Transcript Grand Rounds - University of Louisville Ophthalmology

Grand Rounds Conference
Reema Syed, MBBS
University of Louisville
Department of Ophthalmology and Visual Sciences
October 16, 2015
History
CC: “when will I see?”
HPI: 56 yr old white male, unhelmeted
motorcyclist, involved in MVA, sustained
multiple injuries, intubated on arrival in ED.
 Ophthalmology consulted when patient
extubated 10 days later and complained he
couldn’t see
History
POH, PMH: unremarkable
Medications: none
Allergies: none
Hospital Course

Extensive polytrauma: facial and orbital fractures,
bilateral pubic and femur fractures, right humerus and
sacral fractures

Liver laceration, intraperitoneal bladder rupture

Underwent exploratory laparotomy and coiling of left
internal iliac artery, intramedullary nails for the femur
fractures, open reduction and internal fixation for right
humeral fracture
Exam
OD
BCVA:
Pupils:
IOP:
OS
NLP
20/200
3 mm non-reactive 3 to 2 mm
+ rAPD
12 mmHg
11 mmHg
Exam
Exam
PLE:
OD
OS
E/L/L
Conj/sclera
Cornea
AC
Lens
Vitreous
proptosis
complete ptosis
temporal chemosis OU
clear OU
formed OU
wnl OU
clear OU
Exam
Dilated fundus exam
Optic nerves sharp and pink OU
Small peri-papillary flame heme OU
MVP wnl OU
CT Face without contrast
CT Face without contrast
CT Face without contrast
Assessment/Plan

56 year old male with no vision OD, low vision OS + CN III
and CN VI palsy OS s/p motorcycle accident with multiple
orbital and long bone fractures

Differentials:
 Traumatic orbital apex syndrome
 Carotid cavernous fistula
 Traumatic optic neuropathy
 Orbital compartment syndrome
 Posterior ischemic optic neuropathy

Plan: CTA
CTA
Angiogram
Right ICA
Left ICA
Treatment

Coiling of bilateral ICA dissections and
embolization of left CC fistula
1 month Follow-up
BCVA: LP OD, 20/25 OS (-1.00+0.50x180)
 IOP 13, 12

CC Fistula

Abnormal communication between venous
cavernous sinus and carotid arterial system
Carotid Cavernous Sinus Fistula

Classification:
 Etiology: traumatic vs spontaneous
 Hemodynamic: high vs low flow
 Arterial architecture: direct or indirect
 Barrow classification
 Type A:
direct (80% trauma)
 Type B-D: indirect (meningeal arteries)
CC Fistula

Presentation:
 Classic triad: exophthalmos, bruit,
conjunctival chemosis
 venous
congestion of eyelids/conj/episclera
 CN palsies III, IV, VI
 elevated IOP (from increased episcleral
venous pressure)
CC Fistula

Treatment
- endovascular approach
 coil embolization
 transarterial
 transvenous (preferred tx for indirect)
 anterior approach through superior
ophthalmic vein

Retrospective review of 40 CCF patients

Most common presentations: proptosis (65%), binocular
diplopia (60%), redness (57.5%), and chemosis (47.5%)

No radiologic evidence of enlarged SOV in 26% of patients on
noninvasive imaging and in 8% on catheter angiography

To avoid inappropriate interventions or delays in diagnosis and
care, it is important to recognize that CCF can exist without
SOV enlargement.
Traumatic Optic Neuropathy

Indirect: transmitted shock from an orbital
impact to the intracanalicular portion of optic
nerve

Direct: penetrating injury, bony fragments in the
optic canal, orbital hemorrhage and optic nerve
sheath hematoma causing compression of optic
nerve
Indirect Traumatic Optic Neuropathy

High dose steroids – extrapolated from the National
Acute Spinal Cord Injury Study II

CRASH study (Corticosteroid Randomization After Significant
Head injury) - increased relative risk of death in patients
given high dose steroids after significant head injury

The International Optic Nerve Trauma Study – no
difference in final visual acuity between patients that
were observed compared with those given steroids
• 48 year M, unhelmeted motorcyclist involved
in MVA
• Fracture of left sphenoid sinus involving the
optic canal
• Vision improved from LP to 20/40 in 6 weeks
References




BCSC Neuro-ophthalmology
BCSC orbit, eyelids and lacrimal system
Moron F, Klucznik R, et al. Endovascular treatment of high-flow carotid
cavernous fistulas by stent-assisted coil placement. AJNR Am J Neuroradiol
2005;26:1399-1404.
Korkmazer B, Kocak B, et al. Endovascular treatment of carotid cavernous
sinus fistula: A systematic review. World J Radiol 2013;5(4):143-155
Thank you