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Red Eye and Choroidal Detachment in an Older Woman

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 64-year-old woman presented with diminution of vision, progressive redness, and dull aching pain in the right eye for 8 months. There was no history of trauma. Her medical history was unremarkable.

On examination, her best-corrected visual acuity measured 20/60 OD and 20/25 OS. The anterior segment showed dilated corkscrew conjunctival vessels (Figure 1), a shallow anterior chamber in the right eye, and nuclear cataract in both eyes. Pupillary reaction and color vision were normal in both eyes. Intraocular pressure was 16 mm Hg by Goldman applanation tonometry in both eyes. Gonioscopy revealed an occludable angle in the right eye without evidence of blood in the Schlemm canal. Both eyes’ extraocular movements were full and free in all directions of gaze. Dilated fundus examination showed a clear vitreous cavity in the right eye, 360° serous choroidal detachment partly obscuring the optic disc nasally (Figure 1), and the fundus in the left eye was unremarkable.

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Low-flow carotid cavernous fistula

D. Magnetic resonance imaging with magnetic resonance angiography or digital subtraction angiography

Carotid cavernous fistula (CCF) is an abnormal communication between the carotid artery and its branches and the cavernous sinus (CS), causing high-pressure arterial blood flow within the low-pressure veins, sinuses, and cavernous sinus.1 Direct CCF (high-flow fistula) is a direct connection between the intracavernous segment of the internal carotid artery and CS, commonly caused by head injury. Presentations include blurred vision, pulsatile proptosis, orbital bruit, chemosis, corkscrew conjunctival vessels, raised intraocular pressure, and nerve palsies.1,2

Indirect CCF (low-flow fistula) involves 1 or more meningeal branches of the internal carotid artery, external carotid artery, or both, communicating with CS. It can be spontaneous, associated with hypertension, older age, and female gender. Often asymptomatic, the most common presentation is conjunctival congestion misdiagnosed as conjunctivitis.1,3 This patient had corkscrew vessels with serous choroidal detachment (CD) and normal intraocular pressure.4,5 This may occur due to increased orbital venous pressure and intracapillary pressure in the choroid, resulting in transudation into the suprachoroidal space.5

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Article Information

Corresponding Author: Muna Bhende, MS, Shri Bhagwan Mahavir Vitreoretinal Service, Medical Research Foundation, Nethralaya, 41 College Rd, Nungambakkam, Chennai 600006, Tamil Nadu, India (drmuna@snmail.org).

Published Online: May 18, 2023. doi:10.1001/jamaophthalmol.2023.1513

Correction: This article was corrected on June 8, 2023, to delete the corresponding author’s middle initial.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information. We also thank Ambika Selvakumar, MD, Department of Neuro-Ophthalmology, Medical Research Foundation, and Swatee Halbe, MD, Apollo Specialty Hospitals.

Henderson  AD , Miller  NR .  Carotid-cavernous fistula: current concepts in aetiology, investigation, and management.   Eye (Lond). 2018;32(2):164-172. doi:10.1038/eye.2017.240PubMedGoogle ScholarCrossref
Barrow  DL , Spector  RH , Braun  IF , Landman  JA , Tindall  SC , Tindall  GT .  Classification and treatment of spontaneous carotid-cavernous sinus fistulas.   J Neurosurg. 1985;62(2):248-256. doi:10.3171/jns.1985.62.2.0248PubMedGoogle ScholarCrossref
Slusher  MM , Lennington  BR , Weaver  RG , Davis  CHJ  Jr .  Ophthalmic findings in dural arteriovenous shunts.   Ophthalmology. 1979;86(5):720-731. doi:10.1016/S0161-6420(79)35454-9PubMedGoogle ScholarCrossref
Berk  AT , Ada  E , Kir  E , Saatci  AO .  Choroidal detachment associated with direct spontaneous carotid-cavernous sinus fistula.   Ophthalmologica. 1997;211(1):53-55. doi:10.1159/000310875PubMedGoogle ScholarCrossref
Komiyama  M , Nishikawa  M , Yasui  T .  Choroidal detachment and dural carotid-cavernous sinus fistula–case report.   Neurol Med Chir (Tokyo). 1997;37(6):459-463. doi:10.2176/nmc.37.459PubMedGoogle ScholarCrossref
Texakalidis  P , Tzoumas  A , Xenos  D , Rivet  DJ , Reavey-Cantwell  J .  Carotid cavernous fistula (CCF) treatment approaches: a systematic literature review and meta-analysis of transarterial and transvenous embolization for direct and indirect CCFs.   Clin Neurol Neurosurg. 2021;204:106601. doi:10.1016/j.clineuro.2021.106601PubMedGoogle ScholarCrossref
Jamison  A , Siddiqui  A , Lockington  D .  Persistent red eye unresponsive to topical treatment.   JAMA Ophthalmol. 2021;139(1):119-120. doi:10.1001/jamaophthalmol.2020.4062PubMedGoogle ScholarCrossref
Gemmete  JJ , Chaudhary  N , Pandey  A , Ansari  S .  Treatment of carotid cavernous fistulas.   Curr Treat Options Neurol. 2010;12(1):43-53. doi:10.1007/s11940-009-0051-3PubMedGoogle ScholarCrossref
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Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
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