Case 1

Oh, well, it all started about 4 hours ago. Is something terrible happening? Am I going to go blind?

Oh, no! I’ve never had anything like this before. I’m really quite worried!

Well, I’m a retired Green Bay Packers cheerleader. Now, I’ve taken up woodworking

Well, I have been having this headache for the past 2 weeks. It’s kind of annoying.

No, thankfully I don’t have any eye pain. Just headaches.

No, I’ve always been very healthy. My doctor did say I had high cholesterol, but once I started that tablet, it got better.

No, I haven’t had any accidents or falls recently. I try to stay away from dangerous situations since I broke my hip 3 years ago.

Not that I know of. My father had cataracts, but he was older – about my age now, when he got them.

Incorrect: Angle closure glaucoma presents with constant pain +/- vomiting, nausea, and abdominal cramps.

Correct: Central retinal artery occlusion is associated with sudden painless loss of vision. Associated risk factors include hypertension, hypercholesterolemia, diabetes, vascular disease, prior MI, transient ischemic attacks, and stroke.

Correct: As the name suggests, transient monocular vision loss causes sudden painless loss of vision. This may be benign in a person younger than 45 years old.

Incorrect: Cataracts are typically slow growing.

Correct: Giant cell arteritis classically presents in an older person with sudden permanent or transient visual loss. Associated symptoms often include headache, jaw claudication, scalp pain, and polymyalgia rheumatica.

Incorrect: Herpes simplex keratitis causes a superficial infection of the cornea, often in a dendritic pattern. Symptoms include red eye, photophobia, and some degree of eye irritation.

Incorrect: Pseudotumor cerebri classically occurs in young obese females, and produces bilateral visual changes due to increased intracranial pressure. Visual field is usually affected late in disease. Associated with headache worse on lying down and relieved by standing.

Correct: Central retinal vein occlusion can present with sudden painless loss of vision. Risk factors include hypertension, diabetes, cardiovascular disease, and hyperviscosity states such as polycythemia.

Incorrect: Central retinal artery occlusion has the classic findings of a pale, swollen optic disk, a pale retina with prominent ‘cherry red’ macula.

Incorrect: The optic disk seen in this patient’s eye is pale and edematous, which is consistent with ischemic optic neuropathy.

Incorrect: Central retinal vein occlusion has the classic findings of retinal hemorrhages, dilated torturous retinal veins, cotton wool spots and retinal and macular edema. Classically described as a ‘blood and thunder’ or ‘stormy sky’ appearance.

Correct: The optic disk seen in this patient’s eye is pale and edematous, which is consistent with ischemic optic neuropathy.

Incorrect: The retina in this patient is all in one plane with no signs of detachment.

Correct: The finding (polymyalgia rheumatica) describes proximal muscle weakness, and occurs in 40-50% of patients with GCA.

Incorrect: Malar rash is not a common finding in GCA. If a malar rash was present, a diagnosis of systemic lupus erythematosus would have to be entertained.

Incorrect: Alopecia is not a common finding in GCA. It is also a fairly non-specific finding.

Correct: Jaw claudication is present in 50% of patients with GCA. This may be present with weight loss, or the patient complaining about not being able to chew steaks any more.

Incorrect: Xerostomia (dry mouth) and keratoconjunctivitis sicca (dry eyes) are not commonly associated with GCA. They are however found together in Sjogren’s syndrome.

Incorrect: ANA is positive in many automimmune conditions, including systemic lupus erythematosus, but not in GCA.

Correct: Temporal artery biopsy is the gold standard for diagnosis of GCA. Sample needs to be ≥ 2 cm in length.

Correct: CRP is usually elevated in inflammatory processes, including GCA.

Correct: Platelets can commonly be elevated in cases of giant cell arteritis.

Correct: ESR is usually quite elevated in cases of GCA, often >70 mm/hr.

Incorrect: ANCA is useful for the diagnosis of small and medium vessel vasculitides, but has no role in the diagnosis of GCA.

Incorrect: For suspected GCA, the standard of care is to start high dose steroids (usually prednisone) immediately. Temporal artery biopsy will not be altered by steroid use for up to 7-10 days.

Incorrect: For suspected GCA, the standard of care is to start high dose steroids (usually prednisone) immediately. Temporal artery biopsy will not be altered by steroid use for up to 7-10 days.

Incorrect: There is no role for antibiotics in the treatment of GCA as there is no infection.

Incorrect: There is no role for antibiotics in the treatment of GCA as there is no infection.

Correct: For suspected GCA, the standard of care is to start high dose steroids (usually prednisone) immediately. Temporal artery biopsy will not be altered by steroid use for up to 7-10 days.

Incorrect: For treatment of GCA, high dose prednisone (40-60 mg/day) is the treatment of choice.