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Unilateral, indirect spontaneous caroticocavernous fistula with bilateral abduction palsy

Indian Journal of Ophthalmology
Medknow Publications
Publication Date
DOI: 10.4103/0301-4738.82019
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Dear Editor, Caroticocavernous fistulas (CCFs) are abnormal connections between the carotid artery and the cavernous sinus.[1] These lesions may be classified according to several criteria: angiographically, as direct or dural; pathogenetically, as spontaneous or traumatic; and hemodynamically, as high flow and low flow.[2] Angiographically, type A fistulas are direct shunts between the internal carotid artery (ICA) and cavernous sinus. Type B, C, and D are dural shunts. Type B fistulas are between meningeal branches of the ICA and cavernous sinus; type C fistulas are between meningeal branches of the external carotid artery (ECA) and cavernous sinus; andtype D fistulas are between meningeal branches of both ECA and ICA and cavernous sinus [Fig. 1].[2] Spontaneous CCFs are usually indirect and idiopathic; spontaneous closure is possible and mostly seen in women older than 50 years and hypertension is the most associated disease with fistulas.[13] CCFs can be unilateral or bilateral. A unilateral CCF can cause bilateral eye symptoms, whereas a bilateral CCF can present with unilateral eye symptoms. Signs like proptosis, chemosis, and nerve palsies are mostly seen at the side of the fistula.[4] This article reports bilateral abducens palsies with a unilateral spontaneous indirect CCF, which is very rare. Figure 1 Angiographical classification of the carotid–cavernous fistula. ιnternal carotid artery; external carotid artery A 76-year-old woman was admitted to our clinic with complaints of bilateral protruding eyes, redness, and inappropriate eye movements for 2 months. She had been treated at another hospital with intravenous and oral antibiotics and steroids, but symptoms and signs did not improve. There was no history of trauma. Ophthalmic examination showed corrected visual acuity of 20/50 (on Snellen's chart) in the right and 20/100 in the left eye. There was bilateral proptosis and abduction limitation. At the biomicroscopic examination, conjunctival hy

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