Clinical Case Database / Category: Patient Management

Double trouble: when diplopia strikes, think twice

Publication details

Andrew Elliott, Dr Masara Laginaf
Foundation Years Journal, volume 9, issue 6, p.40 (123Doc Education, London, June 2015)

Abstract

We describe a case of unilateral third and fourth cranial nerve palsy with proptosis, in a 67-year-old female. This was preceded by a two-week history of frontal headaches, neck pain and malaise. Blood results revealed a normal ESR of 36 mm/hr and a raised CRP of 28mg/L. The patient was treated with high dose oral prednisolone for suspected giant cell arteritis (GCA), however, an aneurysmal pathology was considered most likely. Urgent magnetic resonance angiography and venography found no acute vascular pathology or retro-orbital abnormalities.
A temporal artery biopsy performed on day 7 of oral steroids was found to be positive for active GCA. Within one month of oral steroid therapy, the diplopia, right ptosis and proptosis completely resolved. One year later, she has had no further episodes of diplopia or visual disturbance, and remains on a low dose of tapering oral prednisolone.

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Authors

Andrew Elliott

Ophthalmology Department
Frimley Park Hospital
Portsmouth Road
Surrey, GU16 7UJ
andrew.elliott@fhft.nhs.uk

Dr Masara Laginaf (Corresponding author)

Ophthalmology Department
Frimley Park Hospital
Portsmouth Road
Surrey, GU16 7UJ
masara.laginaf@gmail.com

References

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3.Daïen V et al. Acute diplopia after the age of 50; always look for giant cell arteritis. J Fr Ophtalmol 2009, Oct;32(8):579.e1-5.
4.Madge SN et al. Giant cell arteritis presenting as painful third nerve palsy with normal erythrocyte sedimntation rate. Br J Hosp Med (Lond) 2006, May;67(5):268.
5. Moreland LW et al. Temporal arteritis presenting with diplopia. W V Med J 1986, Dec;82(12):481-2.
6.Purvin V, Kawasaki A. Giant cell arteritis with spontaneous remission. Clin Experiment Ophthalmol 2007, Jan-Feb;35(1):59-61.
7.Hayreh et al. Ocular manifestations of giant cell arteritis. Am J Ophthalmol 1998, Apr;125(4):509-20.
8. Haering M et al. Incidence and prognostic implications of diplopia in patients with giant cell arteritis. JRheumatol 2014, Jul;41(7):1562-4.

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T​he Foundation Years Clinical Cases Database is​ a selection of 600 peer-reviewed clinical cases in the field of patient safety and clinical practice, specifically focused on the clinical information needs of junior doctors, based around the Foundation Year Curriculum programme (MMC). The cases have been chosen to align with the Foundation Year Curriculum.

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