Sudden-onset unilateral painless vision loss

Area of Science:

• Ophthalmology
• Rheumatology
• Vascular Medicine

Background:

• Giant cell arteritis (GCA) is a systemic vasculitis affecting large and medium-sized arteries.
• Ocular manifestations of GCA can lead to irreversible vision loss if not promptly diagnosed and treated.

Observation:

• A 75-year-old woman presented with acute, multifocal central vision loss in her right eye.
• Ocular examination revealed subtle intraretinal foveal lesions with corresponding optical coherence tomography findings suggestive of paracentral acute middle maculopathy (PAM).
• Systemic symptoms included lethargy and jaw claudication, with elevated inflammatory markers (sedimentation rate, C-reactive protein).

Findings:

• Cerebrovascular work-up was initially negative, delaying diagnosis.
• Despite initial negative work-up, the clinical presentation and elevated inflammatory markers led to suspicion of GCA.
• Temporal artery biopsy confirmed the diagnosis of giant cell arteritis.

Implications:

• This case highlights the importance of considering GCA in patients with sudden visual disturbances, even with initially negative cerebrovascular imaging.
• Early initiation of high-dose corticosteroids (e.g., 60 mg oral prednisone) is critical to prevent further ischemic events and vision loss.
• Multifocal scotomas and PAM can be presenting signs of GCA, necessitating a thorough diagnostic work-up including inflammatory markers and potentially biopsy.