NELSON’S EYE
Bulletin 13. November 2005
Temporal Arteritis
We have had
a couple of cases of temporal arteritis recently, both of which were accurately
diagnosed by the GP and sent to me for confirmatory biopsy. In temporal
arteritis, both the disease and the treatment are hazardous for the patient.
This really is a true ophthalmic emergency. This newsletter is “an ophthalmic
take” of some of the challenges.
What’s at stake?
o
if
untreated, produces visual loss in 60%
o
in
60% of patients with visual loss, it is severe and irreversible
o
the
second eye is involved in 65% - 1/3 within 24 hours, 1/3 within 1 week,
1/3 within 1 month
o
patients
with temporal arteritis have a considerably higher incidence of death due to
vascular disease in the first year after diagnosis
o
failure
to diagnose is an important and frequent cause for medico legal claims
Presentation:
o
female 3:1 male ,
o
age is the number one factor - almost
unheard of under 55 yrs, rare under 65 yrs
o
headache – but this varies from
4-100% of patients!!
o
jaw claudication in 4-60% - but
pathognomonic if present
o
scalp tenderness
o
diplopia in 11%, sudden visual loss
or transient visual obscurations
o
tongue/throat pain or ulceration
o
constitutional symptoms
o
neurologic presentations
o
polymyalgia rheumatica (there is a
spectrum between the two)
o
thoracic artery aneurysms in 15%
So, there
is an absolute plethora of presentations. Anything goes. All clinicians
must therefore have a high index of suspicion.
In a study
of 363 patients, the odds of a positive biopsy are
o
9
times greater if jaw claudication is present
o
2.4
times greater if CRP elevated
o
3.2
times greater if neck pain present
o
2
times greater if ESR over 47
o
more
likely if anorexia, weight loss and scalp tenderness present
Biochemistry:
The CRP is
100% sensitive, the ESR 92% sensitive, and both the CRP and ESR together are
97% specific. The platelets may be over 400.
Common misdiagnoses:
o
39%
in one series had an initial wrong diagnosis
o other red herrings are “needs new glasses, blocked carotid arteries, tooth decay or TMJ tenderness, sinusitis, muscle pains or stress”.
Treatment:
o
high
dose steroids to start with (IV if visual symptoms)
o
titrate
steroids with disease activity as judged by symptoms and ESR
o
a
dose of 7.5mg/day is usually adequate after 6-9 months and withdrawal usually
possible after 2 years
What lies ahead?
A better understanding of the pathogenesis, new
diagnostic tools and the introduction of targeted immunotherapy.
Key points:
o
an
ophthalmic emergency
o
the
stakes are high for the patient
o
there
is a plethora of presentations so
o
have
a high index of suspicion
Eye Dept News
Most of you will be aware that Derek Sherwood is on
sabbatical (Newcastle, UK) until mid January 2005. He reports it has rained
every day! Dr Wayne Birchall is doing a locum for Derek. Wayne trained in
Manchester and has a specialist interest in glaucoma and it is great to have
him join us. He was a GP for 8 years before doing ophthalmology.
We look forward to any comments, requests or opinions.
Regards, Graham Wilson