Choroidal detachment associated with spontaneous carotid cavernous fistula

A rare case is presented in which an 87-year-old woman with choroidal detachment was subsequently found to have an atypical carotid cavernous fistula (CCF). In this case, the intraocular pressure of the affected eye was higher than that of the contralateral eye. However, tonography showed no increased ocular pulse (amplitude of Schioetz reading) of the affected eye, which is characteristic of CCF. Choroidal detachment accompanied with CCF is thought to be a result of severe choroidal hemostasis and transudation caused by increased episcleral venous pressure. Furthermore, the enlarged perichoroidal space due to choroidal detachment reduced the ocular pulse of the affected eye. This combination may not be as rare as it has been previously reported. Attention to these symptoms can provide clues to the elucidation of the pathogenesis of choroidal detachment.     

Ophthalmoplegia in carotid cavernous sinus fistula.

The aetiology of ophthalmoplegia in 15 patients with carotid-cavernous sinus fistula is discussed, and the clinical findings are correlated with angiographic and orbital CT appearances. After closure of the fistula the majority of patients with generalised ophthalmoplegia recovered full ocular movements rapidly, while patients with an isolated abduction weakness required much longer to return to normal. Orbital CT studies showed enlarged extraocular muscles in the patients with generalised ophthalmoplegia but muscles of normal size in those with abduction failure alone. After closure of the fistula repeat CT studies of patients with enlarged extraocular muscles showed a diminution in muscle size. We suggest that generalised ophthalmoplegia in carotid cavernous sinus fistula is due to hypoxic, congested extraocular muscles. Isolated abduction weakness is due to a sixth nerve palsy, which probably occurs either in the cavernous sinus or more posteriorly near the inferior petrosal sinus. A combination of these 2 mechanisms may be found in some patients.     

Stereotactic gamma surgery combined with endovascular surgery for treatment of a spontaneous carotid cavernous sinus fistula

A Barrow type D carotid cavernous sinus fistula (CCF) with varices proved unamenable to endovascular surgery. Follow-up angiography showed a persistent CCF fed by a recurrent meningeal branching of the ophthalmic artery division with drainage into the ophthalmic vein, resulting in a secondary glaucoma and central retinal thrombosis. Stereotactic gamma surgery was successfully performed, and aggravation of the visual symptoms was prevented. The CCF disappeared and intraocular pressure normalized one month after the radiosurgery. Stereotactic radiosurgery is thus an appropriate treatment for cavernous sinus dural arteriovenous fistulas resistant to endovascular treatment, especially with small, slow flow target residual fistulas.     

Cataract extraction in spontaneous low-flow indirect dural bilateral carotid cavernous fistula

Background Cataract extraction in a carotid cavernous fistula can cause multiple intraoperative complications during surgery. Methods This was a case of bilateral, indirect, carotid, cavernous fistula, type D. The patient developed cataract and visual deterioration in both eyes. We present the difficulties we encountered during extracapsular cataract surgery on one of the eyes. Results Cataract extraction was done successfully. A self-sealing scleral incision was made. An intraocular lens was implanted. Conclusion Cataract extraction can be done in carotid cavernous fistulas; however, the surgeon should be extremely cautious during the surgery.     

直接外伤性颈动脉海绵窦瘘1例

一位14岁的马来男童发生车祸,身体多处受伤。患者因眶周血肿转交眼科,眼部检查正常,但发现右眼眼球突出,后来伴随眼压(intraocular pressure,IOP)增加。经血管造影诊断为直接型颈动脉海绵窦瘘(carotid cavernous sinus fistula,CCF)并给予栓塞治疗。     

Surgical transvenous embolization of spontaneous carotid cavernous sinus fistulas in two patients

BACKGROUND: Arteriovenous communications in which blood flows from meningeal branches of the internal and external carotid arteries into the venous circulation around and in the cavernous sinus are termed spontaneous (dural) carotid sinus cavernous fistulas. Due to their mostly low shunt volume they are rarely life threatening, but without treatment they may cause severe ocular complications like episcleral secondary glaucoma, central vein occlusion or exudative retinal detachment. Traditional therapy is the transarterial approach by an interventional neuroradiologist. If such an approach is not possible or unsuccessful a transvenous route has to be considered. PATIENTS AND METHODS: Two patients underwent anterior orbitotomy via sub brow incision or infraciliary incision with cannulation of the superior ophthalmic vein or the inferior ophthalmic vein and embolization of the cavernous sinus with platinum coils. RESULTS: Successful closure was achieved on angiography and normalisation of clinical symptoms after a short period of progressive venous congestion. CONCLUSIONS: For arteriovenous fistulas that cannot be embolized arterially the surgical transvenous orbital route may work as a method of second choice. When performed by an interdisciplinary team (orbital surgeon, interventionell neuroradiologist) it is a technically straightforward, effective and promising approach.     

Bilateral blindness in cavernous sinus thrombosis

An unusual case of bilateral blindness secondary to a cavernous sinus thrombosis is reported. A woman who had undergone reconstructive surgery after tumor resection of the floor of the mouth, was readmitted 1 month later with bilateral proptosis and signs of sepsis. There were no complaints of blurred vision. A CT-scan of the orbits demonstrated a bilateral cavernous sinus thrombosis (CST) secondary to an infection at the skull base behind the myocataneous flap. A few days later she became blind, due to bilateral central retinal artery occlusion and anterior ischemic optic neuropathy. The general critical condition improved with intensive AB treatment. The patient recovered well without neurological defects apart from her permanent bilateral blindness. There were no signs of tumor recurrence. To our knowledge, this is the first documented case of bilateral blindness in a patient suffering from CST.Presented at the Combined meeting of the Macula Society and Retina Society. Fluorescein conference, June 21, 1989, Boston.     

Ophthalmoscopic findings in spontaneous carotid cavernous fistula: An analysis of 20 patients

The pathophysiological influence of spontaneous carotid cavernous fistula (CCF) on retinal/orbital circulation is discussed. Of 20 patients, 1 case of papilloedema, 4 of choroidal detachment (CD), 2 of exudative retinal detachment (ERD) and 3 cases of central venous thrombosis (CVT) were seen, associations that on rarely reported in the literature. An elevation in the episcleral venous pressure was measured that was more than twice the normal, which explains the ophthalmoscopic findings.     

28例颈动脉海绵窦瘘影像诊断分析

目的探讨超声、CT、MRI和数字减影血管造影(DSA)等各种影像学检查在颈动脉海绵窦瘘(CCF)诊断中的价值。方法收集我院经DSA证实诊断的CCF共28例,所有患者行眼科标准化A／B超声、DSA检查,部分患者行彩色多普勒超声、CT及MRI检查中的一项或多项。结果超声检查可发现眼上静脉增粗与脉搏同周期的搏动等,并能检测血流频谱。CT和MRI检查可发现海绵窦扩大及异常表现。DSA检查显示CCF分为颈内动脉海绵窦段直接供血和颈动脉的供应硬膜的动脉供血,供血动脉包括：颈内动脉海绵窦区细小脑膜分支;颈外动脉来源的脑膜中动脉、副脑膜动脉、咽升动脉、圆孔动脉等;瘘血向眼静脉、岩下窦、海绵问窦、侧裂静脉及皮层引流等。结论超声、CT、MRI等影像学检查对CCF的诊断各有所长,联合应用多可做出正确的临床诊断;DSA是诊断CCF的“金标准”,可明确瘘的大小、瘘血来源及引流方向。（中华眼科杂志,2004,40：674-678)     

Etiology of carotid cavernous fistula in Japanese

Background  A carotid cavernous fistula (CCF) develops spontaneously or after trauma, and older publications suggest that the majority of CCF cases are caused by trauma. However, more recent reports question the prevalence of CCFs caused by trauma. Methods  The clinical records of 37 consecutive patients diagnosed with a CCF were reviewed. The disease etiology, patient demographics, anatomical classification, and clinical course were investigated. Results  The CCF was spontaneous in 30 patients, and was related to head or neck trauma in seven patients. The mean age of all patients was 65.8 ± 10.5 years, and 30 (81.1%) were women. Eight had diabetes and 14 had hypertension. The major signs and symptoms were congestion (86.4%), diplopia (81.1%), bruit (59.5%), and headaches/orbital pain (62.2%). Exophthalmos (67.6%) and elevated intraocular pressure (40.5%) were also frequently noted. In the Barrow classification, seven patients were classified as type A, four as type B, three as type C, and 20 as type D. The classification could not be established in three patients who did not undergo angiography. Of note, almost all patients had consulted an ophthalmologist before the diagnosis. Conclusion  Spontaneous/low-flow CCF is more prevalent than previously reported. The role of ophthalmologists is important because the majority of patients initially consult ophthalmologists, and the signs of low-flow CCF are subtle and may be overlooked.     

颈动脉海绵窦瘘介入治疗观察

目的探讨颈动脉海绵窦瘘介入治疗效果。方法对8眼(8例)颈动脉海绵窦瘘采用介入治疗并随访分析。结果7例经颈内动脉置入成功。1例经颈内动脉失败后，经眼上静脉置入成功。术后症状逐渐减轻，1～6月随访观察症状体征消失，瘘口消失，血管造影证实颈内动脉通畅，海绵窦不显影。结论颈动脉海绵窦瘘介入治疗安全性高，创伤轻，恢复快，并发症少。是一种较为理想的治疗方法。     

外伤性颈内动脉海绵窦瘘临床观察

目的 分析6例外伤性颈内动脉海绵窦瘘的临床特点。诊断，鉴别诊断和治疗，方法 回顾性地对外伤性颈内动脉海绵窦瘘的致伤原因，致伤物，就诊时间，临床特点，诊断，鉴别诊断及治疗效果进行讨论。结果 本文2例行股动脉插管可脱球囊栓塞术后第二天杂音消失，眼球突出明显好转。结论 早期诊断，及时治疗愈后较好。     

栓塞治疗颈动脉海绵窦瘘的良好效果(英文)

目的:报告外伤后颈动脉海绵窦瘘患者应用螺圈栓塞的成功经验。方法:连续病例。结果:两名颈动脉海绵窦瘘(CCF)患者成功接受了螺圈栓塞治疗。他们分别在机动车事故后2wk和4mo出现CCF的临床症状。一名患者视力良好但眼内压(IOP)升高,另一名则视力低下伴有临界眼内压。CCF的诊断均得到脑血管造影证实,采用螺圈栓塞治疗后两名患者视力恢复正常,在未用任何抗青光眼药物前提下眼压降至正常范围。CCF的症状诸如眼球突出,眼肌麻痹,结膜充血水肿,眼眶杂音及眼底改变也随之消失。结论:颈动脉海绵窦瘘宜早诊断和治疗以避免发生视力丧失严重并发症的发生,血管内栓塞是当代治疗选择。     

Spontaneous dural cavernous sinus fistula in a child

We describe the clinical course of a 9-year-old boy in whom a spontaneous dural cavernous sinus fistula developed. The patient initially presented with proptosis and conjunctival congestion believed to be caused by a cavernous sinus hemangioma and was prescribed oral prednisone. He subsequently developed pain, increased proptosis, and decreased vision. Emergent angiography revealed a dural cavernous sinus fistula, which was successfully embolized. This is the first case to our knowledge of a dural cavernous sinus fistula in a noninfant child that was treated successfully with embolization during angiography.     

Lower lid epiblepharon as the presenting feature of spontaneous dural carotid cavernous fistula in an Asian patient

Lower lid epiblepharon is a relatively common problem among young Asian patients. Occasionally, it may be secondary to underlying orbital pathology. We report a 33-year-old Chinese patient with a dural carotid cavernous fistula who presented with an ipsilateral lower lid epiblepharon in the absence of any other significant signs. After a recurrence following primary corrective lid surgery, she was investigated further because of mild ipsilateral proptosis. CT-scans of the orbit revealed an enlarged superior ophthalmic vein and a dural carotid cavernous fistula was confirmed on angiography. Subsequent embolisation of the fistula led to resolution of the proptosis as well as the epiblepharon. We believe that extension of orbital fat to the inferior tarsal border in Asian eyelids together with a poorly fixed anterior lamella contributes to the occurrence of epiblepharon when the Asian orbit becomes congested. The new onset of such features in the Asian patient should lead one to suspect underlying orbital pathology, even in the absence of other, more classic signs.     

颈动脉海绵窦瘘的眼部表现与血管内治疗

目的：分析颈动脉海棉窦瘘的眼部临床特点，评价血管内治疗的效果。方法：回顾分析126例经全脑血管造影证实为颈动脉海绵窦瘘患的病史、眼部表现、临床特点及进行的可脱性球囊栓塞治疗。结果：手术1次性栓塞成功112例(88．9％)，14例行2次栓塞。术后无并发症。98例视力较术前提高1～4行(国际标准视力表)。术后眼部淤血肿胀、眼球突出度均明显减轻或消失，眼球运动恢复正常，复视消失，视网膜出血吸收。眼部血管杂音全部消失，术后脑血管造影，瘘口均封闭。结论：对于颈动脉海绵窦瘘应及时治疗，尽快改善眼部淤血状态，以利于视功能恢复。血管内栓塞是目前治疗颈动脉海绵窦瘘最为理想的方法。