Carotid Cavernous Fistula

Power point of case presentation of 66-year-old female with chronic red eye OU x 2 months, misdiagnosed as conjunctivitis. Exam showed dilated, tortuous episcleral vessels OU with proptosis OU and elevated intraocular pressure. MRI showed suspicion of carotid cavernous fistula (CCF), confirmed by angiography. Endovascular coiling was performed, after which fistula was closed and patient's salient findings on exam resolved. Discussion includes review of types of high and low flow CCFs, neuro-ophthalmic features, work-up and treatment options. Imaging: Slide 5: Figure 1: Table 1: Ocular findings in case Slide 6: Figure 2a and 2b: External photos of the patient's eyes. In the right eye (Figure 2a, on left) there is subconjunctival hemorrhage, chemosis, and corkscrew vessels that extend to the limbus. The left eye findings (Figure 2b, on right) include chemosis and corkscrew vessels that extend to the limbus. Slide 9: Figure 3: Axial T2 weighted MRI brain. The cavernous sinus appears grossly normal, but on close inspection one can appreciate extra flow voids within the dura around the cavernous sinus representing the indirect carotid cavernous fistula. Slide 10: Figure 4: Contrast enhanced T1 weighted fat suppressed MRI with an axial cut through cavernous sinus. Extra flow voids are seen within the dura at the posterior cavernous sinus (red arrows). Slide 11: Figures 5 and 6: These are MRI images with cuts through the superior ophthalmic veins. The right superior ophthalmic vein is larger than the left one but neither can be considered enlarged. Slide 20: Figure 7: On this image of the angiogram of the right internal carotid artery there is early filling of the cavernous sinus during the arterial phase (red arrow), Slide 21: Figure 8: A still image from the angiogram of the left internal carotid artery angiogram demonstrating early filling of the left cavernous sinus (red arrow) as well as the superior ophthalmic vein (blue arrow). Slide 24: Figure 9: These X-rays show the extensive coiling that was done to achieve adequate embolization of the patient's bilateral carotid cavernous fistulas. Slide 29: Figure 10: External photos of the patient's eyes prior to embolization. Slide 29: Figure 11: External photos of the patient's eyes after embolization show resolution of the corkscrew vessels, chemosis, and subconjunctival hemorrhage. Although it is difficult to appreciate from these images, her bilateral proptosis resolved as well.