Sudden, painless, monocular visual loss in a patient over 50 is one of the presentations where the department's next twenty minutes decide the other eye. Anterior ischaemic optic neuropathy comes in two forms, and this joint position paper from Spanish internal medicine and retina societies is written around the consequences of confusing them.
The arteritic form is usually giant cell arteritis, and it is both a medical and an ophthalmological emergency: untreated, the fellow eye is at immediate risk. The non-arteritic form is far more common, carries the vascular risk factors internists recognise, and has no specific effective treatment. The authors' central observation is that management in practice is heterogeneous — variable care pathways, variable aetiological workup, variable follow-up and secondary prevention — and that the fix is a defined pathway with ophthalmology and internal medicine working together rather than sequentially.
They are candid about the evidence base: much of the document is expert consensus, and they say so, particularly where high-quality evidence does not exist. That does not weaken the operational point. What an emergency department can implement is a fixed sequence — inflammatory markers on every patient over 50 with this presentation, explicit questioning for the arteritic features, and a decision about steroids made on suspicion rather than after confirmation.
- Send ESR and CRP on every patient over 50 with sudden painless monocular visual loss
- Ask specifically about jaw claudication, scalp tenderness, temporal headache and polymyalgic symptoms
- Treat suspected arteritic disease as an emergency — the fellow eye is the stake
- Do not treat the non-arteritic form as having a specific therapy; it does not
- Refer for vascular risk assessment, which is where the non-arteritic form is usually neglected
Why it matters
The commoner diagnosis has no treatment and the rarer one has a treatment that must start today; nothing else about the presentation distinguishes them.
Don't overread it
This is an expert consensus document, and the authors state that high-quality evidence is lacking for several of its recommendations.
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