Case report

Cataract surgery and preexisting bilateral carotid cavernous fistula

Dowlut, Mohammad MB CHB*; Quinlan, Mike FRCOphth; Barry, John S. FRCOphth

Author Information
Journal of Cataract and Refractive Surgery Online Case Reports: June 2013 - Volume 1 - Issue 1 - p e17-e18
doi: 10.1016/j.jcro.2013.06.003
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We describe the surgical dilemma of cataract surgery in a patient with coexisting bilateral carotid cavernous fistula (CCF).


A 78-year-old woman presented with a 1-week history of horizontal binocular diplopia secondary to left-sided sixth cranial nerve palsy. Bilateral corkscrew episcleral vessels (Figure 1), pulsatile elevated intraocular pressures (IOPs) with open angles (Shaffer grade 2–3) controlled with g.timolol 0.25%, and mild nuclear cataracts were present. Bilateral indirect CCFs were diagnosed, confirmed on magnetic resonance angiography secondary to uncontrolled hypertension (which was managed medically).

Figure 1.
Figure 1.:
Corkscrew episcleral vessels and dense cataract of both eyes. Top: Right eye. Bottom: Left eye.

Six months later, the patient presented with markedly reduced corrected distance visual acuity (CDVA) of counting fingers bilaterally. Examination revealed shallow anterior chambers (Shaffer grade 1–2), dense nuclear cataracts, and no intraocular pathology on B-scan ultrasonography.

After consulting further with interventional neuroradiology, CCF embolization was successfully performed with decreased episcleral vascularity. Sequential bilateral cataract surgery under local anesthesia was subsequently carried out with meticulous wound construction to maintain anterior chamber stability. The final CDVA was 6/12 in the right eye (initially complicated by cystoid macula edema) and 6/9 in the left eye. The sixth nerve palsy had fully resolved.


Carotid cavernous fistulae (direct and indirect) are abnormal communications between the carotid arterial system and the cavernous sinus. Patients with CCFs can present with blurred vision, conjunctival chemosis, external ophthalmoplegia, proptosis, or high IOP.1,2

Anecdotal evidence of outcomes following cataract surgery in patients with unilateral CCF suggests intraoperative bleeding can occur from iris vessels, resulting in a difficult view of the anterior chamber during surgery.1,3 There is theoretically an increased risk for suprachoroidal hemorrhage. A shallow anterior chamber could be further exacerbated by raised choroidal venous pressure in untreated CCF.

Rapid cataract maturation with phacomorphic narrowing of anterior chambers (with the risk for acute angle closure) represents a significant management problem in cataract surgery, particularly with increased hemorrhagic risks. We are not aware of a hypothesis that explains rapid worsening of cataracts due to CCF. This may have been coincidental in our case.

Meticulous wound construction may have helped to reduce the risk for intraocular hemorrhage by providing a “closed environment” with a stable anterior chamber.3,4 The multidisciplinary approach to patient management may have reduced the risk for hemorrhagic complications, although informed consent is imperative as CCF embolization can have serious complications.5


1. Chaudhry IA, Elkhamry SM, Al-Rashed W, Bosley TM. Carotid cavernous fistula: ophthalmological implications. Middle East Afr J Ophthalmol 2009; 16:57-63. Available at: Accessed May 21, 2013.
2. Yu J-K, Hwang G, Sheen SH, Cho Y-J. Bilateral visual loss as a sole manifestation complicating carotid cavernous fistula. J Korean Neurosurg Soc 2011; 49:229-230. Available at: Accessed May 21, 2013.
3. Jethani J, Ajani JK. Cataract extraction in spontaneous low-flow indirect dural bilateral carotid cavernous fistula. Graefes Arch Clin Exp Ophthalmol 2006; 244:404-406.
4. Ling R, Cole M, James C, Kamalarajah S, Foot B, Shaw S. Suprachoroidal haemorrhage complicating cataract surgery in the UK: epidemiology, clinical features, management, and outcomes. Br J Ophthalmol 2004; 88:478-480. Available at: Accessed May 21, 2013.
5. Kim DJ, Kim DI, Suh SH, Kim J, Lee SK, Kim EY, Chung TS. Results of transvenous embolization of cavernous dural arteriovenous fistula: a single-center experience with emphasis on complications and management. AJNR Am J Neuroradiol 2006; 27:2078-2082. Available at: Accessed May 21, 2013.
© 2013 by Lippincott Williams & Wilkins, Inc.
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