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Show Journal of Neuro- Ophthalmology 21( 4): 266- 273, 2001. © 2001 Lippincott Williams & Wilkins, Inc., Philadelphia Original Contribution Visual Function and Quality of Life Among Patients with Giant Cell ( Temporal) Arteritis Mark J. Kupersmith, MD, Robert Speira, MD, Regina Langer, MS, Margorie Richmond, RN, Margaret Peterson, PhD, Harry Speira, MD, Hal Mitnick, MD, and Stephen Paget, MD Objective: To investigate patient perception of visual and systemic disability associated with giant cell arteritis ( GCA) and whether the perceived disability can be correlated with visual performance measures. Methods: We prospectively evaluated and compared the visual performance and quality of life survey for 20 patients with GCA after 4 to 5 weeks of corticosteroid therapy and after one year of therapy. We measured visual acuity, contrast sensitivity, and threshold perimetry and patients completed the Activities of Daily Vision Scale ( ADVS) and the short- form of the Health Survey ( SF- 36). The results were grouped by GCA affected or unaffected eye or by better or worse eye and reported as a decimal and percent impairment for acuity, log units for contrast, mean deviation and the Advanced Glaucoma Intervention Study ( AGIS) score for perimetry. The results for patients with and without visual loss were compared. Correlation analyses between ADVS categories and visual performance measures, SF- 36 categories and the presence of visual loss, total corticosteroid dose, systemic symptoms, secondary hypertension or diabetes mellitus, the presence of vertebral fracture, and visual performance were performed. Results: Day driving was the only ADVS category significantly reduced at baseline in patients with visual loss ( 62.5) compared with those without visual loss ( 96.3, P = 0.04). Modest to moderate correlations between ADVS categories were most frequent for percent binocular acuity impairment with day driving ( r = - 0.62, P = 0.017), with distance vision ( r = - 0.5, P = 0.02), and with glare ( r = - 0.59, P = 0.006); and the AGIS score of the worse eye with day driving ( r = - 0.66, P = 0.01), with near vision ( r = - 0.49, P = 0.03), and with glare ( r = - 0.48, P = 0.04). The baseline SF- 36 scores did not correlate with the presence of vision loss at baseline or Hyman- Newman Institute for Neurology and Neurosurgery at Beth Israel Medical Center, New York, New York Eye and Ear Infirmary, New York University School of Medicine, Hospital for Special Surgery, New York Hospital, Mount Sinai Hospital, New York, New York. Address correspondence and reprint requests to Mark I. Kupersmith, MD, Beth Israel North, The INN 170 East End Ave., New York, NY 10128; E- mail: mkuper@ bethisraelny. org Support provided by The Andrus Foundation, Washington, DC, and The Arthritis Foundation, New York. systemic complications. The ADVS and SF- 36 scores were similar at one year. The total dose of corticosteroids only had a modest correlation with the one- year mental health score ( r = - 0.45, P = 0.05), but there was no correlation between SF- 36 scores and other systemic side effects of steroid therapy. Conclusion: Except for the day driving score, the ADVS did not differ between patients with and without visual loss. The SF- 36 did not distinguish between patients with and without visual loss and did not reveal significant trends. The ADVS and SF- 36 did not reveal significant disability in GCA patients and there were no strong correlations with any visual performance or systemic measures. Unless treatment with corticosteroids is begun early, visual loss, which is frequently severe, occurs in almost 50% of patients with giant cell arteritis ( GCA). The inflammatory changes of the ophthalmic artery branches lead to ischemia of the orbital tissues and profound optic neuropathy, retinal and choroidal infarction, and less commonly ocular movement limitation ( 1^). When a patient experiences monocular visual loss, corticosteroid therapy is initiated as soon as the diagnosis is suspected because in approximately 33% of untreated patients, the second eye will lose vision within several weeks ( 5). Unfortunately, the required long- term duration ( typically 6 to 24 months) of treatment with corticosteroids can cause severe systemic complications ( osteoporosis, gastric ulcer, diabetes, high blood pressure, immunosuppression, depression, weight gain) ( 6,7) and less often, ocular morbidity ( cataract, glaucoma) ( 8- 11). Thus, both the disease and the therapy can lead to significant visual, physical, social, and emotional functional disability. The severity of disease and the effects of therapies on daily living activities can be evaluated using methods that have been used to evaluate patients perceived visual and global function disability in several ophthalmic disorders, including cataract, glaucoma, and retinal diseases ( 12,13,14). In applying this approach to patients with GCA several issues should be addressed: 266 GIANT CELL ARTERITIS 267 1. Do patients with GCA caused visual loss have more visual impairment in daily activities than those without GCA associated visual loss? 2. At one year, after six to twelve months of corticosteroids, do patients with GCA have a change in their perceived visual, emotional, physical, or social functioning? 3. Does the GCA patient's perceived visual disability correlate with accepted measures of visual function? 4. Does six to twelve months of corticosteroid therapy worsen the disability or create a systemic or ocular disorder that reduces the GCA patient's perceived ability to function? To answer these questions we assessed patients entered into a prospective clinical trial at three university medical center rheumatology and neuro- ophthalmology services. The primary goal of the study was to compare conventional corticosteroid therapy with a combination of methotrexate and corticosteroid treatment to address the question of disease control and rate of drug related complications. However, difficulties with recruitment precluded sufficient numbers to answer the question whether methotrexate is beneficial but the prospective collection of data on visual performance ( 15) and quality of life measures has provided informative results. PATIENTS AND METHODS Inclusion criteria, clinical studies Patients age more than 55 years with giant cell arteritis who met study criteria for diagnosis were entered into a randomized, prospective, placebo- controlled study. The criteria that is more exact than the classification of the American College or Rheumatology to ensure the inclusion only of patients with GCA included: 1. Patients must have symptoms suggestive of GCA and a temporal artery biopsy ( performed within one week of steroid initiation), with signs of panarteritis including chronic inflammatory cells, disruption of the internal elastic lamina, with or without giant cells, except for 2 or 3. 2. Patients with acute anterior or posterior ischemic optic neuropathy with symptoms suggestive of GCA, and ESR more than 60 mm/ h ( without other cause for elevated ESR, i. e., blood dyscrasia, lymphoma, tuberculosis, renal failure) even if negative temporal artery biopsy. 3. Patients with symptoms suggestive of GCA and pulseless disease with ESR more than 60 mm/ h. Patients were excluded if they had additional visual or systemic illnesses that contraindicated the use of corticosteroids or methotrexate or could complicate or bias the study. Twenty of the 22 patients participated in the quality of life evaluations with the two additional patients excluded because they did not have quality of life assessments at the baseline evaluation. Patients with symptoms or signs of ophthalmic involvement were examined immediately prior to or after the onset of visual disturbance by MJK. Study baseline and all subsequent evaluations ( 1, 3, 6, and 12 months) included full ophthalmologic evaluation with best corrected visual acuity testing using Bailey- Lovie logMAR chart under standard conditions, contrast sensitivity testing using Peli- Robson charts under standard conditions ( 16), complete ophthalmologic examination, and visual field testing with the Humphrey 24- 2 strategy. For OU, the visual acuity was expressed as decimal ( 20/ 20 = 1.0, finger counting = 0.012, hand motion = 0.006 , light perception = 0.001 , no light perception = 0), the lowest contrast seen in log units of contrast, and the visual field threshold as mean deviation ( MD). For each patient, the AMA guide to permanent impairment was used to determine a percent of central vision impairment for the eye with worse acuity and a percent binocular impairment for both eyes using the visual acuity ( 17). In addition, the visual fields were scored using the AGIS scoring system ( 18). All patients initially received daily corticosteroid therapy ( range from 40 mg to 1000 mg) after diagnosis as determined by the patient's physician and the severity of the disease. Over four to five weeks the daily steroid dose was reduced to the equivalence of 30 to 40 mg of prednisone at which time ( baseline) each patient was entered into the study. The suggested regimen for subsequent prednisone therapy included a gradual reduction by 5 mg per week until attaining 20 mg daily at the end of the second month followed by tapering by 2.5 mg per week until the drug was completely suspended or symptoms or signs of a relapse occurred that were unresponsive to changing the study drug ( methotrexate or placebo). At baseline, patients were randomized to the addition of either oral placebo or methotrexate of 10 mg per week to the daily steroid dose. If a relapse occurred and no sign of drug toxicity existed, the study drug, not the prednisone, was to be increased. At one year, if a remission was achieved, the study drug was to be reduced until it was completely withdrawn. There were 11 patients in the methrotrexate group and nine patients in the placebo group. Patients in both groups received comparable initial doses and total cumulative doses at one year ( mean 6,184 mg, SD 2,048 for methotrexate group, mean 5,436 mg, SD 1,600 for placebo group, P = 0.39) of prednisone. All patients received 1500 mg/ d of calcium carbonate and 400 IU of vitamin D to prevent osteoporosis, folic acid 1 mg orally each day, an H- 2 blocking agent or carafate 1 g daily to prevent gastrointestinal ulceration. After additional drugs to prevent osteoporosis became available, seven patients received one of these agents, usually after several months of starting steroids. When necessary, the appropriate agent was added to control blood pressure or blood glucose. Radiographs were taken of the spine and hip at baseline and at one year to determine the prevalence of fractures after one year of corticosteroid therapy. J Neuro- Ophthalmol, Vol. 21, No. 4, 2001 268 M. J. KUPERSMITH ET AL. Quality of life measurements At baseline and at each visit, in addition to a standardized examination, patients were asked whether they experienced any of these nine symptoms of GCA: jaw claudication, polymyalgia rheumatica, tongue claudication, fever, ischemia of the extremities, headache, malaise, unintentional weight loss, loss of appetite. We also prospectively documented the new onset or significant worsening of diabetes mellitus, systemic hypertension, hip and vertebral fractures, or osteoporosis in the hip and spine. At baseline and at one year, patients were administered a quality of life assessment in person or by telephone by the clinical coordinator ( RL) who was blinded to the patients medications. The first part of the questionnaire was the SF- 36 Health Survey ( 19,20), which assesses 8 areas: limitations in physical function ( PF), social function ( SF), or usual role activities due to health problems ( RP), bodily pain ( BP), limitation in usual role due to emotional problems ( RE, emotional role), vitality ( VT), general health ( GH), and mental health ( MH). The second part of the questionnaire used the Activities of Daily Vision Scale ( ADVS) developed by Mangione et al. ( 21,22) These questions asked about the individuals ability to perform night driving ( ND), day driving ( DD), see at distance ( DV) and near ( NV), and handle glare ( GL). Data analysis The values for ADVS ( 21,22) and SF- 36 ( 19,20) categories were normalized. Higher scores suggested better visual and daily living functioning. Because there was no difference for the ADVS or SF- 36 scores between the placebo and methotrexate treated patients, their data are reported together. Data were grouped by the presence or absence of GCA associated visual loss. Data from the one patient with congenital vision loss in one eye and no GCA caused vision loss were grouped with the patients without GCA loss ( in fact, the baseline ADVS and SF- 36 scores were approximately at the median for the scores obtained from the patients without GCA vision loss). The data were analyzed to determine whether patients with GCA visual loss had quality of life scores significantly different than patients without visual loss and whether the quality of life measures at one year changed after treatment with steroids. The mean for the five categories of ADVS and for eight categories of the SF- 36 at baseline and at one year were compared for all patients using the t test and for patients with visual loss and patients without visual loss using the Wilcoxan signed- rank test ( 23). We also determined the 95% confidence intervals for each ADVS category for patients with and without visual loss. The baseline visual acuity, contrast sensitivity, mean deviation and AGIS score for the worse eye and the visual acuity, mean deviation and AGIS score for the better eye for each patient, the percent central vision impairment of the worse eye, and the percent binocular central impairment for each patient were correlated with each of the five categories of the ADVS using the Spearman rank correlation method ( 23). The Spearman rank correlation was used to evaluate the number of GCA symptoms, the various visual performance parameters at baseline with the baseline score in each baseline SF- 36 category and the total cumulative dose of corticosteroid, hypertension, diabetes mellitus, and hip or vertebral fracture at one year with the score in each one- year SF- 36 category. There were too few systemic GCA symptoms at one year to measure a potential correlation with the SF- 36 scores. For all correlation values, only values with a P value less than 0.05 were considered significant with relationships categorized as weak ( r < 0.32), modest ( r = 0.32 to 0.55), moderate ( r > 0.55 to 0.75), or strong ( r > 0.75). RESULTS Baseline vision GCA caused visual loss ( anterior ischemic optic neuropathy or central retinal artery occlusion) was present at baseline in five eyes of four patients; the other 16 GCA patients had no ischemic visual loss ( Table 1). One patient in the group without GCA visual loss had one eye with a congenital toxoplasmosis maculopathy and a visual acuity of 0.05. The remainder of the eyes had minimal or no visual performance abnormalities secondary to baseline cataract, glaucoma, age related maculopathy. TABLE 1. Baseline visual performance Patients with no visual loss, mean SD Patients with visual loss, mean SD P = Worse eye acuity 0.71 0.27 0.21 0.30 0.004 Better eye acuity 1.11 0.35 1.04 0.41 0.87 Worse eye contrast, log units 1.36 0.31 0.24 0.39 0.0001 Better eye contrast log units 1.43 0.31 1.26* 0.26 0.31 Worse eye MD db - 5.87 2.40 - 24.38 8.44 0.0001 Better eye MD db -. 390 2.72 - 7.94* 9.83 0.19 Central impairment worse eye, % 12.1 23.3 78.8 37.9 0.0003 Binocular impairment, % 4.4 6.1 27.7 22.1 0.002 Worse eye AGIS 5.14 0.57 15.8 6.94 0.0002 Better eye AGIS 2.36 1.18 6.4* 6.71 0.09 * Includes the results from the less- affected eye in the case of bilateral GCA ischemia, with visual acuity of 0.2, MD ( mean deviation) = - 26.9, contrast sensitivity 1.0 log units, and AGIS ( Advanced Glaucoma Intervention Study) score of 19. / Neuro- Ophthalmol, Vol. 21, No. 4, 2001 GIANT CELL ARTERITIS 269 TABLE 2. Comparison ofADVS in patients with and without vision loss at baseline and one year Baseline, cases vision loss 95% CI Baseline, cases no vision loss 95% CI Baseline, cases no vision loss vs cases with vision loss, P = One year, cases vision loss 95% CI One year vs baseline cases vision loss P = One year, cases no vision loss 95% CI One year, cases no vision loss vs baseline no vision loss P = One year no vision loss vs vision loss, P = Baseline, all cases One year, all cases One year vs baseline, all cases P = Night driving Mean, SD 60.0, 28.8 20.0- 100.0 77.8, 28.0 55.0- 100.6 0.46 56.3, 32.7 10.9- 101.6 0.59 83.9,21.5 68.8- 99.0 0.40 0.34 71.4,29.5 75.3, 28.6 0.73 Day driving Mean, SD 62.5, 34.6 14.5- 110.5 96.3, 10.5 87.8- 104.8 96.3 vs 62.5 0.04 63.3, 37.5 11.3- 115.4 0.65 83.3, 19.2 67.6- 99.0 0.18 0.07 84.2, 27.6 76.2, 28.8 0.48 Distance vision Mean, SD 71.2,26.1 34.9- 107.4 86.2, 16.8 76.5- 95.8 0.42 69.2,29.1 28.8- 109.5 0.72 93.3, 8.6 88.1- 98.4 0.14 0.22 82.4, 20.6 86.9, 19.7 0.50 Near vision Mean, SD 70.8, 31.5 27.0- 114.5 96.5, 4.4 94.0- 99.0 0.22 65.9, 21.8 35.6- 96.2 0.89 92.3, 8.9 87.0- 97.7 0.08 0.22 90.1, 19.7 85.4, 17.9 0.45 Glare Mean, SD 51.2, 26.3 14.7- 87.8 85.1, 14.0 77.1- 93.2 0.22 65.0, 18.4 39.4- 90.6 0.14 91.8, 12.1 84.6- 99.1 91.8 vs 85.1 0.01 0.27 76.7,23.1 84.8, 13.4 0.25 Bold for correlation with P £ 0.05. The means for visual acuity, contrast sensitivity, AGIS score, and mean deviation for eyes with visual loss were significantly worse than the results in eyes without visual loss. Although, there was a trend for worse percent of binocular impairment in patients with visual loss than those without loss, it was not significant ( P = 0.08). Baseline quality of life measures and correlations Patients with and without GCA visual loss averaged three other symptoms of systemic GCA ( Tables 2 and 3, Figs. 1 and 2). There was no particular symptom that was significantly more prevalent in either group. In particular, 3 of 5 patients with vision loss and 6 of 15 patients without vision loss had jaw claudication. Patients with visual loss had markedly reduced day driving score ( mean 62.5, P = 0.04) compared with patients without visual loss ( mean 96.3) ( Fig. 1, Table 2). There was a trend for patients with visual loss to have worse night driving, distance vision, near vision, and glare scores as well. The one patient with bilateral visual loss had the worst score in all ADVS categories: night driving 12.5, DD 0, DV 30, NV 19.4, GL 31.2. TABLE 3. Spearman rank correlation of baseline ADV categories Worse eye acuity* correlation value P = Worse eye contrast sensitivity* correlation value P = Worse eye MD* correlation value P = % worse eye central impairment* correlation value P = % binocular impairment* correlation value P = Better eye acuity* correlation value P = Better eye MD* correlation value P = Worse eye AGIS* correlation value P = Better eye AGIS* correlation value P = % binocular impairment at one yearf correlation value P = ND 0.43 0.13 0.13 0.67 0.43 0.13 - 0.47 0.09 - 0.45 0.10 0.24 0.42 0.47 0.09 - 0.44 0.13 - 0.41 0.17 - 0.36 0.15 DD 0.50 0.07 0.53 0.06 0.60 0.02 - 0.54 0.04 - 0.62 0.017 0.07 0.81 0.28 0.34 - 0.66 0.01 - 0.40 0.17 - 0.36 0.20 DV 0.41 0.07 0.14 0.58 0.04 0.86 - 0.43 0.05 - 0.50 0.02 0.62 0.004 0.37 0.10 - 0.19 0.44 - 0.31 0.19 - 0.58 0.008 NV 0.07 0.76 0.23 0.34 0.16 0.50 - 0.09 0.71 - 0.19 0.42 0.23 0.33 0.35 0.14 - 0.49 0.03 - 0.42 0.07 - 0.56 0.01 GL 0.53 0.02 0.19 0.44 0.28 0.23 - 0.54 0.15 - 0.59 0.006 0.41 0.07 0.36 0.12 - 0.48 0.04 - 0.60 0.007 - 0.52 0.02 Bold for correlation with P £ 0.05. * Baseline visual performance. f One- year visual performance. J Neuro- Ophthalmol, Vol. 21, No. 4, 2001 270 M. J. KUPERSMITH ET AL. Glare score Near vision Distance vision Day driving Night driving FIG. 1. The mean ADVS for all patients, patients with GCA visual loss, and patients without visual loss are expressed as a percent score along the x axis. At baseline, the day driving ( P = 0.04) was significantly worse in patients with visual loss compared with patients without visual loss ( remaining P value range 0.22- 0.46). At one year, the ADVS scores were lower, but not significantly, for patients with visual loss than for those without visual loss ( range of P values 0.07- 0.34). DOne Year, Patients, Visual Loss • One Year, Patients, No Visual Loss • Baseline, Patients, Visual Loss D Baseline, Patients, No Visual Less The AGIS score of the worse eye and the percent binocular impairment had the most significant correlations with the ADVS ( Table 3). Night driving did not demonstrate significant correlation with any other visual parameter. Day driving demonstrated a moderate correlation with the worse eye mean deviation ( P = 0.60), a moderate negative correlation with the percent of binocular impairment ( P = - 0.62) and the AGIS score of the worse eye ( P = - 0.66), and a modest negative correlation with the percent of central impairment in the worse eye ( P = - 0.54). The distance vision had a moderate correlation ( P = 0.62) with better eye acuity. The FIG. 2. The mean SF- 36 scores for all patients, patients with GCA visual loss and patients without visual loss are expressed as a percent score along the x axis. At baseline, there was no significant difference between the mean category for patients with or without visual loss ( range P values 0.11- 0.79). At one year, there was no significant difference for any category except the vitality score ( P= 0.02) between all the patients at baseline and one year ( range P values 0.25- 1.0). There was no significant difference for any category at one year between patients with or without visual loss ( range P values 0.08- 0.92). Mental Health Vitality General Health Body Pain Social Function Emotion Role Role Problems Physical Function 100 a One year, Patients, Visual Loss • One year, Patients, No Visual Loss • Baseline, Patients, Visual Loss • Baseline, Patients, No Visual Loss / Neuro- Ophthalmol, Vol. 21, No. 4, 2001 GIANT CELL ARTERITIS 271 TABLE 4. Spearman correlation of SF- 36 category scores r* number systemic symptoms P = r* percent of central vision impairment of worse eye P = r* percent binocular impairment P = rf cumulative steroid dose P = PF 0.17 0.48 0.09 0.70 0.08 0.73 - 0.36 0.12 RP 0.26 0.27 0.20 0.39 0.16 0.49 - 0.18 0.44 RE 0.42 0.06 0.16 0.51 0.11 0.64 - 0.22 0.34 SF 0.31 0.18 0.21 0.37 0.16 0.49 - 0.13 0.58 BP - 0.43 0.06 - 0.21 0.37 0.15 0.53 - 0.10 - 0.66 GH - 0.08 0.73 0.03 0.91 - 0.01 0.95 0.07 0.76 VT 0.06 0.80 - 0.03 0.91 0.06 0.78 0.32 0.16 MH - 0.03 0.91 - 0.42 0.06 - 0.43 0.06 0.45 0.05 * Baseline correlation values ( Worse eye visual acuity, worse eye contrast sensitivity, worse eye MD not shown since no r value showed a trend or significant P value). f One year correlation values. Bold for correlation with P £ 0.05. distance vision had a modest negative correlation with percent worse eye central impairment ( P = - 0.43) and percent binocular impairment ( P = - 0.50). The near vision ( P = - 0.49) had a modest negative correlation with the AGIS score of the worse eye. The glare score had a modest negative correlation with the worse eye acuity ( P = 0.02), and a modest to moderated negative correlation with the percent binocular acuity impairment ( P = 0.006), the worse eye AGIS score ( P = 0.04), and the better eye AGIS score ( P = 0.007). The SF- 36 scores for each category were not significantly different for patients with and without visual loss ( Fig. 2). The SF- 36 scores for the patient with bilateral visual loss were not worse than the scores from the other patients ( data not shown). Mental health was the only category that correlated with any visual performance parameter ( data shown only for percent binocular impairment, Table 4); there was a modest inverse correlation with the percent worse eye central impairment ( r = - 0.42, P = 0.06) and percent binocular impairment ( r = - 0.43, P = 0.06). The number of GCA symptoms ( Table 4) only correlated modestly with the score of two SF- 36 categories ( r = 0.42 for limitation due to emotional problems and - 0.43 for body pain, P = 0.06). No specific GCA symptom correlated with any SF- 36 category ( data not shown). One- year vision In general, the visual dysfunction in the worse eye of patients with GCA caused visual loss at baseline persisted at one year ( Table 5). No patients had new GCA visual loss after the baseline testing. For all patients, the mean deviation in the worse eye was better at one year ( mean - 3.6, SD 7.2, P = 0.002) than at baseline ( mean - 10.5, SD 9.5). Although the trend was for patients with visual loss to have better MD at one year ( mean - 9.3, SD 11.9) than at baseline ( mean - 24.4, SD 9.4), the improvement was not significant ( P = 0.08). The visual acuity, contrast sensitivity, mean deviation, and AGIS score in the worse or better eye, the percent of binocular impairment were not significantly different from baseline. The visual acuity, contrast sensitivity, the AGIS score, and the mean deviation in the worse eye; and the percent binocular impairment remained significantly worse in patients with GCA induced visual loss. One- year quality of life measures and correlations At one year 14 patients had no symptoms of active GCA or polymyalgia rheumatica. Four patients without visual loss had one symptom, steroid responsive polymyalgia rheumatica ( Tables 2 and 3, Figs. 1 and 2 ). Two patients with visual loss had symptoms, one with steroid responsive polymyalgia rheumatica and one with ischemia of the upper extremities that was also controlled with steroids. Three patients required oral hypoglycemic agents to lower elevated blood glucose and six others had elevation in blood glucose requiring no medication. No patient developed new systemic hypertension. At one year there were two vertebral fractures and no hip fractures. TABLE 5. One- year visual performance Patients with no visual loss, mean SD Patients with visual loss, mean SD P = Worse eye acuity 0.83 0.29 0.34 0.37 0.01 Better eye acuity 1.00 0.26 1.06* 0.31 0.72 Worse eye contrast, log units 1.14 0.52 0.45 0.40 0.01 Better eye contrast, log units 1.56 0.26 1.43* 0.20 0.33 Worse eye MD db - 3.87 4.24 - 24.55 7.42 0.0001 Better eye MD db - 1.65 3.64 - 8.55* 9.12 0.04 Binocular impairment, % 5.2 7.6 18.8 12.3 0.01 Worse eye AGIS 2.93 3.03 17.2 5.6 < 0.0001 Better eye AGIS 2.36 3.41 7.6* 6.83 0.05 * Includes the results from the less affected eye in the case of bilateral GCA ischemia with the vision in this eye: visual acuity = 0.5, MD ( mean deviation) = - 30.1, and contrast sensitivity = 1.42 log units, and AGIS ( Advanced Glaucoma Intervention Study) score of 20. J Neuro- Ophthalmol, Vol. 21, No. 4, 2001 272 M. J. KUPERSMITH ET AL. For all patients, those with vision loss and those without vision loss, the one- year ADVS scores were not significantly different from the baseline scores ( Table 2, Fig. 1). Day driving was still worse in patients with vision loss than those without vision loss, but less significantly ( P = 0.07). The trend for all the other ADVS categories was still worse in the patients with vision loss. The percent of binocular impairment had a significant moderate negative correlation with distance vision ( r = - 0.58), and near vision ( r = - 0.56), and a modest negative correlation with the glare score ( r = - 0.52) ( Table 3). At one year, the SF- 36 scores were not significantly different from the baseline scores for all patients or patients with or without visual loss ( Fig. 2). Patients with visual loss had SF- 36 scores that were not significantly different from patients without visual loss. The Spearman analysis showed no correlation between the total steroid dose and any SF- 36 category ( Table 4) except the mental health score was modestly inversely correlated ( r = - 0.45, P = 0.05). The presence of hypertension, diabetes mellitus, or vertebral fracture did not correlate with any SF- 36 category score ( data not shown). DISCUSSION Patients with GCA caused visual loss had worse visual perception for all categories, but the difference from patients without visual loss was significant only for day driving. The sole patient with a global ADVS reduction was the only patient with bilateral GCA visual loss. In this small prospective study, when using nonparametric analysis, there were no strong correlations between the Activity of Daily Vision Scale categories and a variety of visual performance measures in patients with the systemic illness giant cell arteritis. Although there was a modest to moderate correlation with scores in some ADVS categories and visual performance, not all visual parameters exhibited a consistent or significant Spearman correlation. The percent acuity impairment in the worse eye and the percent binocular impairment negatively affected the day driving and distance vision perception. The AGIS scoring of the worse eye and the percent binocular impairment each correlated with the most number of ADVS categories, three. Better visual acuity in the better eye of each patient was associated with improved distance vision perception. Our finding of modest to moderate, but not strong, correlations between the ADVS categories and visual performance has been reported in patients with visual loss from other causes ( 12,13). At one year, the various measures of visual performance were unchanged from the baseline ( point of entry into the study after four to five weeks of steroids) findings. The ADVS scores at one year were also similar to the baseline results. At one year, day driving and glare vision scores remained inversely correlated with the percent of binocular impairment ( the greater impairment the worse the worse the patient's perception). The day driving score no longer correlated. The SF- 36, a global quality of life instrument, baseline scores did not correlate with the presence or absence of visual loss or the number of systemic symptoms at baseline. Only the mental health score had any significant correlation with visual performance. There was a modest inverse correlation for the percent of binocular and worse eye central impairment Except for a modest inverse correlation with the mental health score and total steroid dose, no SF- 36 category score at one year correlated with the amount of steroids taken, the presence of visual loss, hypertension, diabetes mellitus, or vertebral fracture. Similar to results reported for patients with glaucoma ( 12), in general, patients with GCA, even those with visual loss, did not have the perception that their visual loss significantly impacted their general well- being. This was unexpected since GCA is a systemic disorder, which caused numerous symptoms in addition to loss of vision in our patients. Even the one patient with bilateral visual loss did not seem to complain of general health problems. Similar to other studies ( 22), we found that mental distress was the SF- 36 category, which was worse in patients with vision loss at baseline. In this study with a small sample size, we found that in an elderly population with a general systemic and visual disorder, the ADVS scale but not the SF- 36 appeared to distinguish between those patients with and without visual loss. In the patient with bilateral visual loss, the ADVS reflected the dysfunction but the SF- 36 still failed to be profoundly affected. Acknowledgment: Paul Lee MD provided the ADVS scale and guidance used in analyzing data. Douglas Gaasterland, MD provided the computer software and manual to perform the AGIS analysis of the visual fields. REFERENCES 1. Wagener HP, Hollenhorst RW. Ocular lesions of temporal arteritis. Am J Ophthalmol 1958; 45: 617- 30. 2. Russell RWR. giant cell arteritis: a review of 35 cases. Quat J Med 1959; 28: 471- 8. 3. Henkind P, Charles NC, Pearson J. Histopathology of ischemic optic neuropathy. Am J Ophthalmol 1970; 69: 78- 90. 4. Wilkinson IMS, Russell R, Ross W. Arteries of the head and neck in giant cell arteritis, a pathologic study to show the pattern of arterial involvement. Arch Neurol 1972; 27: 378- 91. 5. Grahm E, Holland A, Avery A, Russell RWR. Prognosis in giant cell arteritis. Br Med J 1981; 282: 269- 71. 6. Delecoeuillerie D, lolly P, Cohen de Lara A, et al. Polymyalgia rheumatica and temporal arteritis: A retrospective analysis of prognostic features and different corticosteroid regimens ( 10 year survey of 29 patients). Ann Rheum Dis 1988; 46: 733- 739. 7. Paget SA, Healey IH, Williams- Russo P, et al. Osteoporosis in steroid- treated patients with polymyalgia rheumatica and temporal arteritis: What is the magnitude and rate over 1 year. Arth Rheum 1992; 35: S9. 8. Adhikary HP, Sells RA, Basu PK. Ocular complications of systemic steroid after renal transplantation and their association with HLA. Br J Ophthalmol 1982; 66: 290- 91. 9. Godel V, Feiler- Ofry V, Stein R. Systemic steroids and ocular fluid dynamics. I. Analysis of the sample as a whole. Influence of dosage and duration of therapy. Acta Ophthal 1972; 50: 655- 663. 10. Godel V, Feiler- Ofry V, Stein R. Systemic steroids and ocular fluid dynamics. II. Systemic versus topical steroids. Acta Ophthal 1972; 50: 664- 76. / Neuro- Ophthalmol, Vol. 21, No. 4, 2001 GIANT CELL ARTERITIS 273 11. Urban RC, Cotlier E. Corticosteroid- induced cataract. Surv Ophthalmol 1986; 31: 102- 110. 12. Parrish RK, Gedde SJ, Scott IU, Feuer WJ, Schiffman JC, Mangione CM, Montenegro- Piniella A. Visual function with quality of life among patients with glaucoma. Arch Ophthalmol 1997; 15: 1447- 55. 13. Gutierrez P, Wilson MR, Johnson C, Gordon M, Cioffi GA, Ritch R, Sherwood M, Meng K, Mangione CM. Influence of glaucomatous visual field loss on health- related quality of life. Arch Ophthalmol 1997,115: 777- 84. 14. Scott IU, Schein OD, Bandeen- Roche K, et al. Functional status and quality of life measurement among ophthalmic patients. Arch Ophthalmol 1994; 12: 329- 35. 15. Kupersmith MJ, Langer R, Mitnick H, Spiera R, Spiera H, Richmond M, Paget S. Visual performance in giant arteritis ( temporal arteritis) after 1 year of therapy. Br J Ophthalmol 1999; 83: 796- 801. 16. Pelli DG, Robson JG, Wilkins AJ. The design of a new letter chart for measuring contrast sensitivity. Clin Vis Sci 1988; 2: 187- 99. 17. American Medical Association. The visual system. In: Guides to the evaluation of permanent impairment. 4th ed. Chicago, 111: American Medical Association; 1994: 209- 22. 18. The Advanced Glaucoma Intervention Study Investigators. Advanced glaucoma intervention study. 2. Visual field test scoring and reliability. Ophthalmology 1994; 101: 1445- 55. 19. Ware JE, Sherbourne CD. The MOS 36- item short- form health survey ( sf- 36). I. Conceptual framework and item selection. Med Care 1992; 30: 473- 83. 20. McHorney CA, Ware JE, Lu JFR, Shelbourne CD. The mos 36- item short- form health survey ( sf- 36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care 1994; 32: 40- 66. 21. Mangione CM, Phillips RS, Seddon JM, Lawrence MG, Cook EF, Dailey R, Goldman L. Development of the ' activities of daily vision scale'. Med Care 1992; 30: 1111- 26. 22. Mangione CM, Lee PP, Pitts J, Guiterrez P, Berry S, NEI- VFQ Field Test Investigators. Psychometric properties of the National Eye Institute visual function questionnaire ( NEI- VFQ). Arch Ophthalmol 1998; 116: 496- 1504 23. Fisher LM, van Belle G. Biostatistics: A methodology for the health sciences. John Wiley and Sons, Inc. New York, 1993. J Neuro- Ophthalmol, Vol. 21, No. 4, 2001 |