Eye Signs of Systemic Disease: Case 4 Giant Cell Arteritis

Sudden profound vision loss in her left eye prompted an82-year-old woman to seek evaluation. She also complainedof "just not feeling well" and reported new-onsettemporal and occipital headaches of 6 weeks' duration.Visual acuity was 20/40 in the right eye with a mildnuclear sclerotic cataract and hand motion vision in theleft eye. A positive relative afferent pupillary deficit wasnoted on the left side. A dilated fundus examination of theleft eye demonstrated a pallid swollen disc with venousengorgement and a cotton-wool spot within the supratemporalarcade (A). The patient's erythrocyte sedimentationrate (ESR) and C-reactive protein (CRP) level were grosslyelevated. A temporal artery biopsy confirmed the suspecteddiagnosis of giant cell arteritis (B).Giant cell arteritis--an inflammatory arteritis that affectsprimarily the medium-sized arterioles of the head andneck--is also called temporal arteritis or cranial arteritis.This disease is typically seen in elderly patients; symptomsinclude sudden unilateral or bilateral vision loss, diplopia, headache, scalp or temple tenderness, malaise, myalgiasand arthralgias, jaw claudication, recent weight loss and,possibly, altered mental status.When giant cell arteritis is strongly suspected, measurethe patient's ESR and CRP level immediately. If thevalues are extremely elevated, initiate either high-dose oralprednisone or intravenous methylprednisolone. A temporalartery biopsy is required for histopathologic confirmationof the disease.In this patient, oral prednisone, 80 mg/d, was initiatedafter her blood test results were known and before thebiopsy was performed. Her vision did not recover.Permanent loss of vision is common in giant cell arteritis.Treatment prevents further deterioration and lossof vision in the other eye.