Carotid-Cavernous Fistula: Hemodynamic Dysfunction after Shingles? A Case Report and Review Literature

The patient, a 67-year-old female, presented with esotropia, diplopia, and eye redness, as seen in Figure 1. The diplopia started two months prior to the initial visit while the eye started to crossed in. The patient also complained of severe daily headaches along with ringing in her ears. She believes the symptoms started while she was recovering from shingles on her right side of the forehead. Prior MRI imaging was reported to be unremarkable. The patient was referred to neuro-ophthalmology service with possible diagnosis of thyroid eye disease given the red eye and esotropia. Patient had no history of other medical conditions except shingles in trigeminal distribution that occurred about 4-6 weeks before the onset of her symptoms. Central VA was recorded to be unaffected at 20/20 in both eyes with correction. On sensorimotor exam, there was severe horizontal diplopia at the primary, increasing in left, and right gazes due to bilateral VI nerve palsy. Intraocular pressure testing 22mmHg right eye and 19mmHg left eye, indicating ocular hypertension in the right eye. She had corkscrew blood vessels in both eyes. Optical coherence tomography (OCT) revealed normal retinal nerve fiber layer (RNFL) thickness in both eyes.