Vision loss in giant cell arteritis

Ocular ischaemic syndrome due to giant cell arteritis

Giant cell arteritis (GCA) is a large vessel vasculitis with devastating visual consequences if left untreated. Classically, GCA has a predilection for the short posterior ciliary arteries which supply the optic nerve head, causing sudden painless visual loss with the development of arteritic anterior ischaemic optic neuropathy (AAION). Other ocular manifestations of GCA include central retinal artery occlusion, oculomotor nerve palsy, posterior ischaemic optic neuropathy and ocular ischaemic syndrome (OIS). OIS is a rare clinical entity, typically stemming from severe, unilateral carotid artery disease. It may present with anterior segment ischaemia heralded by hypotony and corneal oedema. Rarely, it may occur in cases of GCA. We describe an atypical presentation of OIS and oculomotor nerve palsy with contralateral AAION in an elderly patient with a delayed diagnosis of biopsy-proven GCA. This case exemplifies the importance of suspicion, early diagnosis and initiation of treatment in GCA to prevent irreversible loss of vision.

Combining Paracentral Acute Middle Maculopathy and Peripapillary Fluid as Biomarkers in Anterior Ischemic Optic Neuropathy

PURPOSE

To determine if paracentral acute middle maculopathy (PAMM) and peripapillary intraretinal and subretinal fluid (IRF/SRF) could help distinguish between arteritic anterior ischemic optic neuropathy (A-AION) and nonarteritic AION (NA-AION) at an early stage.

DESIGN

Nested prospective cross-sectional diagnostic accuracy study.

METHODS

This study used single-center optical coherence tomography (OCT) data from 8 patients with A-AION and 24 patients with NA-AION from two prospective cross-sectional studies with consecutive sampling (ClinicalTrials.gov: NCT05248906 and NCT05305079). The diagnosis of A-AION was based on expert interpretation of biochemical markers of inflammation, temporal artery biopsy and positron emission tomography/computed tomography. The diagnosis of NA-AION was made in cases without suspicion or clinical evidence of A-AION and with confirmed neuroophthalmological expert diagnosis. For this substudy patients were also required to have an OCT scan in relation to the diagnosis of AION. Macular OCT scans were graded by two independent, masked graders for the presence of PAMM and for IRF/SRF. The extension of IRF/SRF was assessed using an Early Treatment Diabetic Retinopathy Study (ETDRS) grid.

RESULTS

PAMM was found in 50% of patients with A-AION and in 0% of patients with NA-AION (P = .0019). In the setting of AION, the sensitivity of PAMM for the diagnosis of A-AION was 50% (95% CI: 16%-84%) while the specificity was 100% (95% CI: 86%-100%). Conversely, peripapillary IRF/SRF with extension into the ETDRS grid was observed in 83% of patients with NA-AION but in 0% of patients with A-AION (P = .000047). The sensitivity of central macula-involving IRF/SRF for the diagnosis of NA-AION was 83% (95% CI: 63%-95%), while the specificity was 100% (95% CI: 63%-100%). Combining the two biomarkers, 75% of patients with AION could be classified based on OCT alone.

CONCLUSION

PAMM appears to be a biomarker of A-AION while extensive peripapillary fluid appears to be a biomarker of NA-AION. Combining OCT biomarkers might allow for early classification of AION and warrants further prospective studies.

Atypical Signs and Symptoms of Giant Cell Arteritis: A Systematic Review

BACKGROUND

Giant cell arteritis can present with atypical manifestations that delay treatment and risk severe complications.

OBJECTIVES

To comprehensively describe all atypical signs/symptoms of giant cell arteritis.

DESIGN

In this systematic review, we searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception to October 2022. Primary research articles that included at least one participant with an atypical sign/symptom of biopsy-proven giant cell arteritis were included. Study screening and data extraction were performed in duplicate. The primary outcome was the proportion of participants with atypical giant cell arteritis features. Time to treatment was compared between participants with atypical giant features only and participants with both typical and atypical features.

RESULTS

Of 21,828 screened records, 429 studies corresponding to 746 individuals (median [IQR] age 72 [IQR, 66-78] years, 63% female) with at least one atypical feature of GCA were included. Eighty-two percent had both atypical and at least one concurrent typical giant cell arteritis feature, whereas 18% of patients with atypical signs and symptoms only presented with atypical features. Patients with atypical symptoms presented to clinicians earlier than patients with typical features (p < 0.001). There was no difference between groups in proportion to elevated ESR and CRP (82.3% vs. 83.35%, p = 0.91) or mortality rate (8.2% vs. 10.8%, p = 0.42). Patients with atypical features only experienced greater delay in treatment initiation (p < 0.001). The most commonly reported atypical signs/symptoms were vertigo (11.9%), scalp necrosis/ulceration (7.9%), and dry cough (5.8%).

CONCLUSIONS

Eighteen percent of biopsy-proven giant cell arteritis cases with at least one atypical feature have only atypical features and are more likely to experience delays in treatment. Clinicians should be aware of atypical signs/symptoms of giant cell arteritis and order inflammatory markers early to prevent giant cell arteritis-associated morbidity.

Position paper on retinal arterial occlusion. SEMI-SERV

The retina is an organ frequently affected by ischemic changes. Retinal arterial occlusion can be considered the equivalent of stroke, in terms of presentation, management and treatment. In addition to a specific ophthalmological treatment systemic management is essential with an appropriate study and control of cardiovascular risk factors considering these patients of a very high cardiovascular risk. In this consensus document we aim to provide an update on this relatively frequent pathology in our practices, considering the importance of an early and systematic action.

Updates in the Management of Giant Cell Arteritis

PURPOSE OF THE REVIEW

To briefly review the latest updates in management in giant cell arteritis, an autoimmune vasculitis affecting the medium to large vessels.

RECENT FINDINGS

Here, we review the known and newer trends in management of giant cell arteritis. While high dose glucocorticoids remain the mainstay of therapy, immunosuppressive medications are increasingly utilized to reduce the burden and risk of long-term glucocorticoid use. Published guidelines by the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) suggest early use of steroid-sparing immunosuppressive medications in patients with recently diagnosed or relapsing giant cell arteritis. Immunosuppressive medications include oral small molecules such as methotrexate and leflunomide and biologics, including the recently Federal Drug Administration (FDA) approved tocilizumab. Glucocorticoids remain the cornerstone of management for newly diagnosed disease but with the increasing use of medications such as IL-6 inhibitors, patients are decreasing steroid use within weeks, thereby limiting risks associated with long-term steroid use.

Central retinal artery occlusion or retinal stroke: a neurosonologist's perspective

In central retinal artery occlusion (CRAO) or retinal stroke, which is usually a vision-threatening condition, timely diagnosis is imperative to improve the chances of retinal preservation and to establish adequate secondary prevention measures. Even though retinal strokes have been traditionally assigned to the field of ophthalmology, while considering reperfusion therapy as the only way to avoid permanent vision loss, we suggest prompt evaluation of CRAO causes (primarily related to cardiovascular risk factors) performed by a well-organized interdisciplinary team (ophthalmologist and neurologist) in a neurovascular center with stroke expertise. Therefore, the most suitable adjunct method for rapidly diagnosing non-arteritic CRAO could be target transorbital ultrasound, performed by an experienced neurologist/neurosonologist in the stroke unit. Consequently, after an ophthalmological assessment, a final decision on thrombolytic therapy could be made. We accept that further research is obviously needed to determine whether transorbital ultrasound could replace ophthalmological investigation in the case of a suspected acute retinal stroke. We assert that retinal stroke requires interdisciplinary treatment in cooperation with neurologists and ophthalmologists, with an additive value for each to achieve the best results for the patient.

Intrinsic stenosing and occlusive pathologies of the vertebral artery: A narrative review

Intrinsic pathologies of the vertebral arteries, such as atherosclerosis, dissection, fibromuscular dysplasia, radionecrosis and vasculitis, are important causes of vertebrobasilar insufficiency and cerebrovascular events. This review focuses on non-aneurysmal intrinsic stenosing and occlusive pathologies, covering their epidemiology, diagnosis, and treatment options. It also provides a detailed summary of key clinical presentations and syndromes, including an in-depth examination of lateral medullary syndrome, historically known as Wallenberg's syndrome, which is arguably the most emblematic condition resulting from vertebral artery involvement and is depicted in an illustrative cartoon.

A Case of Visual Hallucination With Frontal Lobe Infarction in a Patient With Giant Cell Arteritis

Giant cell arteritis (GCA) can produce a variety of visual symptoms. Among these, visual hallucinations are rare and are usually accompanied by visual loss. We encountered a 79-year-old female with GCA who presented with visual hallucinations without visual loss. Magnetic resonance imaging (MRI) of the head revealed a stroke in the right frontal lobe, probably caused by GCA, resulting in visual hallucinations. Visual hallucinations are not well recognized by clinicians as a presentation of GCA. However, as shown in the present case, visual hallucinations are an important symptom because they are suggestive of cerebral ischemia or visual loss.

Global epidemiology of vasculitis

The many forms of vasculitis are characterized by inflammation of blood vessels, leading to potentially long-term sequelae including vision loss, aneurysm formation and kidney failure. Accurate estimation of the incidence and prevalence has been hampered by the absence of reliable diagnostic criteria and the rarity of these conditions; however, much progress has been made over the past two decades, although data are still lacking from many parts of the world including the Indian subcontinent, China, Africa and South America. Giant cell arteritis occurs in those aged 50 years and over and seems to mainly affect persons of northern European ancestry, whereas Takayasu arteritis occurs mainly in those aged under 40 years. By contrast, Kawasaki disease mainly occurs in children aged under 5 years and is most common in children of Asian ancestry, and IgA vasculitis occurs in children and adolescents. Although much less common than giant cell arteritis, the different forms of antineutrophil cytoplasmic antibody-associated vasculitis are being increasingly recognized in most populations and occur more frequently with increasing age. Behçet syndrome occurs most commonly along the ancient silk road between Europe and China. Much work needs to be done to better understand the influence of ethnicity, geographical location, environment and social factors on the development of vasculitis.

Ocular Immune-Related Adverse Events Associated With Immune Checkpoint Inhibitors in Lung Cancer

Immune checkpoint inhibitors (ICIs) are novel immunotherapy-based drugs that have become increasingly popular in the treatment of lung cancer. Researchers have recognized ocular immune-related adverse events (irAEs) secondary to ICIs because of their vision-threatening characteristics. However, they are incompletely characterized and no studies have reported the ICI-related ocular irAEs in lung cancer. Therefore, we aimed to comprehensively illustrate the clinical characteristics, contributory factors, diagnosis, and management of ICI-related ocular irAEs in lung cancer, based on previously reported 79 patients. Ophthalmoplegia (40.51%), uveitis (20.25%), and dry eye (17.72%) were the most common ICI-related ocular irAEs in lung cancer. Ptosis was the most common (36.71%) and the highest mortality (23.33%) of ophthalmoplegia. Patients in Asia and patients who underwent combination therapy with programmed cell death-1 and cytotoxic T-lymphocyte-associated antigen 4 inhibitors demonstrated significantly higher frequency of ophthalmoplegia than other ocular irAEs. Most ICI-related ophthalmoplegia and uveitis in lung cancer were observed in the first 10 weeks following the initiation of ICIs. Furthermore, the onset time of dry eye and other ocular irAEs was much longer. In addition, 92.31% of the patients with ocular irAEs other than ophthalmoplegia could be remised. In conclusion, ocular irAEs secondary to ICIs in lung cancer are non-negligible, particularly ophthalmoplegia. Ethnicity and the type of ICIs play important roles in the distribution of ocular irAEs. ICI-related ophthalmoplegia in lung cancer presented with early onset and worse prognosis features, thus necessitating further attention.