Glaucoma Management in Carotid Cavernous Fistula

Area of Science:

• Ophthalmology
• Neuroradiology
• Vascular Surgery

Background:

• Carotid cavernous fistulas (CCF) are abnormal connections between the carotid artery and the cavernous sinus, often presenting with ocular manifestations.
• Ophthalmologists play a crucial role in diagnosing and managing CCF when ocular symptoms are present.
• This case highlights a patient initially treated for glaucoma who was later diagnosed with CCF.

Observation:

• A 73-year-old female presented with a 6-month history of intermittent diplopia, bilateral proptosis, and conjunctival chemosis.
• Despite prior glaucoma treatment and laser iridotomy, she had uncontrolled intraocular pressure (IOP), particularly in the left eye (34 mm Hg).
• Ophthalmological examination revealed visual field defects and elevated IOP, prompting further investigation.

Findings:

• MRI angiography confirmed a Cognard grade 2 carotid cavernous fistula.
• Transarterial embolization successfully closed the CCF.
• Post-procedure, the patient experienced significant improvement in diplopia, proptosis, and conjunctival chemosis.
• Intraocular pressure normalized to 12 mm Hg (OD) and 19 mm Hg (OS) within one week.

Implications:

• Carotid cavernous fistulas can present with symptoms mimicking glaucoma, necessitating a high index of suspicion.
• Ophthalmologists must consider CCF in the differential diagnosis of unexplained elevated IOP and ocular motility disturbances.
• Timely diagnosis with advanced imaging like MRI angiography and multidisciplinary treatment, including embolization, is critical for preventing vision loss and managing ocular complications.