The single decision that matters in anterior ischaemic optic neuropathy is whether it is arteritic. The arteritic form, driven by giant cell arteritis, threatens the second eye within days and is treatable; the non-arteritic form is commoner and has no specific treatment. Getting that question answered late is how a patient loses both eyes.
In practice the failure is a pathway failure, not a knowledge one. The patient presents to whoever is nearest, is referred onwards for an eye opinion, and the inflammatory markers are sent but not chased. If you see sudden painless monocular vision loss in someone over 50: take the history for jaw claudication, scalp tenderness and polymyalgic symptoms in the same consultation, send ESR and CRP the same day, and make the decision about starting steroids on clinical grounds rather than waiting for temporal artery biopsy or ultrasound to be arranged.
- Ask about jaw claudication, scalp tenderness, temporal headache and polymyalgic symptoms at first contact.
- Send ESR and CRP the same day and take responsibility for chasing the result yourself.
- Do not delay steroids for biopsy if the arteritic form is suspected - biopsy remains informative for up to a fortnight.
- Examine and document the fellow eye at presentation, as it is the one at stake.
- Record vascular risk factors: the non-arteritic form still marks a patient needing secondary prevention.
Why it matters
The second eye is lost in the days spent arranging the test that would have confirmed what the history already suggested.
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