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A Management Algorithm for Temporal Arteritis How Not to Miss this Blinding Disease

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No eye pain, headache, jaw claudication, muscle pain, fatigue, malaise, fever, ... Late Aug headache, Fatigue, jaw claudication, weight loss. Sept 23 Blur OD ... – PowerPoint PPT presentation

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Title: A Management Algorithm for Temporal Arteritis How Not to Miss this Blinding Disease


1
A Management Algorithm for Temporal ArteritisHow
Not to Miss this Blinding Disease
  • Duncan P. Anderson, MD
  • University of British Columbia
  • Division of Neuro-Ophthalmology

2
  • 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
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  • 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
  • temporal artery biopsy requested

Case Presentation, TA
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  • 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
  • treated with prednisone and coumadin

Case Presentation, TA
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  • 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
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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

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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

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  • 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

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  • 1 week after finished prednisone he developed
    decrease vision OS on awakening, now cant 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

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  • 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.

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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 Visual Hallucinations ESR 8
HM HM
V
16
EP 77 YEAR OLD ?
Late Aug headache, Fatigue, jaw claudication,
weight loss Sept 23 Blur OD
25 ESR gt 100 IV methylprednisolone 1gm/day x
3days 27 Blur OS IV
methylprednisolone 1gm/day x 3days oral
prednisone 100mg/day Oct 2 temporal
artery biopsy positive 18 tapered to
prednisone 20mg/day
LP LP
V
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Prevalence of giant cell arteritis ()
AGE
50 60 60 70 70 80 80 90
0.01 0.1 0.5 1.0
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CLINICAL positive LR negative LR
Headache Jaw Claudication Abn. temporal
artery Decreased Vision Diplopia Polymyalgia
rheum. Fatigue/weight loss
1.5 5.4 3.1 1.3 3.2 1.0 1.3
1.0 0.9 0.9 1.0 1.0 0.9 1.0
LR Likelihood Ratio
26
LAB positive LR negative LR
ESR lt50 50 100 gt100 ? Platelets
0.6 1.1 2.5 6.0
1.6 0.9 0.8 0.6
LR Likelihood Ratio
27
TEMPORAL ARTERITIS
  • GCA does not equal PMR
  • symptoms to diagnosis
  • diagnosis to Biopsy
  • Arteritic ION without GCA symptoms
  • False Negative biopsy 5

3 4 mos 1 wk 20
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THINK Temporal Arteritis
  1. Age gt 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

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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

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TREATMENT
  • p.o. Prednisone
  • 80 mg/d 1 - 2 weeks
  • 40 mg/d 2 - 3 months
  • 10 mg/d 1 - 2 years

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TREATMENT
  • IV Methylprednisolone 1 gm/day for
  • bilateral disease
  • second eye
  • progressive disease

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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

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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., ODay, 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.
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