A 67-year-old man consulted an ophthalmologist for pain in the right eye in recent days with blurred vision, incessant tearing and extreme gaze diplopia. Examination revealed marked ocular asymmetry with profusion of the right eye with generalised limitation of extrinsic mobility, especially abduction, and intense oedema of the conjunctiva which prolapsed through the parpebral fissure. After a CT scan of the orbit was performed and intraorbital involvement was ruled out, the patient was referred to Internal Medicine. The patient was a male smoker of 30 cigarettes a day since his youth and had no other history of interest. In the anamnesis, in addition to the ocular symptoms that were the reason for the consultation, he reported some respiratory difficulty and dysphonia, but without chest pain, haemoptysis, fever or other systemic symptoms. On physical examination, his general condition was good and there were no signs of increased work of breathing. On physical examination, in addition to the alterations of the right eye, there was a striking increase in volume of the right side of the face and neck. The right jugular vein remained visible and continuously ingurgitated, and dilatation of the superficial venous network was visible at the level of the right temple and the anterior thoracic plane. Palpation of the neck revealed a hard, adherent and non-painful tumour in the right supraclavicular fossa. Vital signs, palpation of the axillary hollows and pulmonary, cardiac, abdominal and lower limb examinations revealed no findings of interest. In the complementary examinations, the haemogram, coagulation study, biochemical profile including tumour markers and arterial blood gases were normal. Chest X-ray showed mediastinal widening at the expense of the right hilum. The cervico-thoracic CT scan showed multiple nodular images in the upper lobe of the right lung, adenopathic conglomerate occupying the anterior mediastinum and extending cranially to the right laterocervical region, compressing the right jugular vein, the left brachiocephalic trunk and the SVC. The cranio-orbital CT scan showed slight right exophthalmos, with thickening of the superior ophthalmic vein and absence of orbital tumour. A fine needle aspiration of the right latero-cervical adenopathic mass was diagnostic of small cell carcinoma metastasis.

