labrèze  C , Hoeger  P , Mazereeuw-Hautier  J ,  et al.  A randomized, controlled trial of oral propranolol in infantile hemangioma.   N Engl J Med. 2015;372(8):735-746. doi:10.1056/NEJMoa1404710 PubMedGoogle ScholarCrossref
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Gorla  K , Mathews  M .  Pharmacological treatment of eating disorders.   Psychiatry (Edgmont). 2005;2(6):43-48.PubMedGoogle Scholar
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Koga  A , Toda  K , Tatsushima  K ,  et al.  Portal hypertension in prolonged anorexia nervosa with laxative abuse: a case report of three patients.   Int J Eat Disord. 2019;52(2):211-215. doi:10.1002/eat.23007 PubMedGoogle ScholarCrossref
7.
Smoker  WR , Gentry  LR , Yee  NK , Reede  DL , Nerad  JA .  Vascular lesions of the orbit: more than meets the eye.   Radiographics. 2008;28(1):185-204. doi:10.1148/rg.281075040 PubMedGoogle ScholarCrossref
8.
Jakobiec  FA , Werdich  XQ , Chodosh  J , Freitag  SK .  An analysis of conjunctival and periocular venous malformations: clinicopathologic and immunohistochemical features with a comparison of racemose and cirsoid lesions.   Surv Ophthalmol. 2014;59(2):236-244. doi:10.1016/j.survophthal.2013.06.003 PubMedGoogle ScholarCrossref
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Margo  CE , Rowda  J , Barletta  J .  Bilateral conjunctival varix thromboses associated with habitual headstanding.   Am J Ophthalmol. 1992;113(6):726-727. doi:10.1016/S0002-9394(14)74810-X PubMedGoogle ScholarCrossref
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Neiberg  MN .  An unusual presentation of a lid varix.   Optometry. 2009;80(5):223-226. doi:10.1016/j.optm.2008.09.013 PubMedGoogle ScholarCrossref
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