[Case Report] 68yo with cardiometabolic risk factors and transient monocular vision loss

Pomegranate Health

Pomegranate [Case Report] is a Q&A style podcast developed by trainees, for trainees. In our debut episode, we hear about w a who man presented to the emergency department reporting sudden onset vision loss in his right eye lasting several hours. He was 68 year old with a history of type 2 diabetes mellitus. Three differential diagnoses being considered were optic neuropathy, vitreoretinal disease, or corneal oedema following from potential uveitis. In this podcast consultant ophthalmologist, Dr Sumu Simon, walks through an approach to this presentation and an exploratory therapy.

Guests
Dr Sumu Simon FRANZCO (Queen Elizabeth Hospital; Royal Adelaide Hospital)
Dr Brandon Stretton (Royal Adelaide Hospital)
Dr Stephen Bacchi (Lyell McEwin Hospital)

Production
Produced by Mic Cavazzini DPhil. Music licenced from Epidemic Sound includes ‘Rockin’ for Decades’ by Blue Texas and ‘Brighton Breakdown’ by BDBs. Image created and copyrighted by RACP. Editorial feedback kindly provided by RACP physicians Aidan Tan and Fionnuala Fagan.

Please visit the Pomegranate Health web page for a transcript and supporting references. Login to MyCPD to record listening and reading as a prefilled learning activity.

Learning points and Key Reference (spoiler alert)
1. This case underscores the critical nature of timely diagnosis and aggressive treatment in conditions like giant cell arteritis (GCA), where delayed treatment can lead to irreversible complications such as vision loss. Thorough history taking and clinical acumen are still key elements in establishing a diagnosis of GCA.
2. The patient's initial response and subsequent decline in vision illustrate the need for ongoing monitoring and readiness to adapt the treatment approach. It also shows the necessity of close monitoring of inflammatory markers and clinical symptoms.
3. Amaurosis fugax warrants urgent referral to an ophthalmologist.
4. High index of suspicion for GCA and prompt referral of GCA suspects will ensure best outcome for patients.
5. Progressive visual loss and elevated inflammatory markers should alert the clinician to glucocorticoid-resistant GCA.
6. The effectiveness of tocilizumab in this case highlights its role as a valuable treatment option for refractory GCA, especially when traditional therapies are not sufficiently effective. Targeted biologic agents may open up new treatment approaches in the future particularly in patients with progressive visual loss despite administration of intravenous methylprednisolone.
7. Managing complex cases like GCA often requires a collaborative approach involving rheumatologists, ophthalmologists, and other specialists to ensure comprehensive care and optimal outcomes.
8. There is often value in case reports to start the evidence cascade that is required to bring new, life altering treatments to the forefront.
The Role of Tocilizumab in Glucocorticoid Resistant Giant Cell Arteritis: A Case Series and Literature Review [J Neuroophthalmol. 2023;43(1)]