Atlas of Ophthalmology

Delayed recognition of forehead necrosis in Giant Cell Arteritis leading to permanent visual loss

Systemic Diseases -> Immunologic Diseases
It is not uncommon for scalp necrosis to precede visual loss in GCA. We report a case of giant cell arteritis presenting with counting fingers visual acuity in both eyes, however the rare sign of forehead necrosis had not been taken into account and was present before the visual symptoms. The novel use of a dermatoscope yielded fascinating visualisation of a thrombosed branch of a superficial temporal vessel and provides an alternative clinical tool in such cases. This case highlights the importance of not ignoring scalp necrosis as this may precede visual loss in giant cell arteritis, the scalp necrosis was also visible macroscopically. A dermatoscope allows superior magnified inspection of skin lesions and subsurface structures not normally visible to the unaided eye (deep reticular dermis and beyond). The Polarised Contact dermatoscope utilises the technique of epiluminescence with the use of a coupling agent to avoid light scatter. The refractive index of the glass plane on the dermatoscope is similar to that of the stratum corneum, optimal linkage between it and skin allows limited light reflection and penetration to deeper skin layers. Deep vasculature viewed under the dermatoscope has a blue/red or blue/black appearance, whilst thrombotic vessels exhibit red/black lagoons.

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