Background: Giant cell arteritis is an immune-mediated, medium to large vessel vasculopathy affecting
individuals over 50 years of age. It can cause sudden, severe and irreversible loss of vision, most commonly
from an arteritic posterior ciliary artery occlusion causing anterior ischaemic optic neuropathy. The optic
nerve appearance would typically be swollen and chalky white. Visual reduction secondary to choroidal
ischaemia is a much less frequent presentation, the signs of which can be more subtle in appearance, making
its early recognition potentially more challenging.
Case Presentation: A 51-year-old male presented to eye casualty complaining of a one-week history of
neck pain, intermittent headaches and jaw claudication, associated with reduced vision in his right eye.
Presenting visual acuity was hand movements and 6/5 in the right and left eyes respectively. On
examination, he was noted to have a right relative afferent pupillary defect, a pale macular area in the right
eye with a possible cherry red spot. There was no optic disc swelling. ESR was 34 and CRP was 46 and he
was wrongly diagnosed with a non-arteritic central retinal artery occlusion. He subsequently re-presented 5
weeks later with vision loss in his left eye. Best corrected visual acuity was now 6/60 and 6/12 in the right
and left eyes respectively. Dilated fundoscopy showed multiple yellow-white lesions in the posterior pole
of the left eye and a retinal cotton wool spot. The right optic nerve was pale, and left was normal. A fundus
fluorescein angiogram showed delayed choroidal filling and the temporal artery biopsy was suggestive of
GCA. He was started on 110mgs of oral prednisolone. After 4 weeks of steroids his BCVA was 6/36 and
6/6 in the right and left eyes respectively. His neck pain, headaches and jaw claudication had all resolved
and his ESR and CRP had returned to normal levels.
Conclusion: Our case highlights the need for increased awareness of this uncommon presentation of this
potentially blinding disease, to allow prompt and appropriate treatment. Our case is unusual in that despite
a delayed diagnosis of 5 weeks, visual acuity initially improved with treatment.
An Atypical Presentation of Giant Cell Arteritis with Bilateral Choroidal Ischaemia
