Carotid-Cavernous Fistula: Direct Type
A 35-year-old male suffered a motor vehicle accident. He visited our emergency room for right eye swelling starting 8 days after the accident. He had complete ptosis and moderate proptosis in his right eye (Fig. 24.1). Right external ophthalmoplegia was noted by assessing range of motion (Fig. 24.2). His vision was finger counting in the right eye and 6/6 in the left. Intraocular pressure was 28 mmHg in the right eye and 12 in the left. Slit lamp examination showed clear corneas and lenses, and a severely congested right conjunctiva with corkscrew vessels (Fig. 24.1). There was relative afferent pupillary defect (RAPD) observed in the right pupil. Fundoscopic examination revealed scattered dot hemorrhage and congested tortuous retinal veins in the right eye (Fig. 24.3). Goldmann perimetry showed a superior altitudinal defect in the right eye (Fig. 24.3). The patient was treated with methylprednisolone 250 mg q6h intravenously under the impression of right traumatic optic neuropathy. A CT of the right orbit revealed an enlarged superior ophthalmic vein (Fig. 24.4), which is compatible with carotid-cavernous fistula (CCF). Carotid angiography showed a direct-type CCF on the right side (Fig. 24.5) and the patient received embolization immediately. His vision improved to 6/20 2 days after embolization and recovered to 6/6 1 year later. Eye swelling and external ophthalmoplegia also resolved rapidly after the embolization.
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