Bilateral Ocular ischemia in a patient with Takayasu arteritis

To describe a rare case of bilateral ocular ischemia as the initial presentation of Takayasu arteritis and highlight the role of early recognition and treatment in preventing irreversible vision loss.

A woman in her 50s presented with a gradual, progressive diminution of vision, initially in the left eye and later involving the right. Comprehensive ophthalmic evaluation, systemic examination, fundus fluorescein angiography, and CT angiography of the head and neck were performed. Laboratory investigations, including ESR, CRP, and ANA, were obtained. The American College of Rheumatology (ACR) criteria were applied to support the diagnosis.

The patient demonstrated severe ocular ischemic features, including attenuated retinal vessels, disc neovascularization, and intumescent cataract in the left eye. Systemic examination revealed feeble brachial and radial pulses with a significant inter-arm blood pressure difference. CT angiography showed narrowing of the right common carotid artery and non-opacification of both subclavian arteries. Laboratory findings revealed elevated ESR and CRP, with a positive ANA. Based on clinical, radiologic, and laboratory features, a diagnosis of bilateral ocular ischemia secondary to Takayasu arteritis was made. The patient was treated with oral corticosteroids (60 mg/day, tapered) and azathioprine. At 4 weeks, visual acuity improved to 6/36 in the right eye, while no improvement was noted in the left eye.

Our case highlights bilateral ocular ischemia as an uncommon but vision-threatening manifestation of Takayasu arteritis. Ocular findings such as retinal vascular attenuation, disc neovascularization, delayed choroidal filling, and peripheral capillary non-perfusion may precede the diagnosis of systemic vasculitis. Recognition of associated systemic signs, including pulse deficits and inter-arm blood pressure discrepancies, facilitated timely diagnosis. Prompt initiation of corticosteroid and immunosuppressive therapy led to visual improvement in the right eye, underscoring the importance of early diagnosis and multidisciplinary management to prevent irreversible visual loss and systemic vascular complications.

Bilateral ocular ischemia may be the first manifestation of Takayasu arteritis. This case underscores the importance of a high index of suspicion in patients with unexplained ischemic ocular features. Early systemic evaluation and prompt initiation of immunosuppressive therapy are essential to preserve vision and prevent further vascular complications.