(BMJ)—An otherwise healthy 69-year-old man presented with a 1-day hx of R eye pain and blurred vision. He had no fever or recent trauma. Exam: vital signs stable; subconjunctival hemorrhage, chemosis, and proptosis. Neuro: R ophthalmoplegia. Labs WNL. What’s the dx?
Graves ophthalmopathy
Carotid-cavernous fistula
Orbital lymphoma
Orbital cellulitis
Acute angle closure glaucoma
You are correct. Cerebral angiography revealed R internal carotid artery aneurysm rupture with direct-type carotid-cavernous fistula (CCF). CCF is an abnormal vascular shunt between the carotid artery and the cavernous sinus. The retrograde blood flow from the cavernous sinus results in an engorged superior ophthalmic vein and leads to the classic triad of exophthalmos, ocular bruit, and episcleral congestion. Most direct CCFs are symptomatic, and tx with endovascular obliteration should be considered.

Orbital cellulitis commonly presents with eyelid redness and swelling, eye discharge, fever, and leukocytosis. Patients with orbital lymphoma typically demonstrate “salmon‐colored lesions” of swollen conjunctiva and a palpable mass in the orbit. CT scanning may reveal an orbital mass. In Graves ophthalmopathy, eye involvement is frequently bilateral and symmetric.

Emergency Medicine Journal 2021;38:494-510