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Show ORIGINAL CONTRIBUTION Intraocular Pressure Is Low in Eyes With Giant Cell Arteritis Ruth Huna- Baron, MD, Iris Ben- Bassat Mizrachi, MD, and Yoseph Glovinsky, MD Background: Although ocular ischemia occurs in giant cell arteritis ( GCA), intraocular pressure ( IOP) has not been systematically evaluated as a diagnostic sign. Methods: We conducted a retrospective, case-controlled, observational study of IOP in patients with ocular manifestations of GCA ( GCA patients), age- matched patients diagnosed with nonarteritic ischemic optic neuropathy ( NAION patients), and age- matched patients with cataract ( control patients). Medical records were examined for all consecutive patients with the diagnosis of GCA from 1995 to 2004 ( n = 16) and NAION from 2002 to 2004 ( n = 16) and for patient candidates for cataract extraction ( n = 16). The eye intended for cataract extraction was chosen as the " affected eye" in the control patients. Results: The mean IOP in the affected eye of 16 GCA patients was 11.9 mm Hg, significantly lower than the 15.1 mm Hg in affected eyes of age- matched NAION patients and 15.8 mm Hg in control patients ( P = 0.002). At presentation, 5 GCA patients had IOP < 10 mm Hg ( mean 6.8 mm Hg) without other signs of anterior segment ischemia. None of the NAION or control patients displayed such low lOPs. Conclusions: IOP was significantly lower in the patients with GCA than in patients with NAION or cataract. Hypotony occurred in one third of GCA patients without other signs of anterior ocular ischemia. These findings suggest that low IOP may be a distinguishing factor between GCA and NAION in patients with ischemic optic neuropathy, but evaluation of a larger group of patients is needed for confirmation. (/ Neuro- Ophthalmol 2006; 26: 273- 275) Goldschleger Eye Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel ( RH, IBM, YG); and Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel ( RH, YG). Address correspondence to Ruth Huna- Baron, MD, Goldschleger Eye Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel 52621; E- mail: Ruth. Huna- Baron@ sheba. health. gov. il Giant cell arteritis ( GCA) is a granulomatous necrotizing vasculitis of medium- to- large size arteries that affects elderly patients. The reported incidence rate is 25 in 100,000 patients. Affected patients may suffer from headaches, myalgia, scalp tenderness, jaw claudication, low- grade fever, malaise, anorexia, and weight loss ( 1,2). Ocular manifestations are reported in 6%- 70% of patients ( 3). Binocular blindness may be preventable by prompt recognition and treatment. Anterior ischemic optic neuropathy ( AION) is the most common complication of GCA. Posterior ischemic optic neuropathy ( PION), central retinal artery occlusion ( CRAO), choroidal ischemia, and ocular motor system ischemia have been reported as well ( 4). Anterior segment ischemia, anterior uveitis, and ocular hypotony with corneal changes are rare manifestations of GCA ( 5- 10). One study of ocular pulse loss in the acute phase of temporal arteritis ( 11) and another concerning dynamic tonometry ( 12) mentioned hypotony in 50% and 22% of patients, respectively, but did not reveal other details of the anterior segment examination. There are no systematic studies of IOP in patients with GCA. Therefore, we decided to examine IOP in patients with ophthalmic manifestations of GCA who did not have signs of anterior segment ischemia. METHODS GCA Patients We reviewed the medical records of all consecutive patients diagnosed with GCA at the Goldschleger Eye Institute, The Chaim Sheba Medical Center, Israel, from 1995 to 2004. Inclusion criteria consisted of 1) ophthalmic manifestations as a presenting features, 2) fulfillment of 1990 criteria for GCA established by the American College of Rheumatology ( 13), 3) positive temporal artery biopsy, and 4) no corticosteroid treatment before the first ophthalmic evaluation. All patients suspected of having GCA underwent ophthalmologic and rheumatologic evaluations. Blood was tested for erythrocyte sedimentation rates ( ESR) and complete blood count. Unilateral temporal artery biopsy was performed within 48 hours of presentation. The IOP was measured J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 273 J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 Huna- Baron et al with a Goldmarm applanation tonometer at presentation and during follow- up visits. All patients were treated with systemic corticosteroids. Nonarteritic Ischemic Optic Neuropathy ( NAION) Patients We reviewed the medical records of all consecutive patients who were examined at our institute between 2002 and 2004 and diagnosed as having NAION according to the Ischemic Optic Neuropathy Decompression Trial ( IONDT) criteria ( 14). Patients with other known eye diseases, such as glaucoma, diabetic retinopathy, or retinal vascular occlusion, were excluded. This group comprised the first 18 patients matched to within 1 year of the age of GCA patients. Their IOP at presentation was recorded. Control Patients We reviewed the charts of consecutive patients examined at the Cataract Clinic during May 2005 who were awaiting surgery. Only patients without any of the aforementioned eye diseases were included. An age-matched group of the first 16, consecutive patients was chosen for detailed comparison. The eye planned for cataract surgery was considered the " affected eye." Details concerning age, sex, IOP, and ophthalmic and medical histories were collected from all three groups. For the GCA group, ESR and complete blood count were recorded. IOP Measurement IOP was measured with a Goldmarm applanation tonometer at presentation before treatment with corticosteroids and at diverse hours during the day by different staff ophthalmologists. Statistical Methods Analysis of the differences between groups for IOP and age was performed by SPSS ( version 8, SPSS Inc., Chicago, IL). Post hoc testing was performed by one- way analysis of variance ( ANOVA) using the Games- Howell post hoc procedure. RESULTS Demographic and Systemic The GCA group comprised 16 patients ( 7 women and 9 men) with an age range of 61 to 81 years ( Table 1). All had systemic symptoms. ESR ranged from 56 to 168 mm/ h ( mean ± SD, 89 ± 12). Primary care was provided to 12 patients in our emergency room service, and 4 patients were examined by a consulting physician at the neuro-ophthalmology clinic. The interval between ophthalmic manifestations and IOP measurement was 28.8 ± 16.7 hours for 10 of the patients. Ophthalmic Manifestations of GCA The ophthalmic manifestations were AION in 12 eyes, CRAO in 2 eyes, PION in 1 eye, and ocular ductional deficit in 1 eye. IOP The IOP at presentation ranged from 5 to 18 mm Hg in the affected eyes ( mean ± SD, 11.9 ± 4.5 mm Hg) in the GCA patients, which was statistically significantly lower than the IOP in the affected eyes of NAION patients and control patients ( P = 0.002; Fig. 1). The same tendency ( P = 0.012; Fig. 2) was found for the fellow eye. The IOP was lower in the affected eye of the patients with unilateral involvement. In patients with bilateral involvement, IOP was lower in the more severely affected eye. Five patients in this group demonstrated IOP < 10 mm Hg ( mean, 6.8 mm Hg). No anterior segment signs of ischemia were detected; and no corneal edema or flair in the anterior chamber was observed. Fifteen eyes were phakic and 1 eye was pseudophakic; 2 of the patients with phakic eyes had pseudoexfoliation. TABLE 1. Demographic characteristics and intraocular pressure Age ( years) IOP in affected eye* ( mm Hg) IOP in fellow eye ( mm Hg) Phakic Eyes Womemmen GCA patients 73.4 ± 5.9 11.9 ± 4.5 13.1 ± 3.2 15 7: 9 measurements of patients NAION patients 73.5 ± 6.1 15.3 ± 2.3 15.1 ± 1.9 11 9: 7 in all three groups Control patients 73.4 ± 5.6 15.8 ± 1.8 15.8 ± 2.2 16 9: 7 Data are expressed as mean ± SD unless otherwise indicated. GCA, giant cell arteritis; NAION, non arteritic ischemic optic neuropathy; IOP, intraocular pressure ( mm Hg); * aifected eye in groups = eye with acute visual loss; affected eye in control patients = eye planned for cataract surgery. P value 1.00 0.001 0.012 GCA and NAION 274 © 2006 Lippincott Williams & Wilkins Intraocular Pressure in Giant Cell Arteritis J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 X E 18- UJ 16 • CC D (/) 14 • LU t '* DC < 10" < 1- 6 z 4 N = 1 GC i 6 | 16 NAION 16 CONTROLS " Si 1 2 0 - ^ 18- cc (/) 16- 0) LU SF 14- CC < 12- - l § 10 < Z 6 • N = 16 GCA 15 NAION 16 CONTROLS FIG. 1. Mean intraocular pressure ( IOP) in the affected eyes of giant cell arteritis ( GCA), nonarteritic ischemic optic neuropathy ( NAION), and control patients. FIG. 2. Mean intraocular pressure ( IOP) in the fellow eyes of giant cell arteritis ( GCA), nonarteritic ischemic optic neuropathy ( NAION), and control patients. Fluorescein angiography was performed in only the 2 eyes with CRAO and revealed choroidal ischemia, but their IOPs were 10 and 12 mm Hg. Mean ± SD IOPs in the NAION and control groups were 15.1 ± 1.9 and 15.8 ± 1.8 mm Hg, respectively ( Fig. 1). In the NAION group, 11 eyes were phakic and 5 eyes were pseudophakic. IOP did not differ between these two groups as seen in Fig. 1. DISCUSSION To the best of our knowledge, the finding of lower IOP in GCA patients with systemic and ocular manifestations has not been reported previously ( 3,4), except as part of anterior segment ischemia ( 5- 10). Our patients had no clinical manifestations of anterior ocular ischemia. However, the low IOP may be attributed to subclinical ischemia of the ciliary body ( 11,12). We do not believe that pseudophakia played a role, given that there were more phakic eyes in the GCA group than in the other groups. Our findings suggest that low IOP may be a finding that can help distinguish GCA from NAION in patients presenting with visual loss. Although our study was retrospective and conducted on a small patient population, it has the rigor of providing a comparison to age- matched groups. 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