Clinical Outcomes and Imaging Findings of Open Superior Ophthalmic Vein Approach for Closure of Carotid-Cavernous Fistulas

Purpose: To identify clinical outcomes, patient characteristics, and complications for open superior ophthalmic vein (SOV) approach and micro-catheterization for closure of carotid-cavernous sinus fistulas (CCF). Methods: Retrospective cohort study performed over 2010 to 2025 for all patients who underwent closure of CCF via a planned open SOV approach. Outcomes measured included occlusion result, post-operative vision, and any sequalae. Preoperative neuroimaging was reviewed and the SOV diameter and cross-sectional area measured on coronal views. Associations of posterior cortical venous drainage (PCVD) with the SOV diameter (≤4mm compared with >4mm) and stroke were determined using Fisher’s exact test with statistical significance at p < 0.05. Results: A total of 29 patients were identified ([ Fig. 1 ]). The majority of CCF were Barrow type D. Mean age was 66 years (23–88 years) and the majority of patients were female (69%). Most patients (72%) had unilateral physical exam findings, and 86% of patients had all three ocular signs: injection, chemosis and proptosis. Mean preoperative intraocular pressure (IOP) by tonometry was 25 mm Hg (12–57 mm Hg) and median vision was 20/40 (20/15 - CF). Cannulization of the SOV was achieved in 97% and there was a complete obliteration rate of 87%. The SOV was cannulized with an SOV as small as 3.1mm and there was no statistically significant association between SOV width and success of cannulization. Five patients (17%) were noted to have PCVD on cerebral arteriography, which correlated with cerebral congestion on preoperative MRI ([ Fig. 2 ]). The most common periocular sequela was upper eyelid ptosis, with 10% of patients undergoing subsequent ptosis surgery. Final follow-up vision ranged from 20/20 to NLP (median 20/30). Three (10%) patients required canthotomy and cantholysis for orbital compartment syndrome (OCS) following embolization, one intraoperatively and two immediately post-operatively. Conclusion: The SOV approach for closure of CCF was effective and relatively safe, achieving an 87% closure rate. Severe iatrogenic visual loss was uncommon. Patients need to be closely monitored immediately postoperatively for OCS. Preoperative diplopia usually resolves. Postoperative ptosis is a common complication. Seventeen percent of patients presenting with periocular findings of CCF also demonstrated PCVD on angiography, predisposing them to potential progressive neurologic deficits. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany