Single intravitreal ranibizumab injection for optic disc neovascularisation due to possibly traumatic, direct carotid cavernous fistula

We report a patient with optic disc neovasculariation due to possibly traumatic direct carotid cavernous fistula treated by a single dose of intravitreal ranibizumab prior to neurointervention. A 25-year-old man had a 10-month history of bilateral proptosis and left sixth nerve paralysis was evaluated. Conjunctival vessels were markedly dilated, especially in the left eye. Clinical examination and fundus fluorescein angiography revealed disc neovascularisation in the left eye with subtle peripheral retinal ischaemia. Magnetic resonance imaging suggested a high-flow carotid cavernous fistula on the left side and this was confirmed by catheter angiography. A single dose of intravitreal ranibizumab was injected prior to neuro-intervention. The disc neovascularisation regressed completely three days later. The left direct carotid cavernous fistula was later treated successfully with coil embolisation. Optic disc neovascularisation is a very rare feature of carotid cavernous fistula and intravitreal ranibizumab may be a useful therapeutic adjunct prior to neuro-interventional techniques to reduce neovascularisation-induced haemorrhage following the intervention.