- A young male patient presented with mild blurring of vision and redness in the right eye, which was initially suspected to be glaucoma. However, further examination revealed proptosis, dilated episcleral vessels, and a bruit heard on auscultation of the orbit, leading to a provisional diagnosis of carotid cavernous fistula. Imaging including MRI/MRA and cerebral angiography confirmed the diagnosis. The patient was treated with endovascular embolization, which resolved his symptoms and signs including the intractable glaucoma. Carotid cavernous fistulas are rare but can be misdiagnosed if not considered, so a high index of suspicion is needed for

1. AN UNUSUAL CASE OF GLAUCOMA
DR. AAYUSH TANDON
M.S Ophthalmology

2. CASE
Presentation
A 21 year old male patient presented with
Mild blurring of vision in right eye
Redness in right eye
3 months
Scar Mark

3. Past History
•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
fractures.

4. Medical History:
No history of headache, hypertension or
diabetes.
Personal History:
Sleep, appetite,bowel and bladder habits unaltered.
General Examination:
•Conscious, oriented
•Averagely built and well nourished
•BP- 118/74 mm of Hg, Pulse- 84/min

5. Systemic Examination:
•CVS: S1S2 heard, no murmurs.
•Lungs: Equal air entry and symmetrical
expansion bilaterally.
•Abdomen: Soft, Non tender.
•Neurological Examination: Alert and oriented.

6. Ophthalmic Examination

7. Ophthalmic Examination

8. MANAGEMENT
• Patient underwent Perimetry – Visual Fields
were normal
• Timolol Maleate 0.5% e/d BD in right eye.
• Frequent follow up was advised for IOP
monitoring and to gauge treatment response.

9. 1st
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
treatment response

10. 2nd
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
angle
• No disc oedema seen on fundus examination

11. IOP still rising ???

12. • Taking in consideration proptosis, dilated
episcleral vessels and past history of trauma
further evaluation was done which revealed
significant findings.
1) On palpation, arterial pulsations were felt on
both sides
2) On auscultation of the orbit, bruit was heard
Provisional diagnosis of CAROTID CAVERNOUS
FISTULA was made

13. • Dorzolamide 2% e/d BD was started in the
right eye over and above Timolol and
Brimonidine e/d
• Timolol 0.5% eye drop BD started in the left
eye also
• Patient was advised further investigations to
confirm the diagnosis

14. COLOUR DOPPLER
Dilated and tortuous superior ophthalmic veins with
reversal of flow in both eyes

15. MAGNETIC RESONANCE IMAGING (MRI) BRAIN
AND ORBIT (CONTRAST STUDY) WITH MAGNETIC
RESONANCE ANGIOGRAPHY (MRA)
Congestion of both superior ophthalmic veins and
cavernous sinuses

16. Clinical diagnosis of
‘Carotid Cavernous Fistula’
was confirmed.

17. • 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.

18. TREATMENT
• Patient was treated by interventional
embolization by coiling of fistula.
• Patient followed up to us regurlarly after
embolization
• His signs and symptoms started reducing
gradually
• Anti glaucoma medication was gradually
tapered.
• IOP in both eyes came down to 18 mm of Hg

19. CAROTID CAVERNOUS
FISTULA

20. • Type of arteriovenous fistula
• Abnormal communication
between the internal or external
carotid arteries and the
cavernous sinus
Direct carotid-cavernous sinus fistulae
2 types1
Dural carotid-cavernous sinus fistulae

21. TYPES
(Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC, Tindall GT: Classification and treatment of
spontaneous carotid-cavernous sinus fistulas. J Neurosurg 62:248–256, 1985)

22. TYPES

23. OPHTHALMIC MANIFESTATIONS

24. OPHTHALMIC MANIFESTATIONS

25. GLAUCOMA IN CAROTID-CAVERNOUS FISTULA
Other Factors
•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

26. TREATMENT
“Completely occlude the fistula while preserving
the normal flow of blood through the ICA”
(I)Endovascular Intervention
(I) Trans arterial Embolization
(II) Trans venous Embolization
(II)Surgical Intervention
(III)Radiosurgical Intervention

27. Summary
– 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
time.

28. • 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
CONCLUSION

29. Our case was Rarest of rare
 Complete resolution of Intractable
glaucoma, proptosis and congestion
occurred after correct treatment
Life threatening complications could be
avoided
Why have we presented this case ?

30. REFERENCES
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,
pg 21–34.
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

31. REFERENCES
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.
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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.

32. THANK YOU

33. CAROTID CAVERNOUS FISTULA patient may
present with raised intraocular pressure and
the etiology may remained undiagnosed unless
thorough evaluation is done