Diagnostic optical coherence tomography findings in arteritic posterior ischemic optic neuropathy: A case report

To describe the finding of paracentral acute middle maculopathy (PAMM) in a patient with posterior ischemic optic neuropathy (PION) leading to the diagnosis of occult giant cell arteritis (GCA).

A 67-year-old man presented with sudden monocular vision loss. Ophthalmic examination revealed profound vision loss with an ipsilateral relative afferent pupillary defect, a cotton wool spot and PAMM on optical coherence tomography (OCT), while the optic disc appeared normal. Fluorescein and indocyanine green angiography revealed a perfusion deficit in the nasal choroid. There were no systemic symptoms and acute phase reactants were normal. Temporal artery biopsy was negative, while temporal artery ultrasound revealed definite signs of GCA. Accordingly, the final diagnosis of arteritic PION was made. At 9-month follow-up the optic disc was atrophic, and retinal ischemic perivascular lesions (RIPLs) had developed at the previous locations of PAMM.

PAMM on macular OCT may occasionally be the only indication of GCA in patients with sudden vision loss. Concurrent findings of PAMM and ischemic optic neuropathy in patients aged 50 and above should prompt urgent investigation for GCA and consideration of initiating treatment with high-dose corticosteroids, even without classic diagnostic features.