Dilated Episcleral Vessels from Carotid Cavernous Fistula

51 year white woman with a 6 months history of chronic right eye redness, periorbital swelling and progressive proptosis. She was seen by multiple providers and treated for dry eye and conjunctivitis. Her examination showed normal visual acuity, color vision and pupils. There was an intraocular pressure difference of 8 mmHg between right and left eye, with the right eye having the higher pressure. Extraocular movements were full. Right eye proptosis was noted. Fundus examination showed slight hyperemia of the right optic nerve head compared with the left. The retinal veins were mildly dilated in the right eye compared with the left. Catheter angiogram demonstrated a Borden type I Barrow type D carotid-cavernous fistula of the left cavernous sinus fed primarily by the bilateral internal carotid arteries, and draining through the left inferior petrosal sinus and across the intracavernous sinus into the right superior ophthalmic vein.