Visual loss caused by choroidal ischemia preceding anterior ischemic optic neuropathy in giant cell arteritis

Three patients with visual loss and normal fundi were discovered to have choroidal ischemia on fluorescein angiography. Each patient had a markedly increased Westergren erythrocyte sedimentation rate, but only one described symptoms of polymyalgia rheumatica, neck pain, and jaw claudication. Biopsy of the temporal artery confirmed giant cell arteritis in the two patients without constitutional symptoms. In one patient, typical anterior ischemic optic neuropathy developed the following day, whereas in the other two, anterior ischemic optic neuropathy later occurred despite the prompt administration of intravenous high-dose corticosteroids. Choroidal ischemia may be the first sign of giant cell arteritis in elderly patients with visual loss. Early diagnosis and treatment are mandatory in an attempt to forestall the development of anterior or posterior ischemic optic neuropathy, or central retinal artery occlusion in the affected or fellow eye.