Question of the Week

You are the resident on-call when a 72-year-old man presents with sudden loss of vision in his right eye. He has also been experiencing a headache on his right side that has not responded to Tylenol or ibuprofen. This morning, he noticed a new pain while chewing. BCVA is HM OD and 20/25 OS. Fundus exam (shown below) of the right eye is suggestive of AION (anterior ischemic optic neuropathy). Given these symptoms and exam findings, you suspect a diagnosis of Giant Cell Arteritis (GCA). You begin treatment with 60 mg per day of oral prednisolone. You plan to confirm your diagnosis with a temporal artery biopsy. The image demonstrates AION due to GCA, likely caused by inflammatory occlusion of the posterior ciliary arteries.

Which of the following statements regarding this case is TRUE?

A. If blood tests were ordered, we should expect increased erythrocyte sedimentation rate (ESR) or decreased C-reactive protein (CRP).

B. If not treated, in up to 10% of patients the second eye may become blind within the next 6-12 months.

C. 80% of patients will regain lost vision after completing the steroid therapy.

D. Initial treatment with intravenous methylprednisolone would have been more appropriate.

E. Due to the complications of steroid treatment such as steroid-induced diabetes, arterial hypertension, cataract, and osteoporosis, you should have waited for the biopsy results before initiating treatment.

Answer

Explanation:

The correct answer is D. In patients with suspected GCA and vision loss, intravenous (IV) methylprednisolone is often preferred over oral steroids, especially in cases of acute, severe visual impairment. The primary purpose of the therapy is not to restore any vision loss (C), but to prevent damage to the other eye. Therefore, initiating IV steroids is considered a more aggressive approach when the vision is threatened or already compromised. After IV therapy, the patient can be transitioned to high-dose oral prednisone. If you had a patient with suspected GCA and intact visual function, it would be appropriate to begin treatment with oral steroids. When GCA is suspected, it is important to initiate therapy quickly (despite the side effects) instead of waiting for a confirmatory test (E) because if not treated, up to 60% of patients may become blind in the second eye within just a few days (B). Finally, because GCA is an inflammatory condition that affects the blood vessels, patients typically present with elevated inflammatory markers such as both ESR and CRP (A).

Source:

Ness T, Bley TA, Schmidt WA, Lamprecht P. The diagnosis and treatment of giant cell arteritis. Dtsch Arztebl Int. 2013 May;110(21):376-85; quiz 386. doi: 10.3238/arztebl.2013.0376. Epub 2013 May 24. PMID: 23795218; PMCID: PMC3679627.

https://webeye.ophth.uiowa.edu/eyeforum/article/gca/index.htm#gsc.tab=0