Ophthalmic manifestations of giant cell arteritis

ABSTRACT

Introduction

Giant cell arteritis (GCA) is an ophthalmic emergency because of its potential for irreversible blindness. Clinicians should be aware of the variable presentations, laboratory features, and evaluation of GCA because earlier diagnosis and treatment can prevent loss of sight.

Areas covered

We have provided an update on recent advances in the diagnosis, treatment, and prognosis of GCA. We searched the PubMed database from 1990 to 2023 for relevant reviews, case reports, and trials. Emerging treatments for GCA are additionally summarized.

Expert opinion

Clinicians should be aware of common and uncommon presentations of GCA. A high index of suspicion is essential for detection of GCA in elderly patients, and early treatment can prevent or reduce permanent vision loss. GCA is a true ophthalmic emergency and high dose empiric glucocorticoid treatment is recommended followed by confirmation with temporal artery ultrasound and/or biopsy. New vascular imaging methods and approaches to acute and maintenance therapy for GCA have emerged over the past several years. Temporal artery ultrasound shows increasing sensitivity and specificity and may eventually replace ‘gold standard’ histopathologic confirmation by temporal artery biopsy. Emerging steroid-sparing therapies like tocilizumab may reduce prednisone dosages and induce long-term remission with less systemic adverse effects.

KEYWORDS:

• Arteritic anterior ischemic optic neuropathy
• central retinal artery occlusion
• giant cell arteritis
• methotrexate
• prednisone
• temporal arteritis
• tocilizumab
• secukinumab

Article highlights

• Giant cell arteritis (GCA) is a common medium to large vessel vasculitis of the elderly.

• Patients may have underlying polymyalgia rheumatica (PMR) which may be on an inflammatory vasculitic spectrum of disease with GCA

• Although systemic symptoms (e.g. headache, scalp tenderness, jaw claudication, and fever) are often present in GCA, ophthalmic complications including permanent vision loss and even bilateral blindness is the most feared complication of GCA.

• Most visual loss in GCA is due to arteritic anterior or posterior ischemic optic neuropathy from posterior ciliary artery occlusion but some patients have non-embolic central retinal artery, cilioretinal artery, choroidal, or ophthalmic artery ischemia.

• To prevent vision loss, rapid detection and treatment with high-dose glucocorticoids is necessary.

• Temporal artery ultrasound is an emerging technique that is already being recommended as first line diagnostic evaluation for GCA although in the United States, temporal artery biopsy likely remains the gold standard.

• Newer targeted immunotherapies are under study in GCA (e.g. tocilizumab and secukinumab).

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Additional information

Funding

This paper was not funded.