A 65-year-old woman presents with the sudden onset of an inability to open her left eye (see photo below). She has noted "noises in her head" since the onset of her illness.
Your exam of the left eye reveals ptosis and proptosis. When you elevate the lid, her eye is deviated down and out. A systolic bruit is audible over the globe and overlying frontal bone.
What is your diagnosis, what test(s) would you order to confirm your suspicions, and what treatment, if any, do you recommend?
DIAGNOSIS: Carotid cavernous sinus fistula.
Usually do to trauma, these fistulas produce proptosis, diploplia, glaucoma, and corkscrew, arterialized conjunctival vessels. Cranial nerves transversing the sinus (III, IV, V, VI) can be compromised. A bruit heard over the orbit - often heard by the patient - is a valuable diagnostic clue. Imaging shows a dilated orbital superior ophthalmic vein and intravascular embolization is the treatment of choice. The differential diagnosis includes indirect fistulas or dural arteriovenous malformations which are more likely to occur spontaneously, especially in older women; the signs are more subtle and frequently the diagnosis is missed.