Cardovascular , respiratory, abdominal and neurological examination
Iop on presentation was ---- Patient did not follow up for a month but continued to use timolol eye drop in the right eye
But he didnot follow up and consulted multiple ophthalmologists who gave him similar anti-glaucoma medication . He finally followed up after 2 month with increase in signs and symptoms
Inspite of being on 2 drops in the right eye patients iop had raised to 34.5 mm of hg …Left eye also showed a rise in intraocular pressure of 24.4 mm of hg
Colour Doppler was done and it showed
MRI brain and orbit (contrast study )with MRA was done and it showed
This is the anatomical classification CCF can be further classified according to the vessels involved .
Type A is a direct / high volume fistula Type B,C,D are indirect / low volume fistula
Some of these manisfestations are seen in extreme cases of CCF specially Direct / High volume fistula
Other factors which may lead to raised iop are
Basic principal of treatment is to Three modalities to achive this goal are Endovascular interventional is is the most widely used technique
Our case was Complete resolution of glaucoma was seen after correct treatment
An Unusual case of Glaucoma
AN UNUSUAL CASE OF GLAUCOMA
DR. AAYUSH TANDON
A 21 year old male patient presented with
Mild blurring of vision in right eye
Redness in right eye
•Road traffic accident one year back,
resulting in fracture of right maxillary bone
& right zygomatic bone.
•Operated by maxillo-facial surgeon by
applying titanium plates for fixation of
No history of headache, hypertension or
Sleep, appetite,bowel and bladder habits unaltered.
•Averagely built and well nourished
•BP- 118/74 mm of Hg, Pulse- 84/min
•CVS: S1S2 heard, no murmurs.
•Lungs: Equal air entry and symmetrical
•Abdomen: Soft, Non tender.
•Neurological Examination: Alert and oriented.
• Patient underwent Perimetry – Visual Fields
• Timolol Maleate 0.5% e/d BD in right eye.
• Frequent follow up was advised for IOP
monitoring and to gauge treatment response.
FOLLOW UP (1 Month)
• Visual acuity remined the same in both eyes
• Dilated and tortous episcleral veins were seen in the RE
• No disc odema was seen on fundus examination
• Perimetry was repeated - Fields were still normal
• Brimonidine 0.2% e/d BD started in the right eye over
and above timolol 0.5% e/d to control the IOP
• Patient was advised frequent follow to gauge the
FOLLOW UP (3 months)
• Mild proptosis seen in both eyes (R>>L)
• More dilated episcleral vessels seen in the right eye
• Gonioscopy was repeated – Both eyes showed open
• No disc oedema seen on fundus examination
• Taking in consideration proptosis, dilated
episcleral vessels and past history of trauma
further evaluation was done which revealed
1) On palpation, arterial pulsations were felt on
2) On auscultation of the orbit, bruit was heard
Provisional diagnosis of CAROTID CAVERNOUS
FISTULA was made
• Dorzolamide 2% e/d BD was started in the
right eye over and above Timolol and
• Timolol 0.5% eye drop BD started in the left
• Patient was advised further investigations to
confirm the diagnosis
Dilated and tortuous superior ophthalmic veins with
reversal of flow in both eyes
MAGNETIC RESONANCE IMAGING (MRI) BRAIN
AND ORBIT (CONTRAST STUDY) WITH MAGNETIC
RESONANCE ANGIOGRAPHY (MRA)
Congestion of both superior ophthalmic veins and
Clinical diagnosis of
‘Carotid Cavernous Fistula’
• Patient was referred to higher centre for
further management to be done by
Neurologist and Interventional Radiologist
• He was advised to get a Cerebral Angiography
(GOLD STANDARD) done to know to exact type
and location of the fistula.
• Patient was treated by interventional
embolization by coiling of fistula.
• Patient followed up to us regurlarly after
• His signs and symptoms started reducing
• Anti glaucoma medication was gradually
• IOP in both eyes came down to 18 mm of Hg
• Type of arteriovenous fistula
• Abnormal communication
between the internal or external
carotid arteries and the
Direct carotid-cavernous sinus fistulae
Dural carotid-cavernous sinus fistulae
GLAUCOMA IN CAROTID-CAVERNOUS FISTULA
•Elevation of orbital pressure secondary to venous
stasis and edema
•Anterior segment neovascularization
•In extreme cases Secondary angle closure occurs
due to congestion of the choroid and ciliary body
and a forward shift of iris diaphragm
“Completely occlude the fistula while preserving
the normal flow of blood through the ICA”
(I) Trans arterial Embolization
(II) Trans venous Embolization
– CAROTID CAVERNOUS FISTULA occurs in just 0.2%
of patients with cranio-cerebral trauma
– Commonly seen in young male patients
– Bilateral involvement is seen in 1% – 2% of patients
with post traumatic fistulas.
- Life threatening sequelae (Intracranial
hemorrhage, SAH etc) if not diagnosed and treated in
• A patient having CAROTID CAVERNOUS FISTULA may rarely
present to an OPHTHALMOLOGIST.
• Because the symptoms and signs of a Carotid Cavernous
Fistula often are mild in the initial stages (specially with
Indirect/Dural fistulas), this lesion is difficult to diagnose
and is often misdiagnosed as chronic conjunctivitis,
blepharoconjunctivitis or POAG
• Therefore a high index of suspicion is required for the
correct diagnosis and management
Our case was Rarest of rare
Complete resolution of Intractable
glaucoma, proptosis and congestion
occurred after correct treatment
Life threatening complications could be
Why have we presented this case ?
1. Jason A , Hannah G, Sande P, Philip M. Carotid-cavernous fistulas.
Neurosurg Focus. 32 (5):E9, 2012, 314-23.
2. Borba LAB, Al-Mefty O: Normal anatomy of the cavernous sinus, in
Eisenberg MB, Al-Mefty O (eds): The Cavernous Sinus: A
Comprehensive Text. Philadelphia: Lippincott Williams & Wilkins, 2000,
3. Pedersen RA, Troost BT, Schramm VL: Carotid-cavernous sinus fistula
after external ethmoid-sphenoid surgery. Clinical course and
management. Arch Otolaryngol 107:307–309,1981.
4. Isamat F, Twose J, Conesa G: Surgical management of cavernous-
carotid fistulas, in Eisenberg MB, Al-Mefty O (eds): The Cavernous
Sinus: a Comprehensive Text. Philadelphia:Lippincott Williams &
Wilkins, 2000, pp 201–208.
5. Hirai T, Korogi Y, Goto K, Ogata N, Sakamoto Y, Takahashi M: Carotid-
cavernous sinus fistula and aneurysmal rupture associated with
6. De Keizer R: Carotid-cavernous and orbital arteriovenous fistulas:
ocular features, diagnostic and hemodynamic considerations in relation
to visual impairment and morbidity. Orbit; 22:121–142, 2003.
7. Lewis AI, Tomsick TA, Tew JM Jr: Management of 100 consecutive
direct carotid-cavernous fistulas: results of treatment with detachable
balloons. Neurosurgery; 36:239–245, 1995.
8. Schroth G, Lovblad O, Ozdoba C, Remonda L. Non-traumatic
neurological emergencies: emergency neuroradiological interventions.
Eur Radiol 2002;12:1648–1662.
9. Uchino A, Hasuo K, Matsumoto S, Masuda K. MRI of dural carotid-
cavernous fistulas. Comparisons with postcontrast CT. Clin Imaging.
10. Elster AD, Chen MY, Richardson DN, Yeatts PR. Dilated intercavernous
sinuses: an MR sign of carotid-cavernous and carotid-dural fistulas.
AJNR Am J Neuroradiol. Jul-Aug 1991;12(4):641-5.