Bilateral idiopathic superior ophthalmic vein dilation
-
David B. Villafuerte
An 83-year-old woman presented to the outpatient clinic in December 2020 with the complaint of recurrent bilateral frontal headaches for 3 months. She did not identify any precipitating factors. She described the headaches as random, dull in nature, non-positional, and non-radiating. She denied nausea, vomiting, phonophobia, or photophobia. Most headaches were rated 6 out of 10 in severity, with 10 being the worst, but she had a severe episode one week prior to the initial outpatient visit where she rated the severity as 10 out of 10, prompting her to go to the emergency department.
Her past medical history consisted of coronary artery disease, congestive heart failure with reduced ejection fraction, sick sinus syndrome with pacemaker, and chronic asthma. A review of hospital records revealed a computed topography (CT) scan remarkable only for bilateral superior ophthalmic vein (SOV) dilation (Figure 1). Because of concerns for increased intracranial pressure (ICP) or carotid cavernous fistula, a CT arteriogram was performed, which was unremarkable. Laboratory workup including complete blood count, basic metabolic panel, thyroid stimulating hormone (TSH), and free thyroxine level (FT4) was performed. A physical examination was unremarkable for neurological or ophthalmic deficits. She was discharged with a prescription for naproxen and instructed to follow-up as an outpatient. She reported minimal relief. In the follow-up outpatient encounter her physical exam was also unremarkable, but osteopathic screening was remarkable for cranial somatic dysfunction upon vault hold. The patient received OMT (mainly CV4 technique) in 10 min sessions twice per week, over four weeks. Condylar decompression, V-spread and venous sinus drainage techniques were used at some, but not all, sessions. The patient reported resolution of symptoms by the fifth session and remained symptom-free at the time of her 6 month follow-up appointment. Given the resolution of symptoms, repeat imaging was deemed unnecessary.
(A) Transverse view of the brain on CT with arrows pointing to bilateral superior ophthalmic vein dilation. (B) Coronal view of the brain on CT with arrows pointing to bilateral superior ophthalmic vein dilation.
Dilated SOV, also known as SOV enlargement, is a rare finding resulting from a wide spectrum of etiologies with clinical implications ranging from benign to sight- and life-threatening. Symptoms and treatment are cause dependent. Dilated SOV is most often found with dural-cavernous fistula or carotid-cavernous fistula, orbital or facial arteriovenous malformation, and venous thrombosis [1]. Rarer causes include Graves’ disease, ophthalmic vein varix, orbital pseudotumor, orbital hematoma, and para-sellar meningioma [2]. Studies in radiology suggest that increased diameter in the SOV may correlate with ICP [3]. However, in ICP cases, headaches are classically worse with laying down, bending over, upon valsalva maneuver, and worsening in intensity over time rather than waxing and waning [4]. Given the patient’s unremarkable past medical history for pathology causing SOV dilation, unremarkable imaging, laboratory findings, physical examination, and the non-positional character and undulating intensity of her headaches, the patient’s dilated SOV was diagnosed as idiopathic in origin. Since idiopathic SOV dilation is an uncommon and scarcely reported phenomenon, no established treatment protocol exists. Although the patient’s headaches, imaging findings and resolution with OMT are highly suggestive that there could be a relation, this cannot be established conclusively.
-
Research funding: None reported.
-
Author contributions: The author has responsibility for the entire content of this manuscript and approved its submission.
-
Competing interests: None reported.
References
1. Adam, CR, Shields, CL, Gutman, J, Kim, HJ, Hayek, B, Shore, JW, et al.. Dilated superior ophthalmic vein: clinical and radiographic features of 113 cases. Ophthalmic Plast Reconstr Surg 2018;34:68–73. https://doi.org/10.1097/IOP.0000000000000872.Search in Google Scholar PubMed
2. Peyster, RG, Savino, PJ, Hoover, ED, Schatz, NJ. Differential diagnosis of the enlarged superior ophthalmic vein. J Comput Assist Tomogr 1984;8:103–7. https://doi.org/10.1097/00004728-198402000-00019.Search in Google Scholar PubMed
3. Lirng, JF, Fuh, JL, Wu, ZA, Lu, SR, Wang, SJ. Diameter of the superior ophthalmic vein in relation to intracranial pressure. AJNR Am J Neuroradiol 2003;24:700–3.Search in Google Scholar
4. Boyter, E. Idiopathic intracranial hypertension. JAAPA 2019;32:30–5. https://doi.org/10.1097/01.JAA.0000554732.85914.91.Search in Google Scholar PubMed
© 2022 the author(s), published by De Gruyter, Berlin/Boston
This work is licensed under the Creative Commons Attribution 4.0 International License.
Articles in the same Issue
- Frontmatter
- Cardiopulmonary Medicine
- Case Report
- Propionibacterium acnes: an uncommon cause of lung abscess in chronic obstructive pulmonary disease complicated with bullous emphysema
- General
- Case Report
- Reactivation of minimal change disease after Pfizer vaccine against COVID-19
- Innovations
- Original Article
- At-home ECG monitoring with a real-time outpatient cardiac telemetry system during the COVID-19 pandemic
- Medical Education
- Original Article
- Multisite assessment of emergency medicine resident knowledge of evidence-based medicine as measured by the Fresno Test of Evidence-Based Medicine
- Neuromusculoskeletal Medicine (OMT)
- Brief Report
- Osteopathic manipulative treatment use among family medicine residents in a teaching clinic
- Public Health and Primary Care
- Original Article
- Impact of an osteopathic peer recovery coaching model on treatment outcomes in high-risk men entering residential treatment for substance use disorders
- Clinical Images
- Recurrent bronchiolitis and stridor in an infant
- Bilateral idiopathic superior ophthalmic vein dilation
- Letters to the Editor
- Comments on “Reported completion of the USMLE Step 1 and match outcomes among senior osteopathic students in 2020”
- Response to “Comments on ‘Reported completion of the USMLE Step 1 and match outcomes among senior osteopathic students in 2020’”
Articles in the same Issue
- Frontmatter
- Cardiopulmonary Medicine
- Case Report
- Propionibacterium acnes: an uncommon cause of lung abscess in chronic obstructive pulmonary disease complicated with bullous emphysema
- General
- Case Report
- Reactivation of minimal change disease after Pfizer vaccine against COVID-19
- Innovations
- Original Article
- At-home ECG monitoring with a real-time outpatient cardiac telemetry system during the COVID-19 pandemic
- Medical Education
- Original Article
- Multisite assessment of emergency medicine resident knowledge of evidence-based medicine as measured by the Fresno Test of Evidence-Based Medicine
- Neuromusculoskeletal Medicine (OMT)
- Brief Report
- Osteopathic manipulative treatment use among family medicine residents in a teaching clinic
- Public Health and Primary Care
- Original Article
- Impact of an osteopathic peer recovery coaching model on treatment outcomes in high-risk men entering residential treatment for substance use disorders
- Clinical Images
- Recurrent bronchiolitis and stridor in an infant
- Bilateral idiopathic superior ophthalmic vein dilation
- Letters to the Editor
- Comments on “Reported completion of the USMLE Step 1 and match outcomes among senior osteopathic students in 2020”
- Response to “Comments on ‘Reported completion of the USMLE Step 1 and match outcomes among senior osteopathic students in 2020’”
