GIANT-CELL ARTERITIS - A BLINDING DISEASE

We report a series of 21 consecutive patients seen at the Ophthalmolog y Department of the University Hospital Zurich, Switzerland, with the arteritic form of anterior ischemic optic neuropathy (AION). 19 patien ts had giant cell arteritis, one had periarteritis nodosa and one had cP-arteritis. They comprised 11 men and 10 women, ranging in age betwe en 66 and 88 years. The median age was 80. We analyzed the course of e vents in each case before and after involvement of the first eye, as w ell as the frequency and possible causes of involvement of the second eye. The diagnosis was regarded as delayed when, despite typical signs , symptoms amd laboratory abnormalities, systemic vasculitis was not c onsidered in the differential diagnosis. Treatment was considered inad equate if, following visual loss in one eye and diagnosis of a systemi c vasculitis, a dose of 1 mg/kg prednisone or less was given, and/or t he initial dose was reduced by more than 50% during the first month. O f 21 patients, 10 suffered bilateral visual loss. 8 of these 10 patien ts became legally blind. In 13 out of 21 cases there was no delay in d iagnosis and treatment was adequately given. All 11 patients with unil ateral involvement, who did not suffer a substantial loss in quality o f life, belong to this subgroup. In 8 cases diagnosis was either delay ed or treatment was inadequate. All of these patients had bilateral oc ular involvement. In one patient, visual loss in the second eye could not be avoided despite correct diagnosis and treatment (M. A., No. 1). In this patient the interval between involvement of the first and sec ond eye was very short (3 days). One patient had a mature cataract in the first affected eye and sought medical help only after his good eye became involved (K. F, No. 15). In this report we would like to draw attention to the extremely poor visual prognosis due to frequent bilat eral ocular involvement in giant cell arteritis. Corticosteroid treatm ent cannot restore vision in the already affected eye, but it is, in t he majority of cases, highly effective in preventing visual loss in th e second eye. Thus, it is crucial to begin treatment immediately, to s tart with a high dose (preferably 1 g methylprednisolone i.v.), and to continue high-dose oral treatment long enough to prevent delayed visu al loss in the second eye. The most vulnerable period appears to be. t he first month following involvement of the first eye. Caring for pati ents with giant cell arteritis who have lost vision in one eye is a ch allenge to all involved physicians. It resembles a ''high-wire act'' w ith the threat of blindness on the one hand and the dangers of long te rm corticosteroid treatment on the other. An interdisciplinary approac h with ongoing communication between the family physician and the opht halmologist is required.