| 박영주(1,2), 정호경(1,3), 손영제(4,5), 김남주(1,6), 곽상인(1,2) |
| 본문 : A 74-year-old lady visited our hospital with a history of painless swelling of right upper eyelid. She was previously diagnosed with epiretinal membrane and normal tension glaucoma in her left eye. She had been treated with hormone replacement therapy(HRT) for her postmenopausal symptoms. She denied any history of systemic hypertension, trauma, cranial surgery, or recent illness.
At the initial examination, her vision was decreased and intraocular pressure(IOP) was increased in the right eye. Relative afferent pupillary defect was observed in her right eye, and slit lamp exam revealed conjunctival chemosis with vessel engorgement in her right eye. Contrast-enhanced CT showed right exophthalmos with engorged superior and inferior ophthalmic vein(IOV). Transfemoral cerebral angiography showed a cavernous sinus dural arteriovenous fistula(CS- DAVF) at the right superior orbital fissure, which was fed by dural branches from internal carotid artery. Since the IOP was still high with 3 different IOP-lowering agents, transvenous embolization was considered as a treatment, but the preferred access route like inferior petrosal vein or SOV was not available due to thrombotic occlusion. Embolization via percutaneous puncture of IOV was considered as an alternative, but the patient was reluctant to take the risk. Among the previously-reported conservative approaches, compression of external carotid artery was thought to be risky due to had a risk of carotid body reaction, and compression of SOV was predicted to be ineffective due to SOV obstruction. Manual compression of the right IOV, which was the only venous drainage route, was chosen, with short-term monitoring of IOP and other ocular presentations. Then symptoms were improved and IOP was controlled with tapering of IOP-lowering agents. After 12 weeks, follow-up MR angiography of her head showed no demonstrable CS-DAVF. Finally, her vision and IOP were normalized within 5 months.
This case of CS-DAVF with sudden ocular symptoms was managed with manual compression of IOV. This approach can be considered when the other choices are thought to be inappropriate due to the inaccessibility to the fistula and possible risk of complication.
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