Clinical Reasoning: A 21-year-old woman with right eye swelling and bruising

Abstract

A 21-year-old woman presented with right eye swelling and bruising. Several weeks prior to admission, she had bifrontal headaches associated with a “whooshing” pulsation in her right ear. She went to a local emergency department where CT scan of the brain was read as negative. One week later, she noticed that her right eye was turned toward her nose. She denied diplopia. On the day of admission, she awoke and noticed bruising under her right eye accompanied by swelling. She also had blurry vision. Her physical examination was remarkable for right eye ptosis, conjunctival injection, and mild proptosis with ecchymosis above and below the eye (figure 1). She was unable to abduct her right eye past midline, visual acuity was 20/30 bilaterally, and her visual fields were intact. There was an ocular bruit auscultated over the right eye. Figure 1 Initial external eye findings Right eye ptosis with proptosis, conjunctival injection, and ecchymosis surrounding the right eye. ### Questions for consideration: 1. What other history is important to obtain? 2. What is the differential diagnosis? The patient denied any history of trauma. Her past medical history was significant for Ehlers-Danlos type IV, complicated by bowel rupture 6 years prior, necessitating subtotal colectomy and colostomy. She also had chronic migraine and corrective surgery for amblyopia as a child. Family history was significant for her mother who died at age 35 of splenic rupture and maternal grandmother who died at age 43 of subarachnoid hemorrhage. The differential diagnosis included thyroid ophthalmopathy, tumor, infection, inflammation (e.g., Tolosa-Hunt), and carotid cavernous aneurysm or fistula. ### Question for consideration: 1. What further testing should be considered? Magnetic resonance angiography revealed enlarged superior ophthalmic veins bilaterally, right greater than left, with an increased prominence in the right cavernous sinus (figure 2, A and B). The patient was diagnosed with carotid cavernous fistula. She was sent to the ophthalmology clinic where her intraocular …