Arteritic Posterior Ischemic Optic Neuropathy: A Case Report

動脈炎性後部缺血性視神經病變之個案報導

林育葳(Yu-Wei Lin) ； 翁林仲(Lin-Chung Woung) ； 張延瑞(Yen-Jui Chang) ； 林潁正(Ying-Cheng Lin)

《中華民國眼科醫學會雜誌》 52卷2期 (2013/10) Pp. 143-149

https://doi.org/10.30048/ACTASOS.201310_52(2).0008

摘要

目的：報告一位動脈炎性後部缺血性視神經病變。方法：病例報告。結果：一位83歲的老先生本身有輕型地中海貧血病史，主述右眼視力逐步下降並且有右側頭痛和下巴跛行（jaw claudication）的情形。起初右眼的最佳矯正視力為6/100，而左眼的最佳矯正視力為6/12。並沒有發現到相對性瞳孔傳入缺陷（RAPD）。眼底檢查及眼底螢光血管造影除了觀察到雙眼的玻璃疣（drusen），此外一切正常。2週後，他的右眼最佳矯正視力下降至無光感，並觀察到有相對性瞳孔傳入缺陷。核磁共振影像（MRI）的檢查並沒有異常發現。視覺誘發電位（VEP）檢查顯示右眼沒有電位波幅的回升。抽血檢查發現有輕度貧血及紅細胞沉降率增加（ESR ＞ 120毫米／小時）的情形。因此，高度懷疑是右眼的動脈炎性後部缺血性視神經病變，並給予口服類固醇使用。使用藥物後，病患的右眼視力改善至可視光感，並且瞳孔對光反應回到正常。6週後嘗試停止服用口服藥物。但是，在追蹤的視覺誘發電位發現到病患的P100反應時間延長，因而再將口服類固醇開立使用。目前病患視力維持穩定，而ESR和CRP回復到正常範圍。結論：當年老病患呈現有逐漸的視力下降，有時甚至並未觀察到相對性瞳孔傳入缺陷跡象或視乳頭水腫時，動脈炎性缺血性視神經病變的可能性仍是不能忽視的。並且臨床上應該仔細尋求病患是否存在顳動脈炎的相關症狀。此外，高分辨率的核磁共振影像檢查以及彩色都卜勒超音波對於診斷顳動脈炎有相當的準確性，尤其是當顳動脈穿刺檢查還尚未有報告之前。最後，此類型病患應立即採用大劑量的類固醇以維護對側眼的視力，並且甚至在某些情況下還能逆轉患眼的視力喪失。

並列摘要

Purpose: To report a case of arteritic posterior ischemic optic neuropathy. Methods: A case report. Result: An 83-year-old gentleman with a past history of thalassemia minor complained of progressive decreased vision in his right eye as well as right side headache and jaw claudication. Initially, the best-corrected visual acuity (BCVA) was 6/100 in the right eye and 6/12 in the left eye. There was no relative afferent pupillary defect (RAPD). Fundus examination and fluorescein angiography were normal except some drusen in both eyes. BCVA in his right eye dropped to no light perception 2 weeks later, and RAPD developed in the same eye. Brain magnetic resonance imaging (MRI) was arranged but there was no unremarkable finding. His visual-evoked potential (VEP) study showed no pick-up response in the right eye. Laboratory evaluation uncovered mild anemia and increased erythrocyte sedimentation rate (ESR ＞ 120 mm/hour). As arteritic posterior ischemic optic neuropathy affecting his right eye was suspected, oral corticosteroid was prescribed. The visual acuity improved to light perception, and the pupillary light response returned. Symptoms relapsed 6 weeks after the cessation of oral medications and prolonged P100 response in the left eye was noted in VEP study follow-up. The vision in both his eyes remained stationary and the ESR and CRP returned back to normal limits with oral corticosteroid continuing. Conclusion: With the image of progressive decreased vision in elderly, we should not neglect the possibility of arteritic ischemic optic neuropathy even lack of a positive relative afferent pupillary defect sign or papilledema. The presence of signs and symptoms of temporal arteritis ought to be carefully sought, and high-resolution magnetic resonance imagings as well as color-coded duplex sonography are helpful in diagnosis making before the results of temporal artery biopsy are available. High-dose systemic steroids should be employed immediately for preserving vision of the fellow eye and in some instances may reverse vision loss in the affected eye.

並列關鍵字

giant cell arteritis ； posterior ischemic optic neuropathy ； temporal arteritis