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.