Severe Unilateral Vision Loss in a 77-Year-Old Man

A 77-year-old man with mild headache and sudden vision loss (no light perception) in his right eye was referred for giant cell arteritis (GCA). Fundoscopy revealed chalky white optic disc edema, focal retinal edema, and 2 Hollenhorst plaques (HHP) in the distal arcades (Fig A). Choroidal filling was delayed (Fig B). Erythrocyte sedimentation rate was 12 mm/hr; C-reactive protein was 5.02 mg/dl (normal ≤5.00 mg/dl). Neuroimaging demonstrated subclinical infarcts (Fig C) and near complete right internal carotid artery occlusion (Fig D). Bilateral temporal artery biopsies were negative. When ophthalmic artery occlusion is suspected, the presence of HHP suggests a thromboembolic source rather than GCA (Magnified version of Fig A-D is available online at www.aaojournal.org).