To report an unusual case of bilateral compressive optic neuropathy caused by orbital varices expanding with habitual Valsalva, adopted by the patient to relieve a funny smell (cacosmia).
Orbital varices are vascular hamartomas that have been reported to cause variable symptoms due to its compressive or mass effect within the orbit. We report a case of a 28-year-old female presenting with sub-acute loss of vision, while volunteering a history of bilateral, variable proptosis on habitual Valsalva manoeuvres, performed up to 30 times each day over a period of 15 years to relieve cacosmia. Examination revealed reduced vision and impaired colour perception Expansion of orbital volume and periorbital venous congestion was observed following Valsalva manoeuvres, with compression of the optic nerve at the orbital apices with neuro-imaging.† Examination of the nasal cavity revealed no pathology accounting for her symptoms. Infiltration of marcaine to the left olfactory bulb provided temporary relief (less than 12 hours).
The patient’s symptoms of cacosmia were stabilized on gabapentin, with reduction of frequency of Valsalva manoeuvres to 2-3 times per day before meal-time.† BCVA stabilized at R counting fingers and L 6/18.† Colour vision remained severely impaired in the right eye and moderately impaired in the left.
While there have been reports of patients adopting habitual Valsalva manoeuvres to relieve cacosmia, to the best of our knowledge this is the first report of a patient who has suffer permanent visual loss from compressive optic neuropathy due to engorged orbital varices from such manoeuvres.