Angle-closure glaucoma consequent to embolization of dural cavernous sinus fistula.

A 74-year-old woman presented with a 3-month history of right facial ache radiating to the right forehead and temporal region. Three weeks prior to presentation the left eye became red and irritated and binocular horizontal diplopia developed. CT demonstrated a dilated left superior ophthalmic vein. The patient was referred for neuroophthalmic evaluation. Medical and surgical history included hypertension, thrombocytopenia, and bilateral intracapsular cataract extractions (left eye, 1984; right eye, 1986). Visual acuity was normal but she had 3-mm left ptosis, 3.5-mm left proptosis, and a mild right afferent pupillary defect. A partial left abduction deficit was present. Slit-lamp evaluation revealed a slightly irregular left pupil and an intact vitreous face. Intraocular pressure was low on the left (TA = 6 OS). The third, fourth, and fifth cranial nerves were normal, as was the remainder of the neurologic examination. Cerebral angiography revealed a left dural cavernous sinus fistula with major feeders from the left external carotid artery (Fig. 1 A). Retrograde blood flow was demonstrated in both superior and inferior ophthalmic veins. Therapy was indicated because of the partial sixth nerve palsy and resultant diplopia. Avitene embolization of the distal left internal maxillary artery was accomplished with no immediate complications. Arteriography revealed complete occlusion of the feeders. Four hours after the procedure the patient experienced decreased vision in the left eye. Her left anterior chamber was flat with iridocorneal touch (Fig. 1 B). Fundus examination revealed large ciliochoroidal effusions in the left eye. MR imaging indicated blood flow rather than thrombus in the superior ophthalmic vein . The intact vitreous face occluded the previous peripheral iridectomies. The patient was treated with cycloplegics and repeated laser iridectomies, which immediately deepened her anterior chamber (Fig. 1 C). The choroidal effusions slowly resolved. Discussion