Evisceration and ocular prosthetic implantation following endovascular coiling for the management of endophthalmitis in a long-standing post-traumatic unilateral carotid-cavernous fistula: A case report and review of the literature

Abstract

Carotid-cavernous fistula (CCF) is a rare condition involving an abnormal communication between the carotid artery and the cavernous sinus. We present a unique case of posttraumatic unilateral CCF initially misdiagnosed as a corneal melt with iris prolapse and orbital cellulitis. The patient, a 25-year-old male, experienced swelling, bleeding, and sudden vision loss in the affected eye following a fall. Imaging confirmed a direct CCF, and the patient underwent endovascular coiling, evisceration, and prosthetic replacement. Partial loss of levator palpebrae superioris muscle function was observed postprocedure. This case underscores the diagnostic challenge of CCF and highlights the significance of early and accurate diagnosis for appropriate management.

Keywords: Carotid-cavernous fistula; endovascular procedures; eye injuries; orbital cellulitis.

Figure 1

(a) Coronal noncontrast computed tomography scan obtained at an external facility demonstrating right proptosis, thickened orbital muscles, periorbital muscle stranding, and a prominent superior ophthalmic vein (SOV). (b) Axial T2-weighted image at the orbital level revealing severe axial proptosis, tenting of the eyeball, stretching of the optic nerve with a pyramidal shape, and intraocular nodular T2 hypointense lesions, suggestive of endophthalmitis, with a possibility of associated retinal detachment. (c) Axial T1-weighted image at a higher level than the T2-weighted image showing the dirty appearance of the periorbital fat indicative of infection, and the sinuous hypointensity coursing medially over the optic nerve near the globe representing the dilated SOV with a flow void. No evidence of intracranial extension of the infection is observed

Figure 2

Clinical images of the patient at various time points. (a) At presentation. (b) After 6 days of endovascular coiling. (c) After evisceration, postoperative day 1. (d) With customized ocular prosthesis implant after 1 month

Figure 3

Images from the cerebral angiogram depicting pre- and post-embolization/coiling status of the carotid-cavernous fistula (CCF). (a) Arterial phase image demonstrating the direct communication (white arrow) between the cavernous segment of the internal carotid artery (ICA) and the cavernous sinus (white asterisk). (b) Early venous phase image showing filling of the superior ophthalmic vein (SOV) (white arrow) and other orbital veins with flow away from the cavernous sinus, indicating increased pressure and proptosis due to the direct fistula. (c) Unsubtracted image during coil deployment (white asterisk) in the cavernous sinus to interrupt the ICA-CS communication. (d) Check angiogram postcoiling, demonstrating complete closure of the CCF with no flow to the cavernous sinus or filling of the SOV