From the Guidelines
Temporal arteritis can cause serious vision complications, including sudden, permanent vision loss, and immediate treatment with high-dose corticosteroids is essential to prevent vision loss, as recommended by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis 1. The most concerning complication is anterior ischemic optic neuropathy, which occurs when inflammation blocks blood flow to the optic nerve. The standard regimen is prednisone 40-60mg daily, started as soon as temporal arteritis is suspected, even before biopsy confirmation, as supported by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1. For patients with visual symptoms, methylprednisolone 500-1000mg IV daily for 3 days may be given before transitioning to oral prednisone. Vision loss that has already occurred is usually permanent, but prompt treatment prevents involvement of the other eye, which occurs in up to 50% of untreated cases. Other vision complications include:
- Diplopia (double vision)
- Amaurosis fugax (temporary vision loss)
- Visual field defects Patients should be monitored by an ophthalmologist during treatment, and the steroid dose should be tapered slowly over 12-24 months to prevent relapse, as suggested by the diagnostic accuracy of symptoms, physical signs, and laboratory tests for giant cell arteritis study 1. The inflammation in temporal arteritis affects the medium and large arteries, particularly branches of the carotid artery that supply the eyes, leading to these vision complications. Key points to consider in the diagnosis and management of temporal arteritis include:
- High index of clinical suspicion to consider giant cell arteritis in the differential diagnosis
- Laboratory testing such as elevated sedimentation rate or C-reactive protein and a compatible semiology may be the only available elements to make a decision to initiate treatment
- Ultrasound finding of a halo sign surrounding a temporal artery may be helpful in diagnosis
- Biopsy confirmation should not be imperative to initiate treatment in cases in which giant cell arteritis seems to be the most likely diagnosis, as recommended by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1.
From the Research
Vision Complications from Temporal Arteritis
- Temporal arteritis, also known as giant cell arteritis, is a condition that can cause vision complications, including blindness 2.
- The condition is characterized by inflammation of the blood vessels, including the temporal artery, which supplies blood to the eyes 3.
- Vision complications can occur due to the inflammation of the blood vessels, which can lead to ischemia and damage to the optic nerve 2.
Diagnosis and Treatment
- Temporal artery biopsy is a common diagnostic test used to confirm the diagnosis of temporal arteritis 3, 4.
- The biopsy involves removing a small sample of tissue from the temporal artery and examining it for signs of inflammation and giant cells 3.
- Corticosteroids are commonly used to treat temporal arteritis, and the duration of treatment can affect the positivity of temporal artery biopsy 4, 5, 6.
- The decision to perform a temporal artery biopsy and the choice of treatment depend on several factors, including patient age, symptoms, and clinical findings 2.
Effect of Corticosteroid Treatment on Biopsy Results
- Previous corticosteroid treatment can affect the biopsy results, with some studies suggesting that the diagnostic yield of temporal artery biopsy is valuable within 4 weeks of starting high-dose steroid treatment 5.
- Other studies have found that the positivity rate of temporal artery biopsy is similar in untreated and corticosteroid-treated patients 6.
- The duration of corticosteroid treatment seems to affect the positivity of temporal artery biopsy, with a more than 7 days' duration of steroid treatment linked to lower rates of positive biopsy 4.