Título

UNILATERAL VISUAL LOSS AND ABDUCENS PALSY AS THE PRESENTING SIGN OF GIANT CELL ARTERITIS

Objetivo

To describe a patient with giant cell arteritis (GCA) that presented with both ischemic optic neuropathy (ION) and abducens palsy.

Relato do Caso

A previously healthy 98-years-old female patient noticed double vision followed by visual loss in one eye. She admitted having mild headache but denied any other complaints. Past medical history was significant for mild dementia and dry age-related macular degeneration. She had approximately 30 prism diopters of left esodeviation in primary position that increased significantly on right gaze and reduced on left gaze. There was a marked right abducens palsy and the rest extraocular motility examination was unremarkable. Visual visual acuity (VA) was 20/40 in the right eye (RE) and light perception in the left eye (LE). There was a marked left afferent pupillary defect. Slit lamp examination showed pseudophakia with well positioned intraocular lens. Fundus examination showed disc with normal color and limits with macular drusen (Fig 1). We suspected of giant cell arteritis and ordered blood tests followed immediately by the introduction of prednisone treatment. Erythrocyte sedimentation rate (ERS) was 113 mm and C-reactive protein (CRP), 2.26 mg/dL. A temporal artery ultrasound disclosed diffuse thickening of inner and medial aspect of the vessel and magnetic resonance imaging was unrevealing. After steroids, the patient referred better disposal and 9 days after treatment right abduction palsy was resolved and ocular misalignment was not seen. Three months later her VA was 20/50 RE and light perception LE. A pale optic disk remained at the left eye and no strabismus was noticed (Fig 2).

Conclusão

While the most common ocular manifestation of GCA is ION our patient shows that acquired paralytic strabismus may also occur. This case shows that diplopia preceding visual loss or acquired strabismus associated with ION should immediately raise suspicion of GCA to avoid treatment delay and further visual loss..