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