Keeping NAION visual loss: discriminating urgent versus emergent visual loss in an elderly female

A 72-year-old woman presented with sudden, monocular vision loss and a temporal headache without eye pain. Examination revealed complete loss of vision in the right eye in bilateral superior visual fields and hyperaemic oedema with haemorrhages of the optic disc. She had significant vasculopathic risk factors, including age greater than 50 years, hypertension, recent coronary artery bypass graft and hyperlipidaemia. Atypical features were investigated, including simultaneous vision changes in contralateral eye, prodrome, jaw claudication, scalp tenderness and headache. The patient indicated persistent temporal headaches since the onset of the visual changes, prompting investigation with temporal biopsy and inflammatory markers with initiation of steroids. Diagnostic studies excluded inflammatory disease and retinal vascular thrombosis. The patient was diagnosed with non-arteritic anterior ischaemic optic neuropathy (NAION) and the steroids were tapered off. At 6 months, the patient has maintained altitudinal visual loss, but her central vision in the affected eye has remained 20/25.