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Temporal artery biopsy in the management of giant cell arteritis with neuro-ophthalmic complications
  1. Paul Riordan-Eva, lead clinician (paulreva@doctors.org.uk)a,
  2. Klara Landau (Landau@opht.unizh.ch)b,
  3. Justin O'Day (JustinODay@bigpond.com)c
  1. aDepartment of Ophthalmology, King's College Hospital, Denmark Hill, London SE5 9RS, UK, bNeuro-Ophthalmology and Strabismus Unit, University Hospital, Zurich, Switzerland, cDepartment of Ophthalmology, University of Melbourne and Royal Victorian Eye and Ear Hospital, Australia

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    Giant cell arteritis (GCA) with neuro-ophthalmic complications requires treatment with systemic steroids, initially in high dose and continued at a gradually reducing dose for at least 6 months and usually for 1 year or longer.1 There is a high risk of complications from the steroid therapy and thus the diagnosis of GCA needs to be as certain as possible. Histopathological evidence, usually by temporal artery biopsy, is the definitive investigation.2 However, patients are still being treated with systemic steroids without a biopsy being performed.

    Three actual cases are presented and discussed to illustrate the role of temporal artery biopsy in the management of possible GCA with neuro-ophthalmic complications.

    Case 1: “Occult GCA”

    A 75 year old white woman presented with sudden visual loss in her left eye. She denied any headache, scalp tenderness, jaw claudication, muscle pains, or systemic disturbance. The left eye was blind with a relative afferent pupillary defect and a pale, swollen, optic disc (Fig1), consistent with anterior ischaemic optic neuropathy (AION). The left temporal artery was not tender, but was cord-like and pulseless. The right temporal artery was pulsatile and not tender. Erythrocyte sedimentation rate (ESR) was 80 mm in the first hour. High dose systemic steroid therapy was instituted. Left temporal artery biopsy showed granulomatous inflammation with giant cells.

    Figure 1

    Case 1. Pallid swollen left optic disc.

    Despite the absence of classic systemic symptoms of GCA the index of suspicion for arteritic AION in this patient must be very high. The objective pointers to the diagnosis were (a) pallid swelling of the optic disc in a blind eye, (b) pulseless temporal artery, and (c) highly elevated ESR. “Occult GCA” has long been known to ophthalmologists.3 4 Patients present with severe ischaemic ocular complications and no systemic symptoms or signs of GCA. ESR may not be elevated …

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