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Editor,—Obstruction of the superior vena cava (SVCO) is a condition which causes a variety of symptoms and signs in the upper body, such as oedema of the face, arms and neck, facial erythema, dyspnoea, cough, hoarseness, dysphagia, and mental status changes.1 It may, however, present to an ophthalmologist through features such as conjunctival venous engorgement, chemosis, non-pulsatile proptosis, glaucoma, retinal venous changes, and papilloedema.2 3 It is an important diagnosis as there is usually associated serious pathology, frequently malignancy.1 We present a case of SVCO presenting with minor ocular complaints and findings.
A 68 year old white man was referred with a 3 month history of “chronic conjunctivitis” not responding to topical medications; at his consultation he complained of persistent watering of both eyes with lid swelling. Only on direct questioning did he admit to facial and neck swelling with inability to button his shirt collar. His symptoms were more marked on waking. He had previously been in good health, with no past medical or ocular history. He had no cardiovascular or respiratory complaints and his weight was stable; he did however smoke 15 cigarettes per day.
On examination he had a plethoric complexion, large neck, and thickening of his facial and upper limb skin; his periorbital skin was also slightly swollen (Fig 1). There was anterior blepharitis, but otherwise ocular examination was unremarkable; in particular there was no proptosis or conjunctival injection, the intraocular pressures were normal and funduscopy showed no vessel or disc changes. The nasolacrimal ducts were patent on syringing. In view of the upper body signs, a chest x ray was performed; this demonstrated a right paratracheal mass. A clinical diagnosis of superior vena cava obstruction was made.
The patient was referred to a cardiothoracic surgeon. The diagnosis was confirmed by angiography, and angioplasty with insertion of a stent was carried out (Fig 2). Anterior mediastinotomy allowed biopsy of the mass, histology reporting a low grade carcinoma, probably of pulmonary or thymic origin. This was treated with a course of palliative radiotherapy. Following these measures his symptoms and signs resolved.
Our patient is interesting considering the paucity and seemingly trivial nature of his presenting complaints, the potentially distracting presence of blepharitis, and also the relative lack of ocular findings associated with SVCO. Many patients present with epiphora and puffy eyes. It is as well to remember that these symptoms may be due to serious pathology.