Giant cell arteritis presenting with acute monocular vision
The present case has been published in the journal Neurology. An 80-year-old man with medical history of hypertension developed a sudden loss of vision in the left eye without any associated pain, flashes, or floaters. The review of systems was negative for any headaches, jaw claudication, scalp or temporal tenderness, or other symptoms suggestive of polymyalgia rheumatica (PMR).

Visual acuity testing revealed 20/20 vision on the right and hand movement perception only in the temporal field of the left eye, with no light perception on the nasal field of the same eye. Pupils were 3 mm bilaterally, round, and reactive with a relative afferent pupillary defect on the left.

Dilated funduscopic examination was unremarkable on the right side and revealed macular whitening and retinal blanching with cherry-red spot on the left. Temporal artery pulses were present.

Acute lateralized monocular vision loss with relative sparing of the temporal field was suggestive of an intraorbital lesion compressing the optic nerve. An MRI of the orbits with and without contrast was performed, which revealed bilateral enhancing intraconal mass lesions, left greater than right. However, the funduscopic findings in this case were consistent with acute central retinal artery occlusion (CRAO).

Keeping the possibility of an uncommon presentation of a common and treatable condition in mind, the diagnosis of GCA was considered in this elderly man with vision loss, despite the lack of usual systemic and inflammatory markers associated with GCA.

Learning Points:-
• Monocular loss of vision is an ocular emergency. Urgent assessment, rapid diagnosis, and early treatment initiation has been shown to improve clinical outcomes and reduce disability.

• This case represents an uncommon presentation of a common condition and emphasizes the importance of considering GCA in the differential diagnosis of any form of acute monocular vision loss.

• Rapid institution of glucocorticoids (GC) remains the mainstay of treatment of GCA, with variable duration of treatment depending on individual treatment response as GCA is associated with a high risk of relapse.

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