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Essentials of Diagnosis
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General Considerations
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Acute retinal arterial ischemia, including central and branch retinal artery occlusion, is a true ocular and medical emergency
Consider giant cell arteritis in patients with central retinal artery occlusion and either
Age ≥ 50 years
No visible emboli
Carotid and cardiac sources of emboli must be sought so that treatment can be given to reduce the risk of stroke
In young patients, causes include
Consider internal carotid artery dissection when there is neck pain or a recent history of neck trauma
In all patients, consider
Diabetes mellitus
Hyperlipidemia
Systemic hypertension
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Central retinal artery occlusion
Presents as sudden profound monocular visual loss
Visual acuity is usually reduced to counting fingers or worse
Visual field may be restricted to an island of vision in the temporal field
Branch retinal artery occlusion
May also present with sudden loss of vision if the fovea is involved, but more commonly sudden loss of a discrete area in visual field in one eye is the presenting complaint
Fundus signs of retinal swelling and adjacent cotton-wool spots are limited to the area of retina supplied by the occluded artery
Identify risk factors for a cardiac source of emboli, including arrhythmia, particularly atrial fibrillation, and cardiac valvular disease; and check the blood pressure
Non-ocular clinical features of giant cell arteritis include
Jaw claudication (which is very specific)
Headache
Scalp tenderness
General malaise
Weight loss
Polymyalgia rheumatica: shoulder and hip girdle pain
Tenderness or thickening of, or absence of pulse in, the superficial temporal arteries
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Test for diabetes (fasting serum glucose, hemoglobin A1C) and hyperlipidemia (fasting serum cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides) in all patients
Erythrocyte sedimentation rate and C-reactive protein are usually markedly elevated in giant cell arteritis but one or both may be normal
Consider testing for other types of vasculitis (eg, antinuclear antibody, rheumatoid factor, anticytoplasmic neutrophil antibody) (Table 22–11)
Particularly in younger patients, consider tests for
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