Eye Signs of Systemic Disease: Case 4 Giant Cell Arteritis

Sudden profound vision loss in her left eye prompted an 82-year-old woman to seek evaluation. She also complained of “just not feeling well” and reported new-onset temporal and occipital headaches of 6 weeks’ duration. Visual acuity was 20/40 in the right eye with a mild nuclear sclerotic cataract and hand motion vision in the left eye. A positive relative afferent pupillary deficit was noted on the left side. A dilated fundus examination of the left eye demonstrated a pallid swollen disc with venous engorgement and a cotton-wool spot within the supratemporal arcade (A). The patient’s erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level were grossly elevated. A temporal artery biopsy confirmed the suspected diagnosis of giant cell arteritis (B). Giant cell arteritis—an inflammatory arteritis that affects primarily the medium-sized arterioles of the head and neck—is also called temporal arteritis or cranial arteritis. This disease is typically seen in elderly patients; symptoms include sudden unilateral or bilateral vision loss, diplopia, headache, scalp or temple tenderness, malaise, myalgias and arthralgias, jaw claudication, recent weight loss and, possibly, altered mental status. When giant cell arteritis is strongly suspected, measure the patient’s ESR and CRP level immediately. If the values are extremely elevated, initiate either high-dose oral prednisone( or intravenous methylprednisolone(. A temporal artery biopsy is required for histopathologic confirmation of the disease. In this patient, oral prednisone, 80 mg/d, was initiated after her blood test results were known and before the biopsy was performed. Her vision did not recover. Permanent loss of vision is common in giant cell arteritis. Treatment prevents further deterioration and loss of vision in the other eye.