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A 57-year-old previously healthy man was referred to our clinic for bilateral vision loss.Six weeks before presentation, the patient developed central graying of vision in his right eye that progressed to blindness over a week. Over the next several weeks, the same occurred in the left eye. There was retro-orbital pain and a new holocephalic headache that was worse in the mornings. He reported lancinating pain down his neck, left arm, back, and left leg with neck movement. An outside ophthalmologist noted bilateral optic disc edema and referred him to our clinic.The patient was employed as a prison guard. Screening for tuberculosis exposure with purified protein derivative testing was negative for at least the last 5 years. He neither drank alcohol nor smoked. His mother had died of a brain tumor in her 70s. He denied fever, chills, cough/dyspnea, epistaxis, recent illness, bowel or bladder dysfunction, hematuria, and any history of neurologic issues. He was current on preventative cancer screening.On examination, the patient had normal vital signs, left-sided anosmia, and a relative afferent pupillary defect (RAPD) on the right with bilateral disc edema. Visual acuity was finger counting at 1 foot OD and 4 feet OS with a large central scotoma in each eye. He had mild nuchal rigidity. The remaining examination was normal.Questions for consideration: