A 67-year-old male with no relevant personal history.
The patient reported sudden double vision and mild ptosis in the right eye which was total in the following hours.
She had no history of seizures.
He did not report weight loss, fever, jaw claudication or decreased vision.
The visual acuity in both eyes was 1.
Extraocular motility in the left eye was normal.
In the RE there was a total ptosis with limitation of the gaze in all positions except location.
Pupillary motility was normal in both eyes.
Intraocular pressure was 16 mmHg in the RE and 18 mmHg in the LE.
The anterior and posterior biomicroscopic studies were normal.
Laboratory tests were not significant with ESR 21 mm/h, protein C 0.3 mg/dl and platelets 125,000/ml3.
The definitive diagnosis was made with biopsy of the temporal artery where occlusion of the temporal artery was found with giant cells around the internal elastic, which appears broken and replicated.
