An 85-year-old man presented with complete loss of vision. During the week prior to presentation, he reported gradually progressive blurred and dark vision in both eyes with dramatic worsening on the day of presentation. He had no other symptoms, including headache. His medical history was significant for hypertension and peripheral vascular disease.
On examination, his blood pressure was elevated. There was no cranial artery tenderness. He was alert with intact language and memory. Visual acuity was light perception OU. Both pupils were 4 mm and nonreactive to light. Eye movements were normal, and corneal reflexes were intact and symmetric. Funduscopic examination showed bilateral optic nerve head edema with right optic nerve sectoral pallor and a left macular infarction (Figure, A and B). The remainder of the neurological examination was normal. Magnetic resonance imaging showed restricted diffusion (Figure, C and D) with a reduced apparent diffusion coefficient signal (not shown) within the left intraorbital optic nerve and at the right anterior optic nerve. The platelet count was 1134/μL, the erythrocyte sedimentation rate was 40 mm/h, and the C-reactive protein level was 17.7 mg/L (to convert to nanomoles per liter, multiply by 9.524).