A 78-year-old woman comes to the emergency department due to acute vision loss. She had rapid-onset monocular vision loss in the left eye that developed over an hour. There is no associated pain in the eye, but the patient has had left-sided headaches most days for the last 3 weeks. She also has had achy pain in the shoulders that has slowly worsened over the last month. Examination shows decreased pupillary light reflex in the left eye with severely impaired visual acuity. Which of the following is the most appropriate treatment for this patient's condition?

Question

A 78-year-old woman comes to the emergency department due to acute vision loss.  She had rapid-onset monocular vision loss in the left eye that developed over an hour.  There is no associated pain in the eye, but the patient has had left-sided headaches most days for the last 3 weeks.  She also has had achy pain in the shoulders that has slowly worsened over the last month.  Examination shows decreased pupillary light reflex in the left eye with severely impaired visual acuity.  Which of the following is the most appropriate treatment for this patient's condition?

Quizplus · Accepted Answer

11ec160b_3c7b_2f26_9249_6d9876e6df26_MD0001_00 This patient has acute, painless vision loss and unilateral headaches. This presentation is most consistent with anterior ischemic optic neuropathy (AION) due to giant cell arteritis (GCA), also termed temporal arteritis. GCA occurs almost exclusively in patients age >50 and is characterized by granulomatous inflammation of the media with fragmentation of the internal elastic lamina, primarily in the arteries of the head and neck. It is often associated with polymyalgia rheumatica (PMR), which presents with achy pain in the proximal skeletal muscles (eg, shoulders, hips). Ocular manifestations are common in GCA and can lead to irreversible vision loss. AION is due to involvement of the ciliary arteries and causes a painless, rapidly progressive decrease in visual acuity. GCA can also cause visual symptoms due to central retinal artery occlusion, extraocular palsies, and infarcts of the visual cortex. Transient monocular vision loss (amaurosis fugax) may also be seen. Treatment for GCA and PMR includes systemic glucocorticoids (eg, prednisone, methylprednisolone). However, for patients with suspected GCA, treatment should be started prior to diagnostic testing (eg, erythrocyte sedimentation rate, temporal artery biopsy) because of the risk of blindness if treatment is delayed. (Choice A) Acetazolamide is a carbonic anhydrase inhibitor/diuretic used for treating idiopathic intracranial hypertension (ie, chronic headache and vision loss; occurs mainly in young, obese women) and angle-closure glaucoma (ie, eye pain, redness, middilated pupil, and cloudy cornea). Neither condition is associated with proximal muscle pain. (Choice B) Antiplatelet agents (eg, aspirin, clopidogrel) are indicated for patients with amaurosis fugax (eg, transient vision loss) due to carotid atherosclerosis. However, this patient's unilateral headaches and proximal muscle pain makes GCA a more likely diagnosis. (Choice C) Ganciclovir is used to treat cytomegalovirus retinitis, which presents with blurred vision, floaters, and photopsia (sensation of flashing lights). It occurs primarily in patients with significant immune suppression (eg, advanced AIDS). (Choice E) Sumatriptan is used for the treatment of migraine, which can cause a variety of ocular symptoms. However, new-onset migraines are uncommon in older individuals, and this patient's other symptoms are more consistent with GCA and PMR. Educational objective: Ocular manifestations in giant cell arteritis (temporal arteritis) can lead to rapid, severe, and irreversible vision loss. Involvement of the ciliary arteries in GCA leads to anterior ischemic optic neuropathy, which presents with a painless, rapidly progressive decrease in visual acuity. Treatment includes systemic glucocorticoids (eg, prednisone, methylprednisolone). __________ References: Giant cell arteritis: ophthalmic manifestations of a systemic disease. (http://www.ncbi.nlm.nih.gov/pubmed/27495301)

A 78-Year-Old Woman Comes to the Emergency Department Due to Acute