Waking up to darkness

An 84 year old woman was referred by her general practitioner to the emergency department with painless binocular blindness. She reported waking four days previously to find that she could no longer see. Fearful of the possibility of malignancy, she delayed presentation to hospital. On further questioning, she recalled focal right frontal headaches of four months’ duration. She denied any previous visual disturbance. On direct questioning, she admitted to pain in her jaw, which was most noticeable at mealtimes.

The neurological examination showed bilateral afferent pupillary defects and no perception of light in either eye. Funduscopy showed bilaterally swollen optic discs. On closer inspection, her temporal regions had an unusual appearance bilaterally (fig 1⇓) and her right temporal artery was pulseless to palpation. Her erythrocyte sedimentation rate was 76 mm in the first hour and computed tomography of the brain was unremarkable for her age.