Transcript Ischemic optic neuropathy: who should get a temporal artery biopsy?

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
• 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
• 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
Case Presentation, TA
temporal artery biopsy requested
• 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
Case Presentation, TA
treated with prednisone and coumadin
• 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
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
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
• 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
• 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
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.
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
HM
V HM
Visual Hallucinations
ESR 8
EP 77 YEAR OLD ♀
Late Aug
Sept 23
25
headache, Fatigue, jaw claudication,
weight loss
Blur OD
ESR > 100
IV methylprednisolone 1gm/day x 3days
27
Blur OS
IV methylprednisolone 1gm/day x 3days
oral prednisone 100mg/day
Oct 2
18
temporal artery
biopsy positive
LP
V
tapered to prednisone
20mg/day
LP
AGE
Prevalence of giant cell
arteritis (%)
50 – 60
0.01
60 – 70
0.1
70 – 80
0.5
80 – 90
1.0
CLINICAL
Headache
positive LR* negative LR
1.5
1.0
Jaw Claudication
5.4
0.9
Abn. temporal artery
3.1
0.9
Decreased Vision
1.3
1.0
Diplopia
3.2
1.0
Polymyalgia rheum.
1.0
0.9
Fatigue/weight loss
1.3
1.0
* LR = Likelihood Ratio
LAB
positive LR*
negative LR
ESR <50
0.6
1.6
50 – 100
1.1
0.9
>100
2.5
0.8
↑ Platelets
6.0
0.6
*LR = Likelihood Ratio
TEMPORAL ARTERITIS
• GCA does not equal PMR
• symptoms to diagnosis:
3 – 4 mos
• diagnosis to Biopsy:
1 wk
• Arteritic ION without GCA 20%
symptoms:
• False Negative biopsy
5%
THINK Temporal Arteritis
1) Age > 50
2) Ischemic Optic Neuropathy
3) Amaurosis Fugax
4) ION with ↓↓ acuity/White Disc
5) ION with CRAO/Choroidal
Ischemia
6) ↑ ESR, Creactive Protein,
Platelets
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
TREATMENT
p.o. Prednisone
80 mg/d
40 mg/d
10 mg/d
1 - 2 weeks
2 - 3 months
1 - 2 years
TREATMENT
IV Methylprednisolone
1 gm/day for:
• bilateral disease
• second eye
• progressive disease
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
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.