Choroidal Infarction in Giant Cell Arteritis

An 80-year-old Caucasian woman presented with a 10-day history of headaches, intermittent binocular diplopia, and jaw pain. Temporal artery biopsy confirmed a diagnosis of giant cell arteritis. Examination showed characteristic large area of choroidal ischemia that is well-known to be associated with GCA. The finding of choroiodal ischemia was confirmed by fluorescein angiography and indocyanine angiography ancillary testing.

Choroidal Infarction in Giant Cell Arteritis Wael A. Alsakran, MD Andre Aung, MD Valérie Biousse, MD 80-year-old Caucasian woman with 10 day history of headaches, intermittent binocular diplopia, blurry vision of the left eye, and jaw pain • Examination: • VA : 20/40 OD, 20/60 OS • Color vision: 14/14 OD, 4/14 OS • +Relative afferent pupillary defect OS • Tender non-pulsatile left temporal artery • Investigations: • Erythrocyte Sedimentation Rate (ESR): 65 mm/hr (age-adjusted nl=45 mm/hr) • C-Reactive Protein: 230.5 mg/L (nl<10 mg/L) • Temporal artery biopsy confirmed giant cell arteritis Figure 1: Optos photo of the right eye showing a normal optic nerve with no edema or pallor. Figures 2: (A) Fundus fluorescein angiography photo of the right eye and (B) Fundus indocyanine angiography photo of the right eye show areas of delayed choroidal filling and non-filling (blue stars) Figure 3: Optos photo of the left eye showing a normal optic nerve with no edema or pallor and an area of choroidal hypopigmentation temporally suggestive of choroidal ischemia (blue star). Figures 4: (A) Fundus fluorescein angiography photo of the left eye and (B) Fundus indocyanine angiography photo of the left eye show areas of delayed choroidal filling and non-filling (blue arrow) Retinal Fluorescein Angiography Figure 5: Fundus fluorescein angiography photo of the left eye after 3 minutes showing persistent delayed and patchy choroidal filling (blue arrows) with abnormal leakage and staining of some of choroidal vessels (orange arrow) Retinal Fluorescein Angiography Figure 6: Fundus fluorescein angiography photo of the left eye after 5 minutes showing persistent delayed and patchy choroidal filling, in addition to abnormal leakage and staining of some of choroidal vessels (orange arrow) Figures 7: (A) Initial optos photo demonstrating area of choroidal hypopigmentation temporally suggestive of choroidal ischemia (blue star) and (B) Optos photo three weeks after presentation demonstrating evolving pigmentary changes in area of choroidal infarction (blue star) Retinal Fluorescein Angiography after 2 months Figures 8: Fundus fluorescein angiography photo of the left eye after 1 minute showing areas of choroidal delayed filling and non-filling in the left eye (blue arrows) in addition to abnormal hyper-fluorescence due to choroidal vessels leakage and staining (orange arrow) Retinal Fluorescein Angiography after 2 months Figure 9: Fundus fluorescein anigography photo of the left eye after 3 minutes showing persistent delayed and patchy choroidal filling with abnormal leakage and staining of some of choroidal vessels (orange arrows) Indocyanine Angiography of the left eye after 2 months A B Figures 10: (A) Fundus Indocyanine angiography photos of the left eye 1 minute and (B) 7 minutes after dye injection show hypocyanescent areas of delayed choroidal filling and non-filling which indicate choroidal ischemia and infarction (blue arrows). Note the filling of choroidal vessels had improved after 2 months compared to ICG at presentation Optical Coherence Tomography after 2 months Figure 11: Optical coherence tomography of the left eye shows the transition from normal retina into the abnormal area with apparent outer retina, RPE, and choroidal thinning. The arrow indicates the transitional area