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).
Funduscopic and magnetic resonance images. A, Right eye funduscopy showing a hyperemic optic nerve head with sectoral temporal pallor and an adjacent cotton-wool spot (white arrow) and a small focus of macular hypopigmentation (black arrow). B, Left eye funduscopy showing diffuse edema of the optic nerve head with blurred disc margins and a cherry-red spot (white arrow) surrounded by a macular infarct (arrowheads), as well as narrowing of the retinal arteries (black arrow). C, Axial diffusion-weighted magnetic resonance image showing restricted diffusion in the right anterior optic nerve adjacent to the junction with the globe (arrow). D, Axial diffusion-weighted magnetic resonance image showing restricted diffusion in the left optic nerve (arrow).
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