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Show Letters to the Editor Giant Cell Arteritis With Arteritic Anterior Ischemic Optic Neuropathy Is Bilateral Until Proven Otherwise W e were very encouraged to read the case report by Liu and Miller (1) dealing with giant cell arteritis (GCA). We published a Letter to the Editor in the Journal of NeuroOphthalmology describing a systematic approach, by means of evaluating 39 possible symptoms and signs recognized as occurring in GCA (2). These may allow the clinician to be reasonably certain of a clinical diagnosis of GCA. The article by Liu and Miller brings to mind a recent patient of ours, an 86-year-old woman with biopsy-proven GCA, who presented late one weekday afternoon with 23 of the symptoms and signs typical for GCA. Although both eyes had a visual acuity of 20/12 after cataract surgery eight months before presentation, the patient's left visual acuity was now 20/400. The left optic nerve was swollen and pale with associated hemorrhages. In the patient report by Liu and Miller, the relative afferent pupillary defect (RAPD) was "small," whereas in our patient, it was moderate (Grade 2/4). Our patient was given immediate intravenous methylprednisolone that evening. Her sedimentation rate was 97 mm/hr, and CRP was 119 mg/L (normal: 0-5 mg/L). The next day, a right temporal artery biopsy was performed and demonstrated features of florid GCA. The patient was maintained on oral steroids and aspirin. Five days later, the RAPD was marked (Grade 4/4) and the right optic nerve which initially appeared a little "full" but normal, now appeared flatter. This suggested that there had been bilateral, arteritic anterior ischemic optic neuropathy at presentation, somewhat "masked" by the symptomatic left eye and its characteristic appearance. As Lui and Miller point out, it was serendipitous in their patient that magnetic resonance imaging (MRI) demonstrated enhancement of both optic nerve sheaths. In addition, positron emission tomography (PET) revealed abnormal, increased fluoro-D-glucose activity in the distribution of the superficial temporal and occipital arteries bilaterally. Liu and Miller cite four other cases from the literature of bilateral optic nerve disease in patients with GCA that were clinically obvious. However, just as in our patient, the disease can be very asymmetric. Indeed, in GCA, clinical and histological presentations can be quite varied (3-5). We are grateful to Liu and Miller for pointing out the importance of recognizing GCA in a patient who presents, not infrequently in our experience, on a Friday afternoon, with unilateral visual loss. The clinician may appropriately obtain hematologic studies for GCA, only to find that by the Letters to the Editor: J Neuro-Ophthalmol 2016; 36: 479-481 following Monday, the possible day for planned temporal artery biopsy, the patient has profound visual loss in both eyes. We concur with Liu and Miller that an MRI and PET are not necessary for diagnosis. But the fact that bilateral optic nerve involvement is sinister, and possibly not infrequent, mandates appropriate, timely diagnostic, and therapeutic intervention. Nandini Singh, BMed Royal North Shore Hospital, Sydney, Australia Adarsh George, BMed University of New South Wales, Sydney, Australia Jeremy Tan, BMed, MD University of Sydney, Sydney, Australia Shaun Y. P. Ewe, MBBS, BMedSci Sydney Institute of Vision Science, Sydney, Australia Ian C. Francis, FRACS, PhD Department of Ophthalmology, Prince of Wales Hospital, Sydney, Australia University of New South Wales, Sydney, Australia The authors report no conflicts of interest. REFERENCES 1. Liu TY, Miller NR. Giant cell arteritis presenting as unilateral anterior ischemic optic neuropathy associated with bilateral optic nerve sheath enhancement on magnetic resonance imaging. J Neuroophthalmol. 2015;35:360-363. 2. George A, Lim NS, Chong CW, Abedi F, Liu Y, Wang SB, Govendir M, Agar A, Francis IC. Diagnostic algorithm for patients with suspected giant cell arteritis. Useful, but no substitute for thorough histopathology. J Neuroophthalmol. [published online ahead of print May 25, 2016] doi: 10.1097/ WNO.0000000000000382. 3. Dubey R, Chui J, Langford-Smith J, Danesh-Meyer H, Francis IC. Jaw dropping: the necessity of a history and a biopsy in suspected temporal arteritis. Neuroophthalmology. 2011;35:156-157. 4. Dubey R, Bhardwaj G, Sanli E, Kalapesi F, Francis IC. Temporal arteritis-reversal of blindness using anticoagulation and steroids. Neuroophthalmology. 2011;35:264. 5. Sim BW, Karaconji T, Bhardwaj G, Dubey R, Harris JP, Francis IC. Scalp necrosis in temporal arteritis: abrupt termination of the superficial temporal artery as a possible precursor. J Dtsch Dermatol Ges. 2013;11:551-552. 479 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. |
