| Affiliation |
(AGL) Chairman, Department of Ophthalmology, The Methodist Hospital, Houston, Texas; Professor of Ophthalmology, Weill Cornell Medicine, New York City, New York; (JG) Class of 2021, Baylor College of Medicine, Houston, Texas |
| Transcript |
So, we're going to talk about giant cell arteritis, but we're going to concentrate today on the unusual manifestations of giant cell arteritis. And as you know, giant cell arteritis is a medium-to-large vessel vasculitis, and what that means is that it can affect any artery in the external carotid distribution. And so, in a patient who has giant cell arteritis, they can have pain in their temple, they can have pain in their jaw, they can have pain in their ear, they can have pain in their neck or their face or their eyes…and so, even though we call it temporal arteritis (that's where we do the biopsy), the arteritis, the vasculitis, can be in any artery in the external carotid distribution. That means the pain can be face, neck, scalp, jaw, mouth, neck, ear…Any of these. And so, one of the things that is super important is: Any elderly patient that has pain in any part of the external carotid distribution should be considered to have giant cell, until proven otherwise. Now, the unusual eye manifestations of giant cell include transient vision loss, amaurosis fugax, or transient diplopia. And those are super dangerous because the eye exam is normal, and even though anterior ischemic optic neuropathy is the most common way that the giant cell [patient] loses their vision (arteritic AION), and often the disk is swollen and pale, which we call "pallid edema", we should recognize that there are also unusual, afferent ways that giant cell can come to us. So, it can come to us as PION, which is posterior ischemic optic neuropathy (the disk is normal, a retrobulbar optic neuropathy in an elderly patient). It can come to us as a non-embolic central retinal artery occlusion (So, if we don't see the embolus but we see the cherry red spot, and we see a CRAO, that could also be a GCA in an elderly patient). If we have choroidal perfusion deficit (and that's usually going to require a fluorescein angiogram to identify that choroidal perfusion deficit). If we have multiple cotton wool patches (that's retinal circulation). So, if we have cotton wool patches, AION, PION, non-embolic CRAO, or choroidal perfusion, or any combination of these… These are really the hallmarks of the unusual presentations of giant cell arteritis. And, we also have to think about it when we have cilioretinal artery occlusions or ophthalmic artery-level occlusions. So, the main take home point from this little video is: giant cell arteritis and temporal arteritis don't just affect the temple. They affect any artery in the external carotid distribution and can produce pain, jaw claudication, scalp tenderness - And in the eye, we have transient vision loss, amaurosis fugax, and transient diplopia. And the most common presentation is AION (arteritic, anterior ischemic optic neuropathy). And the distinctive finding is pallid edema: [the disk] is pale and swollen at the same time. However, [giant cell] doesn't have to be AION. It could be PION (the disk is not swollen, it's a retrobulbar optic neuropathy), a non-embolic CRAO, a choroidal perfusion deficit, cotton wool patches, cilioretinal artery occlusion, or ophthalmic artery occlusion: All of those are giant cell, until proven otherwise, in an elderly patient. |
