CAROTID CAVERNOUS FISTULA- OPHTHALMIC MANIFESTATION OF THE INTERDISCIPLINARY DISEASE. CASE REPORT.

To report a case of a direct carotid-cavernous fistula (CCF) in patient admitted to the hospital over ocular tumor suspicion and  to present diagnostic pathway and interdisciplinary approach to treatment of this condition.

Department of Ophthalmology, Medical University Centre of Medical University of Silesia in Katowice.

78-year-old patient was admitted to the hospital over ocular tumor suspicion. She reported exophthalmos of the right eye from 3 months and decreased visual acuity of this eye from 2 months, she denied any head trauma. During admission she presented visual acuity of the right eye 0,1 and of the left eye 0,6 in Snellen charts, IOP RE 27 mmHg, LE 17mmHg. In the right eye we noted pulsating proptosis, conjunctival chemosis and hyperaemia. In fundoscopy we found detachment of choroid in all quadrants and disseminated haemorrhages in the retina. Ultrasound was performed confirming choroidal detachment in all quadrants and revealed hypoechogenic space behind right eyeball. Doppler US showed dilated superior ophthalmic vein (SOV) and increased, arterialised vascular flow. Magnetic resonance of the head and orbit showed exophthalmos of the right eyeball, enlargement of extraocular muscles and dilated right SOV.  Because of high suspicion of CCF patient was referred to the Department of Interventional Radiology to perform digital subtraction angiography. This examination confirmed our diagnosis revealing right-sided direct CCF. Due to small size of fistula radiologists and ophthalmologists debated on subsequent treatment however because of the significant ophthalmic symptoms and potential sight loss embolisation of CCF was planned. Procedure was done without complications and partial embolisation was achieved. Unfortunately on the next day patient’s general condition deteriorated and MR of head showed ischemic changes of the head of caudatus nucleus, anterior part of internal capsule and lentiform nucleus. Neurological consultation was done and treatment was applied.

Ophthalmic examination was done 2 months after embolisation. Visual acuity of the right eye improved to 0,6, IOP 18 mmHg. We noted only dilated scleral vessels and cataract. No proptosis was seen. However mental condition of patient got worse. She had troubles with memory and had disorientation to the time and place.

Carotid-cavernous fistula is a rare disease however it can be sight-threatening condition and should not be forgotten in our daily practice. Ophthalmologist is usually the first physician to encounter a patient with manifestations of the disease. Decision about treatment should be interdisciplinary and well thought as this procedure carry some complication risk which may exceed sight-threatening risk.