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Sudden loss of vision and headache

Clinical Discipline(s)/Organ System(s)
General Practice, Ophthalmology, Rheumatology
Progress Test Topic(s)
Eyes
Description
An 83 year old NZ European woman presented with a 1 month history of new onset headache, jaw claudication and one day history of sudden loss of vision in the left eye. On examination, she was noted to have reduced vision in the left eye of count fingers only, a left relative afferent papillary defect, constricted visual fields on confrontation testing and a pale swollen left optic nerve. She underwent a temporal artery biopsy which revealed significant inflammation.
Applied Science for Medicine 
   - Vascular supply to the eye (specifically optic nerve and retina in detail)
   - Vascular supply to the head and neck (especially superficial temporal artery)
   - Anatomy of the optic nerve head and optic nerve
   - T-cell mediated immunity and inflammation
   - Role of cytokines in inflammation
Clinical and Communication Skills 
   - Elicit a relevant history of sudden visual loss including review of systems which focus on systemic conditions that cause blindness
   - Perform an ophthalmological examination, particularly focusing on optic nerve function
   - Perform a swinging flashlight test; test visual fields to confrontation; use direct and indirect ophthalmoscopy to assess the fundus
   - Differential diagnosis of swollen optic nerve
   - Other symptoms associated with giant cell arteritis
   - Other ophthalmological presentations of giant cell arteritis
   - Role of blood tests in the diagnosis (erythrocyte sedimentation rate (ESR), C-reactive protein, platelets); role of temporal artery biopsy
   - Indications for admission to hospital for treatment; role of intravenous corticosteroids in management; understanding and management of acute and long-term complications of anti-inflammatory corticosteroid treatment including osteoporosis prophylaxis
   - Visual rehabilitation, legal requirements for driving, criteria for enrolment with Blind Foundation
Personal and Professional Skills 
   - Team work: communication between ophthalmologist, rheumatologist and GP for long-term management
Hauora Māori 
   - Consideration that there may be sensitivity around examination of certain parts of the body and therefore asking permission to examine or touch the head and eye
   - Understanding of inequities in access to health services and quality of medical care for Māori with long term conditions and disability, and application of this to clinical decision making and management
Population Health 
   - Provision of services for temporal artery biopsy
Conditions to be considered relating to this scenario
Common
giant cell arteritis, polymyalgia rheumatica