Sir,

We present a case of giant cell arteritis presenting as macular ischaemia.

Case report

A 65-year-old woman being treated for Ramsay Hunt by her general practitioner was referred to us with acute visual loss in her right eye of 1 week duration. General health included malaise, right-sided jaw pain, ear ache, headache, and leg pains for 2 weeks. A month earlier, she had seen the optician and had Snellen's corrected visual acuity of 6/6+2 Rt and 6/5−2 Lt, and normal bilateral posterior segments (Figures 1a and b).

Figure 1
figure 1

(a, b) Coloured fundus photographs of both eyes of the patient few weeks before onset of the disease. (c) Coloured fundus photograph of the right eye showing pigment epithelial changes in the macular area with loss of choroidal vascular pattern. (d) Coloured fundus photograph of the left eye showing pigment epithelial changes in the macular area. (e) FFA at 19 s for the right eye showing enlargement of the foveal avascular zone with delayed filling. (f) Fundus fluorescein angiography at 52 s for the right eye showing persistence of the enlarged foveal avascular zone.

Full size image

On examination, there were no vesicles present. Best corrected visual acuity was 6/120 and 6/12 in the right and left eyes, respectively, with normal pupil reaction. Dilated fundoscopy showed macular pigment epithelial changes in both eyes with possible loss of foveal architecture suggesting choroidal ischaemia in the right macula (Figures 1c and d). Visual field showed only central scotoma, and fundus fluorescein angiography showed right-sided choroidal ischaemia (delayed choroidal filling even after 52 s) involving only the macular region (Figures 1e and f) and with no change in dye-filling pattern in the retinal vessels. Moderate ischaemic changes were also found in the left macular area. Her ESR was 110 and CRP was 62. Temporal artery biopsy was positive for giant cell arteritis (GCA). Systemic symptoms improved on systemic steroids and repeat angiograms showed some improvement in para-foveal perfusion.

Comment

GCA with eye involvement commonly presents as sudden loss of vision associated with relative afferent pupillary defect and optic disc swelling with haemorrhage, or less commonly as branch or central retinal artery occlusion owing to involvement of the posterior ciliary or branches of the ophthalmic artery.1, 2 Unilateral or bilateral delayed choroidal filling with pupil involvement in biopsy-proven GCA has also been described.3, 4 It can be associated with persistent yellow white retinal lesions in the same patients.5

In our patient, there was no pupil or optic disc involvement and the only ophthalmic finding was pigment epithelial changes in the macular area with loss of foveal architecture. To the best of our knowledge, this has never been reported in literature and GCA should be considered in patients with unexplained loss of foveal architecture.