Ocular Complications of Giant Cell Arteritis: An Acute Therapeutic Emergency

Abstract

The risk of blindness, due to acute ischemic ocular events, is the most feared complication of giant cell arteritis (GCA) since the middle of the 20th century. A decrease of its rate has occurred after the advent of corticoid therapy for this vasculitis, but it seems to have stabilized since then. Early diagnosis and treatment of GCA is key to reducing its ocular morbidity. However, it is not uncommon for ophthalmological manifestations to inaugurate the disease, and the biological inflammatory reaction may be mild, making its diagnosis more challenging. In recent years, vascular imaging has opened up new possibilities for the rapid diagnosis of GCA, and ultrasound has taken a central place in fast-track diagnostic processes. Corticosteroid therapy remains the cornerstone of treatment and must begin immediately in patients with visual symptoms and suspicion of GCA. In that situation, the administration route of corticotherapy, intravenous or oral, is less important than its speed of delivery, any hour of delay worsening the prognosis.

Long delay from symptom onset to first consultation contributes to permanent vision loss in patients with giant cell arteritis: a cohort study

“…This reflects common knowledge among all physicians to immediately start glucocorticoid treatment on suspicion of GCA and then refer patients for further diagnostics. 4 40 …”

“…16 Transient visual symptoms, age and lower blood levels of inflammatory markers are risk factors for impending vision loss. 4 8 12 13 17–19 In contrast, polymyalgia and constitutional symptoms are associated with a reduced risk for PVL. 4 11 13 18 20 In histopathological studies, PVL has been inconsistently associated with the presence of giant cells and higher intimal hyperplasia scores in temporal artery biopsy.…”

“… 4 8 12 13 17–19 In contrast, polymyalgia and constitutional symptoms are associated with a reduced risk for PVL. 4 11 13 18 20 In histopathological studies, PVL has been inconsistently associated with the presence of giant cells and higher intimal hyperplasia scores in temporal artery biopsy. 21–24 Similarly, the detection of temporal arteritis by ultrasound has been associated with ocular ischaemia in some studies.…”

“… 8 However, once vision loss has occurred, it is usually permanent, and glucocorticoids are administered to preserve the remaining vision. 4 27 The introduction of fast-track clinics, including ultrasound as a first-line diagnostic tool for early GCA diagnosis, intended to reduce the incidence of PVL even further compared with conventional clinical practice. 28–30 In a recent study, a fast-track approach reduced PVL incidence by about 50%, but still, 12.7% experienced PVL.…”

“…2 Less often, blindness results from posterior ischaemic optic neuropathy (PION) or occipital lobe infarction. 3 Before the advent of glucocorticoid therapy for GCA, PVL occurred in 40%-48% [4][5][6][7] of cases and decreased to 10%-20% during the last decades, [8][9][10][11][12][13][14] due to an increased awareness of GCA-associated complications and the accepted practice among general practitioners (GPs) to immediately start systemic glucocorticoids in case of suspected GCA. 15 If left untreated, the risk for bilateral AION is high.…”