Giant cell arteritis: difficult decisions in diagnosis, investigation and treatment

Ophthalmic manifestations of giant cell arteritis

This article reviews the ophthalmic manifestations of giant cell arteritis. An overview of giant cell arteritis as a disease spectrum is presented with special emphasis on the ophthalmic involvement.

Predictive clinical and laboratory factors in the diagnosis of temporal arteritis

Surgeons are frequently called upon to perform temporal artery biopsy in patients suspected of having temporal arteritis. In this study, we have attempted to identify clinical and laboratory features that may predict the results of temporal artery biopsy for the diagnosis of temporal arteritis. The medical records of patients undergoing temporal artery biopsy over a 10-year period in one hospital were reviewed. Details of presenting features were recorded and comparisons made between biopsy-positive and biopsy-negative patients. Of 59 patients who underwent temporal artery biopsy, the records of 51 patients were located. Of these, 17 patients had positive biopsy specimens and 33 had negative biopsies. In one patient, no temporal artery was found in the biopsy specimen. In the biopsy-positive patients, 69% had an erythrocyte sedimentation rate of greater than 50 mm/h compared to 31% of biopsy negative patients (P = 0.03). With regard to the other clinical and laboratory parameters that were evaluated, no statistically significant differences were found between biopsy-positive and biopsy-negative patients.

Steroid management in giant cell arteritis

AIM

Ocular involvement in giant cell arteritis (GCA) is an ophthalmic emergency which, if untreated, can progress to permanent blindness. There is little evidence in the literature to support current protocols for the acute treatment of GCA with steroids. The authors sought to review the effects of intravenous and oral steroids in GCA.

METHODS

This retrospective study reviewed the records of 100 consecutive patients with biopsy proved giant cell arteritis. 73 patients with visual loss who were treated at the Royal Victorian Eye and Ear Hospital (RVEEH) and St Vincent's Hospital were included in the final series. The authors studied the management of the patients in the first week after presentation, analysing types of treatment, dose, effect on visual acuity, and complications.

RESULTS

All the patients except one had visual loss due to anterior ischaemic optic neuropathy (AION). 17 patients (23%) had bilateral eye involvement. Visual acuity improved in 21 of 73 patients (29%) by a mean of two Snellen chart lines after commencement of steroids. There was an increased likelihood of improved vision in the group who had intravenous steroids (40%) compared with those who received oral steroids (13%). In all except four patients (95%) vision remained stable at 1 month review.

CONCLUSIONS

Prompt treatment of GCA with steroids leads to improvement of visual acuity in a significant number of cases. Intravenous steroids may offer a greater prospect of improvement compared with oral steroids. A prospective trial comparing intravenous with oral steroids is needed to validate these findings and would not expose elderly patients to unacceptable risks.