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A Clinical Conundrum: Superior Ophthalmic Vein Occlusion (SOVT)

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Title: A Clinical Conundrum: Superior Ophthalmic Vein Occlusion (SOVT)
Author: Christopher D. Conrady, MD, PhD, Dr. Zach Joos, MD, Dr. H. Christian Davidson, MD
Date: 09/26/2016
Keywords/Main Subjects: Superior ophthalmic vein occlusion; Septic cavernous sinus thrombosis
Diagnosis: Left SOVT with concurrent septic cavernous sinus thrombosis
Brief Description: In the following case, we present a 72-year-old lady that presented to her outside physician for cough, congestion, and headaches.  She was started on Flonase for presumed allergic rhinitis but the headaches continue to worsen.  She stopped the Flonase only to develop a complete ophthalmoplegia and ptosis of the left eye with mild proptosis.  She was then sent to her local ED by her PCP for further evaluation and eventually transferred to the University of Utah for treatment.  She was found to have a left SOVT with some involvement of the cavernous sinus.  She underwent sinus surgery, dental extraction, and was started on broad-spectrum antibiotics and anticoagulation.  She has since made a nearly complete recovery.

Images:

Slide 16: External photograph of the patient.  Patient was found to have mild proptosis, ptosis, and severe conjunctivochalasis of the left eye.

Slides 10-14: CT angiogram noting left superior ophthalmic vein occlusion and septic cavernous sinus thrombosis.

Slide 15:  MRA brain without contrast: Flow void of left superior ophthalmic vein consistent with thrombosis.

Slide 16: Coronal MRI brain without contrast with asymmetry of left portion of the cavernous sinus suggesting a septic cavernous sinus thrombosis.

Summary of Case:

  1. Superior ophthalmic vein occlusion needs to be considered in any orbital cellulitis picture as the clinical presentations can closely resemble one another.
  1. Imaging can help guide the diagnosis.
  2. While still somewhat controversial despite a small, randomized control trial, the AAO currently recommends dose-adjusted IV heparin for and an extended course of intravenous, broad-spectrum antibiotics for a SOVT from an infectious etiology.

Format: PDF
Series: Orbit Conference
References:

Desa V, Green R. J Oral Maxillofac Surg. 2012;70(9):2085-2091.

Einhaupl A et al. Lancet. 1991;338(8767):597-600.

Michaelides et al., J. Ophth Scand, 2003.  81:88-90.

Mishima, et al., J Med Case Rep. 2015; 9:244.

Sambhav et al., Int Med Case Rep. 2015; 8:181-183.

Schmitt NJ et al. Ophthal Plast Reconstr Surg. 2005;21(5):387-389

Smith et al., J. Clin NeuroOphtho. 1983. 3: 83.

Syed et al., Proc Univ Med Cent; 2016; 29(1):36-38.
Faculty Approval: Signed off on by orbital conference faculty attendees
Identifier: Moran_CORE_22006
Copyright statement: Christopher D. Conrady, ©2016.. Please see terms of use page for more information.