Let’s examine case-based examples to emphasize the top five neuro-ophthalmic disorders that should not be overlooked.
• Acute painful loss of vision in elderly due to giant cell arteritis
• Acute painful ophthalmoplegia due to orbital apex disease
• Acute painful bitemporal hemianopsia due to pituitary apoplexy
• Acute painful anisocoria with a small pupil due to a Horner syndrome
• Acute painful anisocoria with a large pupil due to a pupil involved third nerve palsy from aneurysm
Clinicians should be aware of the key and distinctive clinical and radiographic findings for each of these potentially vision- or life-threatening conditions.
1. Acute painful vision loss in the elderly
A 75-year-old male presents with acute vision loss in the right eye to the 20/200 level associated with new headaches. This presentation is classic for giant cell arteritis (GCA). The diagnosis of GCA should be considered in any elderly patient with any acute neuro-ophthalmic complaint with or without pain.
The most common presenting symptoms of GCA, however, are intermittent or constant visual loss, new onset headaches, jaw claudication, and scalp tenderness.1-4
Hayreh et al reported 106 of 363 patients with biopsy-proven GCA. The odds of a positive biopsy were 9.0 times greater with jaw claudication (P < 0.0001), 3.4 times greater with neck pain (P=0.0085), 2.0 times greater with an erythrocyte sedimentation rate (ESR) of 47 to 107 mm/hour (P=0.0454), 3.2 times greater with C-reactive protein above 2.45 mg/dl (P=0.0208), and 2.0 times greater for age 75 years or more (P=0.0105).5
The treatment of choice for GCA is immediate high-dose systemic steroids; however the route is still controversial.3,6-8