Quiz: Sudden Loss of Vision in Left Eye

A 73-year-old woman presents with sudden loss of vision in her left eye. On review of systems, she reports headaches and pain with chewing. There is a left relative afferent pupillary defect. Anterior segment exam was normal for both eyes as was her right posterior segment. Her left posterior segment exam is shown in the photo.

60 thoughts on “Quiz: Sudden Loss of Vision in Left Eye”

  4. Preventing visual loss in the other eye is of crucial importance.
    That is the main purpose of treatment.
    This eye has a very guarded visual prognostic even with treatment.
    That should be conveyed to the patient.
    Thanks for a good case !

    Reply

  13. I am a bit concerned about the use of systemic glucocorticoid therapy for as long as one year, given the potential risks involved with this treatment regimen in an elderly patient. Is there merit in observing bio markers like the ESR and CRP as criteria for systemic steroid reduction. Is there evidence to support the unrestricted use for one year of systemic steroid therapy, with non recurrence benefits and at the same time avoiding the risks associated with long term usage of systemic corticosteroids?

    Reply

    • If steroid use is your concern, switch to other NSAID therapy. Basically we are interested in minimize inflammation, which can be achieved by many means. However start on steroids and switch to NSAIDS after controlling symptoms.

      Reply

    • Giant cell arteritis has a risk of complete blindness and cardiac events. No randomized, controlled studies have been done but long-term steroids are indicated, but not at the sustained high dose that is initially indicated. They are taped as the ESR and CRO normalize. Some reasonable guidelines are reprinted here from the American Family Physician:
      https://www.aafp.org/pubs/afp/issues/2022/1000/polymyalgia-rheumatica-giant-cell-arteritis.html

      Starting dosage Prednisone in a dosage of 40 to 60 mg per day until the ESR is normal and the patient is asymptomatic
      Dosage reduction Decrease the dosage by 2.5 to 5 mg per day every two weeks to a dosage of 20 mg per day; then decrease the dosage by 10 percent every 2 weeks to a dosage of 10 mg per day; then decrease the dosage by 1 mg per day every 4 weeks.
      or
      Decrease the dosage by 10 percent every 2 weeks to a dosage of 10 mg per day; then decrease the dosage by 1 mg per day every 4 weeks.
      Monitoring Monitor the patient for symptom recurrence throughout the steroid taper; monitor the ESR every 4 weeks for 2 to 3 months, then every 8 to 12 weeks until 12 to 18 months after the cessation of therapy.

      Reply

    • Giant cell arteritis has a risk of complete blindness and cardiac events. No randomized, controlled studies have been done but long-term steroids are indicated, but not at the sustained high dose that is initially indicated. They are taped as the ESR and CRO normalize. Some reasonable guidelines are reprinted here from the American Family Physician:
      https://www.aafp.org/pubs/afp/issues/2022/1000/polymyalgia-rheumatica-giant-cell-arteritis.html

      Starting dosage Prednisone in a dosage of 40 to 60 mg per day until the ESR is normal and the patient is asymptomatic
      Dosage reduction Decrease the dosage by 2.5 to 5 mg per day every two weeks to a dosage of 20 mg per day; then decrease the dosage by 10 percent every 2 weeks to a dosage of 10 mg per day; then decrease the dosage by 1 mg per day every 4 weeks.
      or
      Decrease the dosage by 10 percent every 2 weeks to a dosage of 10 mg per day; then decrease the dosage by 1 mg per day every 4 weeks.
      Monitoring Monitor the patient for symptom recurrence throughout the steroid taper; monitor the ESR every 4 weeks for 2 to 3 months, then every 8 to 12 weeks until 12 to 18 months after the cessation of therapy.

      Reply

  24. For this Case of Giant cell arteritis, if we consider the therapy of corticosteroid for 12 months, what about their side effects?
    Like steroid induced glaucoma?..
    Do we have to consider anti glaucoma drops as well?

    Reply

    • Only if they develop elevated IOP, not automatically.
      Giant cell arteritis has a risk of complete blindness and cardiac events. No randomized, controlled studies have been done but long-term steroids are indicated, but not at the sustained high dose that is initially indicated. They are taped as the ESR and CRO normalize. Some reasonable guidelines are reprinted here from the American Family Physician:
      https://www.aafp.org/pubs/afp/issues/2022/1000/polymyalgia-rheumatica-giant-cell-arteritis.html

      Starting dosage Prednisone in a dosage of 40 to 60 mg per day until the ESR is normal and the patient is asymptomatic
      Dosage reduction Decrease the dosage by 2.5 to 5 mg per day every two weeks to a dosage of 20 mg per day; then decrease the dosage by 10 percent every 2 weeks to a dosage of 10 mg per day; then decrease the dosage by 1 mg per day every 4 weeks.
      or
      Decrease the dosage by 10 percent every 2 weeks to a dosage of 10 mg per day; then decrease the dosage by 1 mg per day every 4 weeks.
      Monitoring Monitor the patient for symptom recurrence throughout the steroid taper; monitor the ESR every 4 weeks for 2 to 3 months, then every 8 to 12 weeks until 12 to 18 months after the cessation of therapy.

      Reply

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