1 week h/o of diplopia followed by sudden loss of vision

Posted by - Posted on 07/25/2015 16:37:00

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82 year old presented with 1 week h/o diplopia. Examination suggested left 4th CN palsy, VA 20/20 OU/ IOP 12 OU. Routine tests including sed rate were ordered. Pt returned 48 hours later with NLP vision OS, 20/40 OD and IOP of 4 mm Hg OU. Fundus pictures of bothe eyes attached. Sed rate was 68 ; pt denied headaches, no temporal tenderness or jaw claudication. Patient subsequently had a temporal artery biopsy (see atached)

What is the likely hood that this patient will loose her vision in the right eye. Will you treat her immediately (and if so with what) or order diagnostic tests (and if so what). 

Diagnosis:  Temporal arteritis

This patient's is slightly atypical in the sense that she first developed a 4th CN palsy followed later by sudden loss of vision in the same eye in the absence typical clinical complaints (headache, temporal tenderness) with normal sed rate. 

Biopsy suggests mild lymphocytic inflammatory cell infiltrate, reducedlumen and focallydisrupted  elastic lamina consistent with temporal arteritis

The risk of her loosing vision in teh right eye is very high.

The correct treatment is to start IV solumedrol (1 gram) x 3 days followed by oral steroids in the hope of preventing the right eye from going blind.  Labs including biposy can be performed antime in teh first week. 

Fun Facts

More common in females and whites over 40

Smoking increases teh risk

primarily a disease of cell-mediated immunity

primary inflammatory response involves the internal elastic lamina within the media of the arterial wall

End-organ involvement relates to hyperplasia and occlusion of the arteries serving those organs.

A cellular immune reaction to elastin has been implicated in the pathogenesis of GCA

 GCA does not cause a widespread intracranial cerebral vasculitis as they lack an internal elastic lamina.

The most common cause of vision loss in GCA is anterior ischemic optic neuropathy (AION). This results from ischemia of the optic nerve head, which is supplied mainly by the posterior ciliary arteries.

About half of persons with GCA have underlying polymyalgia rheumatica, and about 15% of individuals with polymyalgia rheumatica develop GCA.

Blindness : painless and sudden loss of vision secondary to Ischemic optic neuritis with eventual optic atrophy is the most common cause of visual loss and occurs in 15% of patients.

GCA is associated with increased risks for MI, stroke, and peripheral vascular disease.

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