Sequential vision loss in a patient with headache

A 74 year old woman with a history of bowel cancer and hypertension was admitted under the general medical team from the emergency department because of a constant frontal headache for several weeks and poor oral intake secondary to jaw pain, which was exacerbated by chewing. She described intermittent blurring of vision in her left eye, which had culminated in complete loss of vision three days before presentation. She felt generally unwell with increasing lethargy and generalised myalgia.

On clinical examination she had bilateral tender and pulseless temporal arteries. Fundoscopy of the left eye showed features consistent with central retinal artery occlusion.

Initial blood tests showed raised inflammatory markers (C reactive protein (CRP) 2438 nmol/L, erythrocyte sedimentation rate (ESR) 116 mm in the first hour), and thrombocytosis (platelets 588×10⁹/L). Despite symptomatic and biochemical improvement after prompt institution of appropriate treatment, her right eye deteriorated three days later exhibiting the features seen in the retinal photograph (fig 1⇓). The optic nerve had a swollen pale “chalky white” appearance suggestive of an anterior ischaemic optic neuropathy.