A Management Algorithm for Temporal Arteritis
How Not to Miss this Blinding Disease
Duncan P. Anderson, MD
University of British Columbia
Division of Neuro-Ophthalmology
55 year old female
• 96 09 01: Frontal headache – acetaminophen
• 96 09 15: Diplopia, left ptosis, 20 minutes of blurred vision after bending/lifting
• 96 10 01: Increased headache (10/10), photophobia, diplopia, blurred vision, Left III palsy, dilated pupil, 20/100 OS
Case Presentation, Case Presentation, TATA
• 96 10 02: Admitted to hospital. Normal head CT head, normal fundi, blind OS
Angiogram requested. ESR 28 Left III palsy, 20/20 – NLP, Left afferent +
efferent pupil defects Ophthalmodynanometry 50/20 – 0/0 Left Central Retinal Artery Occlusion Admits decreased appetite, weight, jaw pain treated with i.v. methylprednisolone, heparin temporal artery biopsy requestedCase Presentation, Case Presentation,
TATA
• 96 10 03: temporal artery biopsy positive 20/20 OD, no light perception OS ophthalmodynamometry 40/20 OD, 1/10 OS intraocular pressure 10mmHg OD, 2mmHg OS left ophthalmic artery occlusion, bilateral carotid stenosis
• 96 10 09: 20/20 OD, no light perception OS ophthalmodynamometry 40/20 OD, 10/5 OS intraocular pressure 15mmHg OD, 6mmHg OS treated with prednisone and coumadin
Case Case Presentation, TAPresentation, TA
• 96 11 05: 20/20 OD, no light perception OS ophthalmodynanometry 70/30 OD, 35/10 OS intraocular pressure 16 OD, 12 OS mmHg left III palsy improving Prednisone 80 mg/day
• 97 11 05: stopped steroids Blurriness ]right eye, headache, ESR 42 Prednisone re-started at 60 mg/day• 98 04 : tapered to Prednisone 10 mg/day
Case Case Presentation, TAPresentation, TA
HISTORY• 91 year-old male• awoke with decrease vision OD 6 days ago,
involving superior field• Bad vision OS due to infection at age of six• Past history: hypertension, diabetes, well
controlled• No eye pain, headache, jaw claudication,
muscle pain, fatigue, malaise, fever, temporal artery tenderness, pain on combing hair, or anorexia
EXAMINATION
• Visual acuity: 20/200 OD, 20/100 OS
• Right relative afferent pupil defect
• Fundus: pale swollen disc OD
normal OS
normal retinal artery pressure
• No temporal artery tenderness
• ESR 22mm/hr
• Diagnosis – 1.Nonarteritic anterior ischemic optic
neuropathy RE
- 2. left corneal scar• No evidence to suggest temporal arteritis• Treatment: prednisone 60 mg/day to reduce
swelling for 5 days
• 1 week after finished prednisone he developed decrease vision OS on awakening, now can’t get around the house
• No other symptoms of temporal arteritis
• VA: hand motion OD, light perception OS
• Fundus: pale flat right optic disc
swollen pale left disc
Diagnosis 1.Bilateral anterior ischemic optic neuropathy suspect arteritic cause
Plan: immediate temporal artery biopsy
Rx: predisone 1000 mg/day x 2 day then taper off
• Temporal artery biopsy positive for arteritis• ESR 34/hr• Final visual acuity: count fingers OD, hand
motion OS.
JW 85 YEAR OLD ♀Sept 25 Flashes & Blur OD
26 Flashes & Blur OS
ESR 71 – No arteritic symptoms
i.v. methylprednisolone 1gm/day for 6 days
then oral prednisone 100mg/day
Oct 2 ESR 24
TAB Positive
12 Visual Hallucinations
ESR 8
VHM
HM
EP 77 YEAR OLD ♀Late Aug headache, Fatigue, jaw claudication,
weight loss
Sept 23 Blur OD
25 ESR > 100
IV methylprednisolone 1gm/day x 3days
27 Blur OS
IV methylprednisolone 1gm/day x 3days oral prednisone 100mg/day
Oct 2 temporal artery biopsy positive
18 tapered to prednisone 20mg/dayVLP
LP
AGEPrevalence of giant cell arteritis (%)
50 – 60
60 – 70
70 – 80
80 – 90
0.01
0.1
0.5
1.0
CLINICAL positive LR* negative LR
Headache
Jaw Claudication
Abn. temporal artery
Decreased Vision
Diplopia
Polymyalgia rheum.
Fatigue/weight loss
1.5
5.4
3.1
1.3
3.2
1.0
1.3
1.0
0.9
0.9
1.0
1.0
0.9
1.0* LR = Likelihood Ratio
LAB positive LR* negative LR
ESR <50
50 – 100
>100
↑ Platelets
0.6
1.1
2.5
6.0
1.6
0.9
0.8
0.6
*LR = Likelihood Ratio
TEMPORAL ARTERITIS
• GCA does not equal PMR
• symptoms to diagnosis:
• diagnosis to Biopsy:
• Arteritic ION without GCA symptoms:
• False Negative biopsy 5%
3 – 4 mos
1 wk
20%
THINK Temporal Arteritis1) Age > 50
2) Ischemic Optic Neuropathy
3) Amaurosis Fugax
4) ION with ↓↓ acuity/White Disc
5) ION with CRAO/Choroidal Ischemia
6) ↑ ESR, Creactive Protein, Platelets
TEMPORAL ARTERITIS
• 5 – 10% Arteritic ION lose acuity after Steroids (5d)
• 0.5% temporal arteritis lose acuity Post Steroids
• IV = PO Steroid Effect
• temporal arteritis can remain active ½ - 10 years
• Taper Steroids while following symptoms & ESR/CRP
• Re – Biopsy for Confirmation if necessary
TREATMENT
p.o. Prednisone
80 mg/d 1 - 2 weeks 40 mg/d 2 - 3 months 10 mg/d 1 - 2 years
TREATMENT
• bilateral disease
• second eye
• progressive disease
IV Methylprednisolone 1 gm/day for:
SUMMARY - TEMPORAL ARTERITIS
Diagnosis: • history
• temporal artery biopsy within 1 - 2 weeks
Treatment: • steroids (STAT) • medical emergency
• taper slowly (mos) • manage steroid complications • switch to methotrexate
BIBLIOGRAPHYNiederkohr, R.D. & Levin, L.A. (2005). Management of the Patient with Suspected Temporal Arteritis: A Decision – Analytic Approach. Ophthalmology, 112(5), 744 – 1060.
Younge, B.R., Cook Jr., B.E., Bartley, G.B., Hodge, D.O., Hunder, G.G. (2004). Initiation of Glucocorticoid Therapy: Before or After Temporal Artery Biopsy? Mayo Clin Proc, 79, 483 – 491.
Hayreh, S.S., Zimmerman, B. (2003). Visual Deterioration in Giant Cell Arteritis Patients While on High Doses of Corticosteroid Therapy. Ophthalmology, 110(6), 1204 – 1215.
Smetana, G.W., Shmerling, R.H. (2002). Does This Patient Have Temporal Arteritis? JAMA, 287(1), 92 – 101.
Riordan-Eva, P., Landau, K., O’Day, J. (2001). Temporal artery biopsy in the management of giant cell arteritis with neuro-ophthalmic complications. Br J Ophthalmol, 85, 1248 – 1251.
Hayreh, S.S., Podhajsky, P.A., Zimmerman, B. (1998). Ocular Manifestations of Giant Cell Arteritis. Am J Ophthalmol, 125(4), 509 – 520.
Hayreh, S.S., Podhajsky, P.A., Zimmerman, B. (1998). Occult Giant Cell Arteritis: Ocular Manifestations. Am J Ophthalmol, 125(4), 521 – 526.