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A Management Algorithm for Temporal Arteritis How Not to Miss this Blinding Disease

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

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A Management Algorithm for Temporal Arteritis How Not to Miss this Blinding Disease

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  1. A Management Algorithm for Temporal ArteritisHow Not to Miss this Blinding Disease Duncan P. Anderson, MD University of British Columbia Division of Neuro-Ophthalmology

  2. 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, TA

  3. 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 requested Case Presentation, TA

  4. 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 Presentation, TA

  5. 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 Presentation, TA

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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.

  11. 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 HM HM V

  12. 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/day LP LP V

  13. Prevalence of giant cell arteritis (%) AGE 50 – 60 60 – 70 70 – 80 80 – 90 0.01 0.1 0.5 1.0

  14. CLINICALpositive 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

  15. LABpositive 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

  16. 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%

  17. THINK Temporal Arteritis • Age > 50 • Ischemic Optic Neuropathy • Amaurosis Fugax • ION with ↓↓ acuity/White Disc • ION with CRAO/Choroidal Ischemia • ↑ ESR, Creactive Protein, Platelets

  18. 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

  19. TREATMENT p.o. Prednisone • 80 mg/d 1 - 2 weeks • 40 mg/d 2 - 3 months • 10 mg/d 1 - 2 years

  20. TREATMENT • bilateral disease • second eye • progressive disease • IV Methylprednisolone 1 gm/day for:

  21. 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

  22. BIBLIOGRAPHY Niederkohr, 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.

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