Incorrect

Incorrect

Correct! You are looking at pallid swelling of both optic discs in a patient with a report of newly and severely reduced vision in both eyes. Bilateral simultaneous optic disc swelling often prompts consideration of papilledema from increased intracranial pressure, but papilledema does not usually cause such severe vision loss acutely. Moreover, the optic disc swelling here is pallid, therefore likely ischemic. Yes, she lacks systemic manifestations of giant cell arteritis (although the NSAID medication may be masking them) and does not have elevated acute phase reactants, but the fact that both optic discs are affected SIMULTANEOUSLY nearly excludes non-arteritic ischemic optic neuropathy and demands prompt exclusion of giant cell arteritis. (Giant cell arteritis may sometimes occur without any systemic symptoms and with normal serum acute phase reactants!) Therefore, she must undergo immediate corticosteroid treatment to help protect her against further vision loss, followed by temporal artery biopsy as soon as possible. The pathologist will be looking for thickening and inflammatory destruction of the vascular media–intima junction,

fragmentation of the internal elastic lamina,

and/or Langerhans giant cells.

If biopsy of one side is negative and giant cell arteritis remains a prime suspect, you should consider a biopsy of the other side, which improves the detection rate of giant cell arteritis from 93% to 96%. Optical coherence tomography contributes nothing here. Fluorescein angiography in this setting might be useful to detect choroidal ischemia, a feature of giant cell arteritis, but you would proceed toward excluding giant cell arteritis even if it were negative. Were a double biopsy to be negative, a positive fluorescein angiogram might induce you to treat for giant cell arteritis in spite of the otherwise negative studies.