eMedicine Specialties > Ophthalmology > Orbit
Fistula, Carotid Cavernous: Treatment & Medication
Updated: Feb 27, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Exposure keratopathy may be treated with ocular lubricants, and, in severe cases, a tarsorrhaphy may be needed.
- Glaucoma may require treatment with aqueous suppressants and hyperosmotic agents.
- Laser peripheral iridectomy may be performed to eliminate the contribution of pupillary block, and cycloplegic agents may be used to encourage a posterior shift of the iris-lens diaphragm.
- Laser iridoplasty or goniosynechialysis may help further in opening the angle.
- Proliferative retinopathy and neovascular glaucoma may require panretinal photocoagulation.
Surgical Care
- The optimal treatment of a direct carotid-cavernous sinus fistula is closure of the abnormal arteriovenous communication with preservation of internal carotid artery patency. Techniques for achieving this result include surgical repair of the damaged portion of the intracavernous internal carotid artery, electrothrombosis, embolization, or balloon occlusion of the fistula.
- Dural carotid-cavernous sinus fistulae may close spontaneously, but, for those lesions causing progressive or unacceptable symptoms and signs, standard embolization or endovascular balloon occlusion is generally performed. If these techniques are unsuccessful, direct surgery on the cavernous sinus may be considered. In cases where anatomy makes standard intravascular approach impossible, the superior ophthalmic vein can be cannulated and a balloon or coil threaded into the area of a direct communication.
Consultations
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Medications used to decrease aqueous production include beta-blockers, carbonic anhydrase inhibitors (topical or oral), and alpha2-agonists.
Beta-adrenergic blockers
Decrease intraocular pressure (IOP) by reducing the aqueous production.
Timolol 0.25% or 0.5% (Timoptic, Timoptic XE, Blocadren)
May reduce elevated and normal IOP, with or without glaucoma by reducing production of aqueous humor or by outflow.
Adult
1 gtt bid
Timoptic XE: 1 gtt qd
Pediatric
Administer as in adults
May cause bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects)
Documented hypersensitivity; bronchial asthma; sinus bradycardia; second-degree and third-degree AV block; severe chronic obstructive pulmonary disease; overt cardiac failure; cardiogenic shock
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Product may have sulfites, which may cause allergic-type reactions in susceptible patients; may exacerbate or precipitate heart block, asthma, chronic obstructive pulmonary disease, mental changes (especially in elderly persons)
Levobunolol 0.25% or 0.5% (AKBeta, Betagan)
Nonselective beta-adrenergic blocking agent that lowers IOP by reducing aqueous humor production and possibly increases outflow of aqueous humor.
Adult
1 gtt bid
Pediatric
Not established
May cause bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects)
Documented hypersensitivity; bronchial asthma; severe chronic obstructive pulmonary disease; sinus bradycardia; second-degree and third-degree AV block; overt cardiac failure; cardiogenic shock
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
May have sulfites, which may cause allergic-type reactions in certain susceptible persons
Metipranolol 0.3% (OptiPranolol)
Beta-adrenergic blocker that has little or no intrinsic sympathomimetic effects and membrane stabilizing activity. Has little local anesthetic activity. Reduces IOP by reducing production of aqueous humor.
Adult
1 gtt bid
Pediatric
Not established
May cause bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects)
Documented hypersensitivity; sinus tachycardia; cardiac failure; cardiogenic shock; second- and third-degree AV block
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in diabetes mellitus, bradycardia, asthma, cardiac failure, and AV block
Carteolol 1.0% (Ocupress)
Blocks beta1- and beta2-receptors and has mild intrinsic sympathomimetic effects.
Adult
1 gtt bid
Pediatric
Not established
May cause bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects)
Documented hypersensitivity; congestive heart failure; asthma; cardiac conduction defects; breastfeeding
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Product may have sulfites, which may cause allergic-type reactions in certain susceptible persons
Betaxolol (Betoptic, Kerlone)
Selectively blocks beta1-adrenergic receptors with little or no effect on beta2-receptors. Reduces IOP by reducing production of aqueous humor.
Adult
1 gtt bid
Pediatric
Not established
May have additive systemic effects if patient is already on systemic beta-blockers
Documented hypersensitivity; bronchial asthma; severe chronic obstructive pulmonary disease; sinus bradycardia; second-degree and third-degree AV block; overt cardiac failure; cardiogenic shock
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Product may have sulfites, which may cause hypersensitivity reactions in susceptible persons
Carbonic anhydrase inhibitors
By slowing the formation of bicarbonate ions with subsequent reduction in sodium and fluid transport, it may inhibit CA in the ciliary processes of the eye. This effect decreases aqueous humor secretion, reducing IOP.
Dorzolamide 2% (Trusopt)
Used concomitantly with other topical ophthalmic drug products to lower IOP. If more than one ophthalmic drug is being used, administer the drugs at least 10 min apart. Reversibly inhibits carbonic anhydrase, reducing hydrogen ion secretion at renal tubule and increases renal excretion of sodium, potassium bicarbonate, and water to decrease production of aqueous humor.
Adult
1 gtt tid
Pediatric
Not established
Coadministration with high-dose salicylate therapy may increase toxicity; may have additive systemic effects if patient is already on oral CA inhibitors
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Local ocular adverse effects, primarily conjunctivitis and lid reactions, may occur with chronic administration of dorzolamide (discontinue therapy and evaluate patient before restarting therapy)
Brinzolamide 1% (Azopt)
Catalyzes reversible reaction involving hydration of carbon dioxide and dehydration of carbonic acid. May use concomitantly with other topical ophthalmic drug products to lower IOP. If more than one topical ophthalmic drug is being used, administer drugs at least 10 min apart.
Adult
1 gtt tid
Pediatric
Not established
May have additive systemic effects if patient is already on oral CA inhibitors
Documented hypersensitivity
Pregnancy
Precautions
Local ocular adverse effects, primarily conjunctivitis and lid reactions may occur with chronic administration (discontinue therapy and evaluate patient before restarting therapy)
Acetazolamide (Diamox, Diamox Sequels)
Inhibits enzyme carbonic anhydrase, reducing rate of aqueous humor formation, which, in turn, reduces IOP. Used for adjunctive treatment of chronic simple (open-angle) glaucoma and secondary glaucoma and preoperatively in acute angle-closure glaucoma when delay of surgery desired to lower IOP.
Adult
125 mg or 250 mg PO bid/qid or 5-10 mg/kg q6-8h Acetazolamide sequel: 500 mg PO bid
Pediatric
5 mg/kg PO q6h
Can decrease therapeutic levels of lithium and alter excretion of drugs (amphetamines, quinidine, phenobarbital, salicylates) by alkalinizing urine
Documented hypersensitivity; hepatic disease; severe renal disease; adrenocortical insufficiency; severe pulmonary obstruction
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Patients with impaired hepatic function may go into coma; may cause substantial increase in blood glucose in some diabetic patients
Methazolamide (Neptazane)
Reduces aqueous humor formation by inhibiting enzyme carbonic anhydrase, which results in decreased IOP.
Adult
25 or 50 mg PO bid/tid
Pediatric
Not established
May increase toxicity of salicylate, digoxin; coadministration with other diuretics may induce hypokalemia; decreases effects of lithium and alter excretion of other drugs by alkalinizing urine
Documented hypersensitivity; renal impairment
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in respiratory acidosis and diabetes mellitus; impairs mental alertness and/or physical coordination; hematuria, glycosuria, polyuria, hepatic insufficiency, bone marrow suppression, thrombocytopenia/purpura, agranulocytosis, urticaria, pruritus, and rash may occur
Alpha-agonists
The exact mechanism of ocular antihypertensive action is not established but appears to be a reduction of aqueous humor production.
Brimonidine 0.2% (Alphagan)
Selective alpha2 receptor that reduces aqueous humor formation and increases uveoscleral outflow.
Adult
1 gtt tid before and after laser or surgery, short term
Pediatric
Administer as in adults
Coadministration with topical beta-blockers may further decrease IOP; tricyclic antidepressants may decrease effects of brimonidine; CNS depressants, such as barbiturates, opiates, and sedatives, may potentiate effects of brimonidine
Documented hypersensitivity; patients receiving MAOIs
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
May exacerbate or precipitate ocular irritation, topical sensitivity, vasovagal attack, and optic nerve ischemia in patients with advanced glaucomatous optic neuropathy
Apraclonidine 0.5% or 1% (Iopidine)
Reduces elevated, as well as normal, IOP whether or not accompanied by glaucoma. A relatively selective alpha-adrenergic agonist that does not have significant local anesthetic activity. Has minimal cardiovascular effects.
Adult
1 gtt tid before and after laser or surgery, short term
Pediatric
Administer as in adults
Documented hypersensitivity; patients on MAOIs or have taken them in the past 14 d
Not established
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
May exacerbate or precipitate ocular irritation, topical sensitivity, vasovagal attack, and optic nerve ischemia in patients with advanced glaucomatous optic neuropathy
More on Fistula, Carotid Cavernous |
| Overview: Fistula, Carotid Cavernous |
| Differential Diagnoses & Workup: Fistula, Carotid Cavernous |
 Treatment & Medication: Fistula, Carotid Cavernous |
| Follow-up: Fistula, Carotid Cavernous |
| References |
| « Previous Page | Next Page » |
References
Debrun GM, Vinuela F, Fox AJ, et al. Indications for treatment and classification of 132 carotid-cavernous fistulas. Neurosurgery. Feb 1988;22(2):285-9. [Medline].
Higginbotham EJ. Glaucoma associated with increased episcleral venous pressure. In: Albert DM, Jakobiec FA, eds. Principles and Practice of Ophthalmology. 2nd ed. 2000: 2781-92.
Ishijima K, Kashiwagi K, Nakano K, et al. Ocular manifestations and prognosis of secondary glaucoma in patients with carotid-cavernous fistula. Jpn J Ophthalmol. Nov-Dec 2003;47(6):603-8. [Medline].
Keltner JL, Satterfield D, Dublin AB, Lee BC. Dural and carotid cavernous sinus fistulas. Diagnosis, management, and complications. Ophthalmology. Dec 1987;94(12):1585-600. [Medline].
Kirsch M, Henkes H, Liebig T, et al. Endovascular management of dural carotid-cavernous sinus fistulas in 141 patients. Neuroradiology. Jul 2006;48(7):486-90. [Medline].
Miller NR. Carotid-cavernous sinus fistulas. In: Miller NR, ed. Walsh and Hoyt's Clinical Neuro-Ophthalmology. 4th ed. Baltimore, Md: Williams;1991: 2165-209.
Rai AT, Sivak-Callcott JA, Larzo C, Marano GD. Direct carotid cavernous fistula in infancy: presentation and treatment. AJNR Am J Neuroradiol. Jun-Jul 2004;25(6):1083-5. [Medline].
Troost BT, Glaser JS, Morris PP. Aneurysms, arteriovenous communications, and related vascular malformations. In: Glaser, ed. Neuro-ophthalmology. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins;1999: 589-628.
de Keizer R. Carotid-cavernous and orbital arteriovenous fistulas: ocular features, diagnostic and hemodynamic considerations in relation to visual impairment and morbidity. Orbit. Jun 2003;22(2):121-42. [Medline].
Further Reading
Keywords
carotid cavernous fistula, carotid-cavernous sinus fistula, carotid artery, cavernous sinus
