A 74-year-old woman comes to the emergency department due to sudden onset of complete vision loss in her right eye. Her vision had been blurry for the past 24 hours and acutely worsened an hour ago. The patient has had no weakness or sensory changes in the extremities. Review of systems is positive for 2 months of generalized headaches. She has no nausea or vomiting but does have malaise and fatigue. Medical history is significant for type 2 diabetes mellitus, hypertension, hypercholesterolemia, and bilateral cataract surgeries. Temperature is 37.2 C (99 F), blood pressure is 156/86 mm Hg, and pulse is 78/min. Examination shows complete loss of vision in the right eye. The pupils are 4 mm bilaterally. Funduscopy shows a swollen pale disc with blurred margins. The lateral scalp is tender to palpation. Cardiopulmonary examination is normal. Motor and sensory examinations are normal. Which of the following is the most appropriate therapy for this patient?

Question

A 74-year-old woman comes to the emergency department due to sudden onset of complete vision loss in her right eye.  Her vision had been blurry for the past 24 hours and acutely worsened an hour ago.  The patient has had no weakness or sensory changes in the extremities.  Review of systems is positive for 2 months of generalized headaches.  She has no nausea or vomiting but does have malaise and fatigue.  Medical history is significant for type 2 diabetes mellitus, hypertension, hypercholesterolemia, and bilateral cataract surgeries.  Temperature is 37.2 C (99 F), blood pressure is 156/86 mm Hg, and pulse is 78/min.  Examination shows complete loss of vision in the right eye.  The pupils are 4 mm bilaterally.  Funduscopy shows a swollen pale disc with blurred margins.  The lateral scalp is tender to palpation.  Cardiopulmonary examination is normal.  Motor and sensory examinations are normal.  Which of the following is the most appropriate therapy for this patient?

Quizplus · Accepted Answer

11ec25c8_d53b_b6cc_bc81_f18010bafa01_MD0003_00 This patient has acute monocular vision loss following 2 months of headache and associated lateral scalp tenderness to palpation. In a patient age ≥50, this presentation suggests giant cell arteritis (GCA; also referred to as temporal arteritis), a chronic vasculitis affecting medium and large vessels. Systemic symptoms (eg, fatigue, fever, weight loss) are common, and about half of patients have concurrent polymyalgia rheumatica, which presents with proximal muscle pain and stiffness. In addition to headaches (often temporal) and visual symptoms, other common manifestations of GCA include jaw claudication, thickening and tenderness along the temporal artery (eg, lateral scalp), and asymmetric loss of distal pulses. Vision loss is the most dreaded complication of GCA; most patients experience transient monocular vision loss (ie, amaurosis fugax) prior to developing permanent vision loss. Anterior ischemic optic neuropathy (AION), the most common ocular manifestation, occurs due to partial or complete occlusion of the posterior ciliary artery and is characterized by a pale, edematous disc with blurred margins. Threatened (eg, vision change) or confirmed vision loss in GCA requires high-dose intravenous glucocorticoids (eg, methylprednisolone 500-1,000 mg daily), followed by oral therapy with a slow taper over several months to prevent worsening or contralateral vision loss. Temporal artery biopsy can confirm the diagnosis of GCA; however, therapy should be started immediately when the diagnosis is suspected and should not be withheld while awaiting confirmation. (Choice B) Acetazolamide is used to treat angle-closure glaucoma, which presents with acute vision loss and headache. However, patients frequently have ocular pain, nausea, and vomiting. Examination findings include conjunctival erythema, corneal opacity, and a fixed, mid-dilated pupil. (Choice C) Low-dose glucocorticoids (eg, prednisone 10-20 mg daily) are recommended for polymyalgia rheumatica without GCA. Higher dose oral prednisone (40-60 mg/day) is appropriate for uncomplicated GCA without signs of end-organ damage. However, this patient has acute vision loss and warrants aggressive treatment with parenteral glucocorticoids. (Choice D) Sumatriptan is indicated for acute treatment of migraine headache, which can be associated with visual aura. However, unilateral headaches associated with nausea and photosensitivity are typical, and AION would not occur. (Choice E) Thrombolytic therapy is indicated for treatment of acute ischemic stroke, which typically presents with focal neurologic deficits (eg, hemiparesis, aphasia), not AION. Educational objective: Giant cell arteritis (GCA, or temporal arteritis) presents with headache and systemic symptoms (eg, fatigue, fever) in patients age ≥50. Potential complications include anterior ischemic optic neuropathy, which can lead to blindness. Threatened (eg, vision change) or confirmed vision loss in GCA requires high-dose intravenous glucocorticoids.

A 74-Year-Old Woman Comes to the Emergency Department Due to Sudden