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A 75 year old man describes impaired vision in his left eye upon awakening. He denies any symptoms to suggest a systemic inflammatory disorder. He is under treatment for diabetes mellitus and systemic hypertension, but blood pressures have been slightly elevated in the range of 150/90 mm Hg. Vision is normal in the right eye, but slightly impaired in the left eye with an afferent pupil defect in the left eye. All other aspects of the ophthalmic examination are normal, except for the left optic fundus, as seen here. Serum acute phase reactants (erythrocyte sedimentation rate, C-reactive protein) are normal.

    • Review Topic

    You should order

    A) Optical coherence tomography

    Incorrect

    B) Carotid artery imaging

    Incorrect

    C) High-dose corticosteroid treatment, followed by temporal artery biopsy

    Incorrect

    D) Ambulatory blood pressure monitoring

    Correct! This patient has the profile of optic disc stroke, also called “ischemic optic neuropathy.” Nothing in his history suggests that this is “arteritic,” even though that is always a concern. Temporal artery biopsy, preceded by high-dose corticosteroid treatment, is not medically justified here. You can comfortably diagnose “non-arteritic ischemic optic neuropathy,” which is generally caused by in situ compromise of tiny optic disc pre-capillary arterioles. Thus, carotid artery imaging is not indicated and neither is cardiac echography. Optic coherence tomography contributes nothing here. Ambulatory blood pressure monitoring may guide in establishing a proper blood pressure control regimen.