A 33-year-old male presents with intermittent blurry vision and left eye pain for 3 months, and a left-sided orbital headache for 1 day. He reports getting punched in the left side of the head during an altercation a few months ago. The eye pain is worse with ocular movements and is associated with bilateral conjunctival injection and white/green discharge from the left eye.
The patient was seen at another emergency department 3 months prior for the same symptoms. He was then found to have left-sided proptosis, visual acuity 20/60 in the left eye, no fluorescein uptake, and a normal fundoscopic exam. The patient was instructed to follow up with ophthalmology but did not. The patient denies fevers, chills, dizziness, nausea, vomiting, and abdominal pain.
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Vitals: Unremarkable
General: Oriented to person, place, and time
Head: Atraumatic and normal
Eyes:
- Pupils equal, round, and reactive to light, extraocular movements normal, no chemosis bilaterally
- Conjunctival injection greater in the left eye than in the right, mild proptosis in the left eye, no drainage or discharge from left eye, normal visual fields
- No fluorescein uptake on Wood’s lamp exam
Visual acuity: Both eyes 20/25, Left 20/50, Right 20/32
Intraocular pressure: Right 13 mmHg, Left 34 mmHg
The rest of the exam is unremarkable.
Dilatation of the left ophthalmic vein
Carotid cavernous fistula
Normally, carotid-cavernous fistulas present shortly after trauma, but may not become symptomatic until weeks following the traumatic event. In addition, the elevated intraocular pressures, conjunctival injection, and mild proptosis prompt further investigation with advanced imaging. The computed tomography (CT) angiography of the head with intravenous contrast reveals a carotid-cavernous fistula centered at the level of the posterior genu of the left cavernous internal carotid artery with marked dilatation of the bilateral cavernous sinuses, left sphenoparietal sinus, and the left superior ophthalmic vein. Conventional angiography is the gold standard for diagnosis of a carotid-cavernous fistula, but it can be seen on CT/CT angiography or magnetic resonance imaging (MRI)/magnetic resonance angiogram (MRA) of head. Neurosurgery should be consulted after the diagnosis, along with interventional radiology for cerebral angiography.
This patient was admitted to the neurosurgical service after successful coil embolization of the carotid-cavernous fistula by interventional radiology. He was discharged the next day with anti-platelet therapy.
Take-Home Points
- Make sure to do a complete ophthalmologic exam in a patient with a red, painful eye, including fluorescein stain and intraocular pressures.
- Obtain a complete history, including remote events. The history of assault is key to incorporating a carotid-cavernous fistula into the differential for this patient. Advanced imaging with CTA or MRA should be obtained in the emergency department when carotid-cavernous fistula is in the differential.
- McManus, NM., Offman, RP., et al. An Eye with a Heartbeat: Carotid Cavernous Fistula- Case Report. Jem-Journal. 2018 Sept;55(3):PE75-E76. PMID: 29941376
- Chen, CC., Chang, PC., et al. CT angiography and MR angiography in the evaluation of carotid cavernous sinus fistula prior to embolization: a comparison of techniques. AJNR Am J Nueroradiol. 2005 Oct;26(9):2349-56. PMID: 16219844
- Gemmete, JJ., Chaudhary N., et al. Treatment of carotid cavernous fistulas. Curr Treat Options Neurol. 2010 Jan;12(1):43-53. PMID: 20842489
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