Who Deserves a Second Chance?

An 81-year-old woman presents with a one-month history of blurred vision OS, acutely worse in thepast 5 days. She reports pain with left gaze, left sided forehead tenderness and some weightloss. Medical history includes hypertension, borderline diabetes, cerebral vascular accident and basalcell carcinoma of the face. Her medications include rivaroxaban, metoprolol, atorvastatin andomeprazole. Visual acuity is 20/20 OD and light perception OS. Color vision is 11/11 OD and 0/11OS. Confrontational fields are full in the right eye and non-recordable in the left eye. Pupils arereactive and equal OU, with a greater than 1.2 log unit APD OS. Anterior segment exam revealsbilateral intraocular lenses. Dilated exam: OD is unremarkable, and OS is noted to have pallid discedema with several hemorrhages. Initial blood work reveals an ESR 36mm/hr and CRP 5.4 mg/L(normal <3.0). MRI head obtained at outside facility showed abnormal enhancement along the orbitalportion of the left optic nerve. Prednisone 60mg/day is initiated for presumed GCA and temporal arterybiopsy scheduled. Contact is also made with the patients primary care physician to stop rivaroxaban. Aleft temporal artery biopsy showed calcific atherosclerosis, without evidence of active or treatedarteritis. Vision in left eye progressed to no light perception. Dedicated orbital MRI study with andwithout gadolinium showed mild enlargement and enhancement of the left optic nerve, possibly worsethan prior. Patient admitted to hospital for workup. CT Chest no evidence of sarcoidosis. LP glucose 113 (serum 276), protein 31, WBC