A 72-year-old woman has had a new headache at her temples for two weeks — combing her hair hurts, and her jaw aches when she chews. Three days ago the vision in her right eye suddenly dropped, with the upper half of vision missing. Her right optic disc is swollen and pale. Blood tests show very high inflammation markers.
Examination Findings
A 72-year-old woman with two weeks of new temporal headache, scalp tenderness when combing hair, and jaw pain when chewing. Vision in the right eye dropped suddenly three days ago: acuity 6/60, with an altitudinal field defect (upper half missing). Right optic disc swollen and pale. Right RAPD present. Left eye currently normal. Temporal arteries tender and cord-like. ESR and CRP markedly raised.
Investigations
ESR and CRP are the urgent blood tests — markedly raised here. Temporal artery biopsy is arranged but treatment never waits for it. A full systemic review documents the arteritic features. The fellow eye is examined carefully — it is the eye being protected. Baseline bloods (glucose, blood pressure) prepare for high-dose steroid therapy per local protocol.
Questions to Think About
- Why must steroids start before the biopsy result?
- What is the main goal of the steroid treatment at this point?
- Which symptoms in the history pointed to arteritis before the eye was examined?
Diagnosis
Arteritic anterior ischaemic optic neuropathy due to giant cell arteritis — treated as an emergency with high-dose systemic steroids.
Reasoning
Reasoning: The constellation of new temporal headache, scalp tenderness, jaw claudication, sudden vision loss with a pale swollen disc and altitudinal defect, plus markedly raised ESR/CRP in a 72-year-old, is giant cell arteritis causing arteritic anterior ischaemic optic neuropathy. This is distinguished from non-arteritic AION precisely by the systemic features and inflammatory markers. The emergency is the fellow eye, which can infarct within days without treatment. Diagnosis: arteritic AION from GCA. Management: typical management is immediate high-dose steroids per local protocol on clinical grounds, biopsy within days, slow taper with rheumatology, and fellow-eye vigilance. The case teaches that in GCA, treatment precedes proof.
Differential Diagnosis
- Non-arteritic AION — the critical distinction: ruled out by the systemic symptoms, raised inflammatory markers and age pattern favouring arteritis.
- Optic neuritis — ruled out: the patient is 72, disc is swollen with pallor, and systemic arteritic features are present.
- Infiltrative optic neuropathy — ruled out: no malignancy history; the clinical syndrome is classic for GCA.
Management
Typical management includes immediate high-dose systemic corticosteroids per local protocol — started on clinical suspicion without waiting for biopsy. Temporal artery biopsy follows within days to confirm. The fellow eye is monitored closely for any visual symptoms. Steroids are tapered slowly over months per rheumatology guidance, with bone, glucose and blood pressure protection. The patient is taught that any new visual symptom is an emergency during the illness. Long-term follow-up is shared with rheumatology.
Key Learning Points
- New headache, jaw claudication and scalp tenderness in an older adult with vision loss is giant cell arteritis until proven otherwise.
- Arteritic AION threatens the fellow eye within days — steroids protect the second eye, not the first.
- Never delay steroids for the biopsy — treat first, biopsy within days.
- The pale swollen disc with an altitudinal defect is the classic optic nerve picture.
Red Flags
- Any new visual symptom in the fellow eye during treatment — emergency; the protected eye is under attack.
- Steroids delayed for investigations — the fellow eye can go blind within days.
- Stopping steroids abruptly or without taper plan — disease flare and adrenal risks; rheumatology co-manages.
Educational content only — not medical advice. Clinical decisions must be made by a qualified professional for the individual patient.
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