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Han JY, Gillette JS, Scott IU, Greenberg PB. The Spectrum of Isolated Retinal Artery Occlusion Secondary to Giant Cell Arteritis. Ophthalmic Surg Lasers Imaging Retina 2024; 55:536-540. [PMID: 39037359 DOI: 10.3928/23258160-20240508-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
We systematically reviewed the literature to investigate the clinical features of isolated arteritic retinal artery occlusion (A-RAO) associated with giant cell arteritis (GCA). The four primary types of A-RAO were central retinal artery occlusion (CRAO), hemi-central retinal artery occlusion (hCRAO), branch retinal artery occlusion (BRAO), and cilioretinal artery occlusion (CLRAO). The most reported presentation was unilateral CRAO, followed by bilateral CRAO, unilateral CLRAO, and bilateral BRAO. Most RAOs were accompanied by typical GCA signs and symptoms, which can help distinguish them from non-arteritic RAOs. When reported, temporal artery biopsy confirmed GCA in most cases. Patients with GCA may present with a broad spectrum of isolated unilateral and bilateral A-RAOs. [Ophthalmic Surg Lasers Imaging Retina 2024;55:536-540.].
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Foré R, Liozon E, Dumonteil S, Sené T, Héron E, Lacombe V, Leclercq M, Magnant J, Beuvon C, Régent A, de Mornac D, Samson M, Smets P, Alexandra JF, Granel B, Robert PY, Curumthaullee MF, Parreau S, Palat S, Bezanahary H, Ly KH, Fauchais AL, Gondran G. BOB-ACG study: Pulse methylprednisolone to prevent bilateral ophthalmologic damage in giant cell arteritis. A multicentre retrospective study with propensity score analysis. Joint Bone Spine 2024; 91:105641. [PMID: 37734440 DOI: 10.1016/j.jbspin.2023.105641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/25/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION Giant cell arteritis (GCA) is complicated in 10 to 20% of cases by permanent visual ischemia (PVI). International guidelines advocate the use of intravenous pulse of methylprednisolone from 250 to 1000mg per day, for three days, followed by oral prednisone at 1mg/kg per day. The aim of this study is to assess whether this strategy significantly reduces the risk of early PVI of the second eye, compared with direct prednisone at 1mg/kg per day. METHODS We conducted a multicentre retrospective observational study over the past 15 years in 13 French hospital centres. Inclusion criteria included: new case of GCA; strictly unilateral PVI, prednisone at dose greater than or equal to 0.9mg/kg per day; for the intravenous methylprednisolone (IV-MP) group, total dose between 900 and 5000mg, close follow-up and knowledge of visual status at 1 month of treatment, or earlier, in case of contralateral PVI. The groups were compared on demographic, clinical, biological, iconographic, and therapeutic parameters. Statistical analysis was optimised using propensity scores. RESULTS One hundred and sixteen patients were included, 86 in the IV-MP group and 30 in the direct prednisone group. One patient in the direct prednisone group and 13 in the IV-MP group bilateralised, without significant difference between the two strategies (3.3% vs 15.1%). Investigation of the association between IV-MP patients and contralateral PVI through classical logistic regression, matching or stratification on propensity score did not show a significant association. Weighting on propensity score shows a significant association between IV-MP patients and contralateral PVI (OR=12.9 [3.4; 94.3]; P<0.001). Improvement in visual acuity of the initially affected eye was not significantly associated with IV-MP (visual acuity difference 0.02 vs -0.28 LogMar), even in the case of early management, i.e., within the first 48hours after the onset of PVI (n=61; visual acuity difference -0.11 vs 0.25 LogMar). Complications attributable to corticosteroid therapy in the first month were significantly more frequent in the IV-MP group (31.8 vs 10.7%; P<0.05). DISCUSSION Our data do not support the routine use of pulse IV-MP for GCA complicated by unilateral PVI to avoid bilateral ophthalmologic damage. It might be safer to not give pulse IV-MP to selected patients with high risks of glucocorticoids pulse side effects. A prospective randomised multicentre study comparing pulse IV-MP and prednisone at 1mg/kg per day is desirable.
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Affiliation(s)
- Romain Foré
- Department of Internal Medicine, CHU Dupuytren 2, Limoges, France.
| | - Eric Liozon
- Department of Internal Medicine, CHU Dupuytren 2, Limoges, France
| | | | - Thomas Sené
- Department of Internal Medicine, Rothschild Foundation Hospital, Paris, France
| | - Emmanuel Héron
- Department of Internal Medicine, CH National d'Ophtalmologie des Quinze-Vingt, Paris, France
| | - Valentin Lacombe
- Department of Internal Medicine and Clinical Immunology, CHU d'Angers, Angers, France
| | | | - Julie Magnant
- Department of Internal Medicine, CHU de Tours, Tours, France
| | - Clément Beuvon
- Department of Internal Medicine, CHU La Milétrie, Poitiers, France
| | - Alexis Régent
- Department of Internal Medicine, Hôpital Cochin, Paris, France
| | | | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, CHU de Dijon, Dijon, France
| | - Perrine Smets
- Department of Internal Medicine, CHU de Clermont-Ferrand, site Gabriel-Montpied, Clermont-Ferrand, France
| | | | - Brigitte Granel
- Department of Internal Medicine, Hôpital Nord, Marseille, France
| | | | | | - Simon Parreau
- Department of Internal Medicine, CHU Dupuytren 2, Limoges, France
| | - Sylvain Palat
- Department of Internal Medicine, CHU Dupuytren 2, Limoges, France
| | - Holy Bezanahary
- Department of Internal Medicine, CHU Dupuytren 2, Limoges, France
| | - Kim Heang Ly
- Department of Internal Medicine, CHU Dupuytren 2, Limoges, France
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Bilton EJ, Mollan SP. Giant cell arteritis: reviewing the advancing diagnostics and management. Eye (Lond) 2023; 37:2365-2373. [PMID: 36788362 PMCID: PMC9927059 DOI: 10.1038/s41433-023-02433-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023] Open
Abstract
Giant Cell Arteritis (GCA) is well known to be a critical ischaemic disease that requires immediate medical recognition to initiate treatment and where one in five people still suffer visual loss. The immunopathophysiology has continued to be characterised, and the influencing of ageing in the development of GCA is beginning to be understood. Recent national and international guidelines have supported the directed use of cranial ultrasound to reduce diagnostic delay and improve clinical outcomes. Immediate high dose glucocorticoids remain the standard emergency treatment for GCA, with a number of targeted agents that have been shown in clinical trials to have superior clinical efficacy and steroid sparing effects. The aim of this review was to present the latest advances in GCA that have the potential to influence routine clinical practice.
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Affiliation(s)
- Edward J Bilton
- Ophthalmology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- INSIGHT Health Data Research hub for eye health, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Susan P Mollan
- Ophthalmology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- INSIGHT Health Data Research hub for eye health, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- Transitional Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.
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Springer JM, Kermani TA. Recent advances in the treatment of giant cell arteritis. Best Pract Res Clin Rheumatol 2023; 37:101830. [PMID: 37328409 DOI: 10.1016/j.berh.2023.101830] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/20/2023] [Accepted: 04/23/2023] [Indexed: 06/18/2023]
Abstract
Giant cell arteritis (GCA) is a systemic, granulomatous, large-vessel vasculitis that affects individuals over the age of 50 years. Morbidity from disease includes cranial manifestations which can cause irreversible blindness, while extra-cranial manifestations can cause vascular damage with large-artery stenosis, occlusions, aortitis, aneurysms, and dissections. Glucocorticoids while efficacious are associated with significant adverse effects. Furthermore, despite treatment with glucocorticoids, relapses are common. An understanding of the pathogenesis of GCA has led to the discovery of tocilizumab as an efficacious steroid-sparing therapy while additional therapeutic targets affecting different inflammatory pathways are under investigation. Surgical treatment may be indicated in cases of refractory ischemia or aortic complications but data on surgical outcomes are limited. Despite the recent advances, many unmet needs exist, including the identification of patients or subsets of GCA who would benefit from earlier initiation of adjunctive therapies, patients who may warrant long-term immunosuppression and medications that sustain permanent remission. The impact of medications like tocilizumab on long-term outcomes, including the development of aortic aneurysms and vascular damage also warrants investigation.
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Affiliation(s)
- Jason M Springer
- Vanderbilt University Medical Center, 1161 21st Avenue Sound, T3113 Medical Center North, Nashville, TN, 37232, USA.
| | - Tanaz A Kermani
- University of California Los Angeles, 2020 Santa Monica Boulevard, Suite 540, Santa Monica, CA, 90404, USA.
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Bouffard MA, Prasad S, Unizony S, Costello F. Does Tocilizumab Influence Ophthalmic Outcomes in Giant Cell Arteritis? J Neuroophthalmol 2022; 42:173-179. [PMID: 35482901 DOI: 10.1097/wno.0000000000001514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite appropriate use of corticosteroids, an important minority of patients with giant cell arteritis (GCA) develop progressive vision loss during the initial stages of the disease or during corticosteroid tapering. Tocilizumab is the only clearly effective adjunctive treatment to corticosteroids in the management of GCA, but questions regarding its efficacy specifically in the neuro-ophthalmic population and its role in mitigating vision loss have not been broached until recently. EVIDENCE ACQUISITION The authors queried Pubmed using the search terms "GCA" and "tocilizumab" in order to identify English-language publications either explicitly designed to evaluate the influence of tocilizumab on the ophthalmic manifestations of GCA or those which reported, but were not primarily focused on, ophthalmic outcomes. RESULTS Recent retrospective analyses of populations similar to those encountered in neuro-ophthalmic practice suggest that tocilizumab is effective in decreasing the frequency of GCA relapse, the proportion of flares involving visual manifestations of GCA, and the likelihood of permanent vision loss. Data regarding the utility of tocilizumab to curtail vision loss at the time of diagnosis are limited to case reports. CONCLUSIONS Compared with conventional corticosteroid monotherapy, treatment of GCA with both corticosteroids and tocilizumab may decrease the likelihood of permanent vision loss. Further prospective, collaborative investigation between rheumatologists and neuro-ophthalmologists is required to clarify the ophthalmic and socioeconomic impact of tocilizumab on the treatment of GCA.
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Affiliation(s)
- Marc A Bouffard
- Department of Neurology (MAB), Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Neurology (SP), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Medicine (SU), Division of Rheumatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Amsler J, Kysela I, Tappeiner C, Seitz L, Christ L, Scholz G, Stalder O, Kollert F, Reichenbach S, Villiger PM. Vision loss in patients with giant cell arteritis treated with tocilizumab. Arthritis Res Ther 2021; 23:92. [PMID: 33752737 PMCID: PMC7983214 DOI: 10.1186/s13075-021-02480-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 03/12/2021] [Indexed: 11/10/2022] Open
Abstract
Objectives Giant cell arteritis (GCA) may lead to vision loss. To what extent tocilizumab (TCZ) is able to prevent vision loss is unknown. The aim was to analyze the occurrence of vision loss in a large GCA cohort treated with TCZ. Methods In this observational monocentric study, GCA patients treated with TCZ between the years 2010 and 2018 were studied. Demographic, clinical, and laboratory data were analyzed. Results A total of 186 patients were included (62% female); 109 (59%) fulfilled the American College of Rheumatology (ACR) criteria, in 123 (66%) patients, large vessel vasculitis was diagnosed by magnetic resonance-angiography (MRA). Cumulative duration of TCZ treatment was 224 years, median treatment duration was 11.1 (IQR 5.6–17.9) months. Glucocorticoids (GC) were tapered over a median of 5.8 (IQR 3.0–8.5) months. At baseline, visual symptoms were present in 70 (38%) and vision loss in 21 (11%) patients. Patients with vision loss at baseline were older (p = 0.032), had a lower C-reactive protein (p = 0.002), and showed a negative association with MRA of the aorta (p = 0.006). Two patients (1.1%) developed vision loss, both at the initiation of TCZ treatment. Conclusion Our data show a very low incidence of vision loss in TCZ-treated patient. The two cases of AION occurred at the initiation of therapy, they support the hypothesis that advanced, and established structural changes of arteries are key factors for this accident. Whether a shorter duration of concomitant GC treatment is risky regarding vision loss needs to be studied.
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Affiliation(s)
- Jennifer Amsler
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Iveta Kysela
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Tappeiner
- Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luca Seitz
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lisa Christ
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Godehard Scholz
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Odile Stalder
- Clinical Trial Unit (CTU), Inselspital, University of Bern, Bern, Switzerland
| | - Florian Kollert
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan Reichenbach
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Peter M Villiger
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Samanta J, Naidu G, Mittal S, Nada R, Bal A, Singh R, Gupta V, Gupta A, Sharma A, Pinto B. Temporal Arteritis Revealing Antineutrophil Cytoplasmic Antibody-Associated Vasculitides: Are the Visual Outcomes Different From Giant Cell Arteritis? Comment on the Article by Delaval et al. Arthritis Rheumatol 2021; 73:1345-1346. [PMID: 33605063 DOI: 10.1002/art.41698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/04/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Joydeep Samanta
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gsrsnk Naidu
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sakshi Mittal
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amanjit Bal
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ramandeep Singh
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishali Gupta
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amod Gupta
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Sené T, Arej N, Lecler A, Dupont C, Vasseur V, Mauget-Faÿsse M, Vignal-Clermont C. Visual Recovery with Iloprost Added to Corticosteroids in a Case of Giant Cell Arteritis. Ocul Immunol Inflamm 2020; 30:497-499. [PMID: 32976035 DOI: 10.1080/09273948.2020.1802489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION To date, corticosteroids remain the cornerstone treatment of ocular involvement of GCA, and no other treatment has proven to be effective in this setting. We herein report on a unique case of GCA with ocular involvement worsening despite high dose corticosteroids and recovering with intravenous iloprost. CASE REPORT A 70-year-old man presented with acute vision loss in his left eye related to anterior ischemic optic neuropathy. The diagnosis of giant-cell arteritis was confirmed by a temporal artery biopsy. Despite intravenous pulse methylprednisolone for 3 days then oral prednisone at 60 mg/day, the patient developed from day 5 fluctuating vision loss in the right eye, related to ocular ischemia by occlusion of the ophthalmic artery, and responsive to hyperhydration. Iloprost, an analog of prostacyclin PGI2, was then administered intravenously for 5 days and resulted in a stable improvement in visual acuity in the right eye. CONCLUSION This case highlights the potential role of vasodilatator agents in giant cell arteritis with ocular involvement.
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Affiliation(s)
- Thomas Sené
- Department of Internal Medicine, Rothschild Foundation Hospital, Paris, France
| | - Nicolas Arej
- Department of Ophthalmology (Vitreoretinal Division), Rothschild Foundation Hospital, Paris, France.,Department of Clinical Research, Rothschild Foundation Hospital, Paris, France
| | - Augustin Lecler
- Department of Medical Imaging, Rothschild Foundation Hospital, Paris, France
| | - Chloé Dupont
- Department of Pharmacology, Rothschild Foundation Hospital, Paris, France
| | - Vivien Vasseur
- Department of Clinical Research, Rothschild Foundation Hospital, Paris, France
| | | | - Catherine Vignal-Clermont
- Department of Ophthalmology (Neuro-ophthalmology Section), Rothschild Foundation Hospital, Paris, France
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Sené T, Clavel G, Villeneuve D, Philibert M, Mauget-Faÿsse M, Lamirel C, Lecler A, Gout O, Hage R, Lidove O, Vignal-Clermont C. [Delays in the management of ocular complications of giant cell arteritis: A retrospective monocentric study of 33 patients]. Rev Med Interne 2020; 41:661-666. [PMID: 32682624 DOI: 10.1016/j.revmed.2020.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/05/2020] [Accepted: 06/22/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Ocular complications of giant cell arteritis (GCA) can lead to irreversible bilateral blindness and represent a therapeutic emergency. Recommendations for the management of GCA have recently been updated. The objective of the study was to evaluate delays in appropriate management of the ocular complications of GCA and its determinants. METHOD Retrospective, monocentric study, conducted over the period January 2013-November 2018. All consecutive patients with a final diagnosis of GCA and related visual impairment (permanent visual loss and/or alteration of visual field) were included. RESULTS Thirty-three patients were included (women: 21, men: 12; mean age at diagnosis: 79). Twenty-seven patients (82%) presented with symptoms suggestive of ACG prior to the visual complication, ranging from a few weeks to several months. Seventeen patients (52%) had a known biological inflammatory syndrome (median CRP at 64 mg/L) prior to hospital consultation. The median time from the onset of permanent ophthalmologic manifestations to appropriate corticosteroid management was 3 days (range: 0-134). Two of the 21 patients who consulted an out-of-hospital ophthalmologist received corticosteroid therapy before referral to hospital. Three patients (9%) were treated within 24 h of the onset of the disorders. CONCLUSION There is a significant delay in the appropriate management of ophthalmological complications of ACG and deviations from current recommendations. Numerous actions must therefore be taken to improve the visual prognosis of patients with ACG, both preventively (i.e. early diagnosis and treatment of ACG before the possible occurrence of visual complications), and curatively (rapid recognition and immediate treatment of ocular complications). These elements support the relevance of specific fast-track pathways for GCA.
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Affiliation(s)
- T Sené
- Service de Médecine Interne, Hôpital Fondation Adolphe de Rothschild, 75019 Paris, France; Service de Médecine Interne, Hôpital de la Croix Saint-Simon - Groupe Hospitalier Diaconesses-Croix Saint-Simon, 75020 Paris, France.
| | - G Clavel
- Service de Médecine Interne, Hôpital Fondation Adolphe de Rothschild, 75019 Paris, France
| | - D Villeneuve
- Service de Médecine Interne, Hôpital Fondation Adolphe de Rothschild, 75019 Paris, France
| | - M Philibert
- Service de Neuro-Ophtalmologie, Hôpital Fondation Adolphe de Rothschild, 75019 Paris, France
| | - M Mauget-Faÿsse
- Centre d'Investigations Cliniques, Hôpital Fondation Adolphe de Rothschild, 75019 Paris, France
| | - C Lamirel
- Service d'Ophtalmologie, Hôpital Fondation Adolphe de Rothschild, 75019 Paris, France
| | - A Lecler
- Service d'Imagerie, Hôpital Fondation Adolphe de Rothschild, 75019 Paris, France
| | - O Gout
- Service de Neurologie, Hôpital Fondation Adolphe de Rothschild, 75019 Paris, France
| | - R Hage
- Service de Neuro-Ophtalmologie, Hôpital Fondation Adolphe de Rothschild, 75019 Paris, France
| | - O Lidove
- Service de Médecine Interne, Hôpital Fondation Adolphe de Rothschild, 75019 Paris, France; Service de Médecine Interne, Hôpital de la Croix Saint-Simon - Groupe Hospitalier Diaconesses-Croix Saint-Simon, 75020 Paris, France
| | - C Vignal-Clermont
- Service de Neuro-Ophtalmologie, Hôpital Fondation Adolphe de Rothschild, 75019 Paris, France; Service des Urgences Ophtalmologiques, Hôpital Fondation Adolphe de Rothschild, 75019 Paris, France
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Ralli M, Campo F, Angeletti D, Minni A, Artico M, Greco A, Polimeni A, de Vincentiis M. Pathophysiology and therapy of systemic vasculitides. EXCLI JOURNAL 2020; 19:817-854. [PMID: 32665772 PMCID: PMC7355154 DOI: 10.17179/excli2020-1512] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/15/2020] [Indexed: 12/14/2022]
Abstract
Systemic vasculitides represent uncommon conditions characterized by the inflammation of blood vessels that can lead to different complex disorders limited to one organ or potentially involving multiple organs and systems. Systemic vasculitides are classified according to the diameter of the vessel that they mainly affect (small, medium, large, or variable). The pathogenetic mechanisms of systemic vasculitides are still partly unknown, as well as their genetic basis. For most of the primary systemic vasculitides, a single gold standard test is not available, and diagnosis is often made after having ruled out other mimicking conditions. Current research has focused on new management protocol and therapeutic strategies aimed at improving long-term patient outcomes and avoiding progression to multiorgan failure with irreversible damage. In this narrative review, authors describe different forms of systemic vasculitides through a review of the literature, with the aim of highlighting the current knowledge and recent findings on etiopathogenesis, diagnosis and therapy.
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Affiliation(s)
- Massimo Ralli
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Flaminia Campo
- Department of Sense Organs, Sapienza University of Rome, Italy
| | | | - Antonio Minni
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Marco Artico
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Antonio Greco
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Antonella Polimeni
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy
| | - Marco de Vincentiis
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy
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Lee EJ, Han JC, Park DY, Kee C. A neuroglia-based interpretation of glaucomatous neuroretinal rim thinning in the optic nerve head. Prog Retin Eye Res 2020; 77:100840. [PMID: 31982595 DOI: 10.1016/j.preteyeres.2020.100840] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/02/2020] [Accepted: 01/13/2020] [Indexed: 12/14/2022]
Abstract
Neuroretinal rim thinning (NRR) is a characteristic glaucomatous optic disc change. However, the precise mechanism of the rim thinning has not been completely elucidated. This review focuses on the structural role of the glioarchitecture in the formation of the glaucomatous NRR thinning. The NRR is a glia-framed structure, with honeycomb geometry and mechanically reinforced astrocyte processes along the transverse plane. When neural damage selectively involves the neuron and spares the glia, the gross structure of the tissue is preserved. The disorganization and loss of the glioarchitecture are the two hallmarks of optic nerve head (ONH) remodeling in glaucoma that leads to the thinning of NRR tissue upon axonal loss. This is in contrast to most non-glaucomatous optic neuropathies with optic disc pallor where hypertrophy of the glioarchitecture is associated with the seemingly absent optic disc cupping. Arteritic anterior ischemic optic neuropathy is an exception where pan-necrosis of ONH tissue leads to NRR thinning. Milder ischemia indicates selective neuronal loss that spares glia in non-arteritic anterior ischemic optic neuropathy. The biological reason is the heterogeneous glial response determined by the site, type, and severity of the injury. The neuroglial interpretation explains how the cellular changes underlie the clinical findings. Updated understandings on glial responses illustrate the mechanical, microenvironmental, and microglial modulation of activated astrocytes in glaucoma. Findings relevant to the possible mechanism of the astrocyte death in advanced glaucoma are also emerging. Ultimately, a better understanding of glaucomatous glial response may lead to glia-targeting neuroprotection in the future.
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Affiliation(s)
- Eun Jung Lee
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Jong Chul Han
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Do Young Park
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Changwon Kee
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-gu, Seoul, 06351, South Korea.
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Ciofalo A, Gulotta G, Iannella G, Pasquariello B, Manno A, Angeletti D, Pace A, Greco A, Altissimi G, de Vincentiis M, Magliulo G. Giant Cell Arteritis (GCA): Pathogenesis, Clinical Aspects and Treatment Approaches. Curr Rheumatol Rev 2019; 15:259-268. [DOI: 10.2174/1573397115666190227194014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/30/2019] [Accepted: 02/13/2019] [Indexed: 11/22/2022]
Abstract
:
Giant Cell Arteritis (GCA), or Horton’s Arteritis, is a chronic form of vasculitis of the
large and medium vessels, especially involving the extracranial branches of the carotid arteries, in
particular, the temporal artery, with the involvement of the axillary, femoral and iliac arteries too.
Arterial wall inflammation leads to luminal occlusion and tissue ischemia, which is responsible for
the clinical manifestations of the disease.
:
A substantial number of patients affected by GCA present head and neck symptoms, including ocular,
neurological and otorhinolaryngological manifestations.
:
The aim of this article is to present pathogenesis, clinical aspects and treatment approaches of GCA
manifestations.
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Affiliation(s)
- Andrea Ciofalo
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Giampiero Gulotta
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Giannicola Iannella
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Benedetta Pasquariello
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Alessandra Manno
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Diletta Angeletti
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Annalisa Pace
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Antonio Greco
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Giancarlo Altissimi
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Marco de Vincentiis
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Giuseppe Magliulo
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
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Abstract
PURPOSE OF REVIEW Vision is often threatened or lost by acute ischemic damage to the optic nerves. Such pathology most often affects the anterior portion of the nerve and is visible on funduscopic examination. Ischemic optic neuropathy is associated with typical vascular risk factors and with one systemic disease in particular: giant cell arteritis (GCA). This article provides an overview of the three major classes of ischemic optic neuropathy, including information on risk factors, differential diagnosis, evaluation, and management. RECENT FINDINGS Optical coherence tomography provides precise anatomic imaging in ischemic optic neuropathy, showing neural loss weeks before it is visible on examination. Refinements of optical coherence tomography reveal optic nerve microvasculature and may assist in understanding pathogenesis and verifying diagnosis. New diagnostic algorithms and cranial vascular imaging techniques help define the likelihood of GCA in patients with ischemic optic neuropathy. Finally, intraocular drug and biological agent delivery holds promise for nonarteritic ischemic optic neuropathy, whereas newer immunologic agents may provide effective steroid-sparing treatment for GCA. SUMMARY It is essential to recognize ischemic optic neuropathy upon presentation, especially to determine the likelihood of GCA and the need for immediate steroid therapy. A broad differential diagnosis should be considered so as not to miss alternative treatable pathology, especially in cases with retrobulbar optic nerve involvement.
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Svasti-Salee CR, Mollan SP, Morgan AW, Quick V. Rapid visual recovery following intravenous tocilizumab in glucocorticoid resistant refractory giant cell arteritis. BMJ Case Rep 2019; 12:12/10/e229236. [PMID: 31586951 DOI: 10.1136/bcr-2019-229236] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 72-year-old man presented with a short history of headache, jaw claudication, double vision, amaurosis fugax and distended temporal arteries. A diagnosis of giant cell arteritis (GCA) was confirmed on temporal artery ultrasound and temporal artery biopsy. Despite treatment with high-dose oral glucocorticoid (GC) and multiple pulses of intravenous methylprednisolone, his vision deteriorated to hand movements in one eye. 8 mg/kg intravenous tocilizumab, a humanised, recombinant anti-IL-6 receptor antibody, was administered within 48 hours of vision loss and continued monthly, resulting in marked visual improvement within days, as well as sustained remission of GCA. This case suggests a possible role for tocilizumab as a rescue therapy to prevent or recover visual loss in patients with GCA resistant to GC treatment, termed refractory GCA. Further research is required to elucidate the role of intravenous administration of tocilizumab in this setting.
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Affiliation(s)
| | - Susan P Mollan
- Neuro-Ophthalmology Unit, Ophthalmology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ann W Morgan
- Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Vanessa Quick
- Rheumatology, Luton and Dunstable University Hospital NHS Foundation Trust, Luton, UK
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Saravanan V, Pugmire S, Smith M, Kelly C. Patient-reported involvement of the eighth cranial nerve in giant cell arteritis. Clin Rheumatol 2019; 38:3655-3660. [PMID: 31420810 DOI: 10.1007/s10067-019-04747-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/29/2019] [Accepted: 08/08/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The frequency of eighth nerve lesions in patients with giant cell arteritis (GCA) has rarely been examined. However, sudden onset deafness has been recorded as a presenting feature of GCA on several occasions. This study sought to establish how common this and other symptoms of eighth nerve involvement are in a large retrospective survey. METHODS We contacted 170 patients with GCA and 250 matched PMR patients, inviting them to participate in a questionnaire survey of symptoms of eighth nerve dysfunction. We compared the presence of deafness, tinnitus, loss of balance and vertigo in both groups and examined the relationship between the onset of these symptoms and other features of GCA. RESULTS A total of 317 patients were recruited. The percentage of patients with symptoms of possible vestibulocochlear disease prior to commencement of steroid therapy was significantly greater among GCA patients than PMR patients for all domains. Hearing loss which was twice as common in GCA as in PMR (53% vs 26%) [p = 0.001]. Deafness was concurrent in 35% of GCA patients with other symptoms and 45% reported colocation with headache. Recovery with steroids occurred in 56% of these. CONCLUSION Symptoms of eighth nerve dysfunction are present in over half of patients with GCA. Recovery with steroids was predicted by concurrence with headache in terms of both timing and location. It appears that eighth nerve involvement, especially acute hearing loss, is a not infrequent feature of GCA and often responds well to steroid therapy. Clinicians should enquire about these symptoms when evaluating a patient for possible GCA.Key Points• Deafness is a frequent presenting feature of giant cell arteritis.• Vertigo, tinnitus and loss of balance are also often reported by GCA sufferers.• Steroid therapy is more likely to relieve these symptoms if they are ipsilateral and concurrent with headache.
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Affiliation(s)
- Vadivelu Saravanan
- Department of Rheumatology, Queen Elizabeth Hospital, Sheriff Hill, Gateshead, UK
| | - Susan Pugmire
- Department of Rheumatology, Queen Elizabeth Hospital, Sheriff Hill, Gateshead, UK
| | - Mavis Smith
- Department of Rheumatology, Queen Elizabeth Hospital, Sheriff Hill, Gateshead, UK
| | - Clive Kelly
- Department of Rheumatology, Queen Elizabeth Hospital, Sheriff Hill, Gateshead, UK.
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Abstract
Glucocorticoids (GC) remain the gold standard of the treatment of giant cell arteritis provided objectives of GC-tapering are accurately followed: 15 to 20mg/day at 3 months, 10mg/day at 6 months, 5mg/day at 9-12 months and withdrawal between 12 and 18 months. In case of corticodependance at ≥7.5 mg/day of prednisone or intolerance to GC, a GCsparing therapy has to be introduced, mainly methotrexate or tocilizumab. Individual characteristics of each patient, data about the efficacy of the treatment, its cost and how easy the follow-up under this treatment is are important factors to consider for choosing the right GC-sparing therapy. For all these reasons, except particular situations, we prefer using methotrexate before tocilizumab. Prevention of cardiovascular events is an important aspect of the treatment of GCA. We recommend using aspirin (75-100mg/day) during the first month of treatment or longer in case of occurrence of an ischemic complication. Each patient treated for GCA should receive a prevention of osteoporosis with respect of usual recommendations.
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Giant cell arteritis relapse presenting as idiopathic orbital inflammation. Can J Ophthalmol 2019; 55:e36-e39. [PMID: 31712038 DOI: 10.1016/j.jcjo.2019.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 04/06/2019] [Accepted: 05/03/2019] [Indexed: 11/22/2022]
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18
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Mukhtyar C, Cate H, Graham C, Merry P, Mills K, Misra A, Jones C. Development of an evidence-based regimen of prednisolone to treat giant cell arteritis - the Norwich regimen. Rheumatol Adv Pract 2019; 3:rkz001. [PMID: 31431989 PMCID: PMC6649920 DOI: 10.1093/rap/rkz001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/02/2019] [Indexed: 01/07/2023] Open
Abstract
We have reviewed the literature to form a bespoke regimen for daily oral prednisolone (DP) in GCA. Initial DP in clinical trials is 40-60 mg daily, but relapse rates are 67-92%. Cumulative prednisolone (CP) of 3.2 and 3.9 g (at 6 months) resulted in a relapse rate of 83 and 67%, respectively; and 3 and 3.9 g (at 12 months) resulted in 92 and 82% relapse, respectively. CP was 6.2-7.1 g in the first year. Mean DP was 18.8 mg at 3 months and 6.6-7.4 mg at 12 months. The duration of treatment with prednisolone for GCA was 22-26 months. The CP to achieve discontinuation was 6.5-12.1 g. Using these data, the Norwich regimen starts DP at 1 mg/kg/day of lean body mass, discontinuing over 100 weeks. For the average UK woman, initial DP is 45 mg daily, reaching 21 mg daily by 12 weeks and 6 mg daily by 52 weeks. The CP for the average UK woman would be 6.5 g at 52 weeks and 7.4 g to discontinuation.
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Affiliation(s)
| | - Heidi Cate
- Department of Ophthalmology, Norfolk and Norwich University Hospital, Norwich, UK
| | | | | | | | - Aseema Misra
- Department of Ophthalmology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Colin Jones
- Department of Ophthalmology, Norfolk and Norwich University Hospital, Norwich, UK
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19
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AlShaker S, Shemesh AA, Margolin E. Enhancement of optic nerve sheath in AAION: a case of visual recovery in fulminant GCA. Can J Ophthalmol 2018; 53:e236-e239. [PMID: 30503002 DOI: 10.1016/j.jcjo.2018.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 02/19/2018] [Accepted: 02/27/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Sara AlShaker
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont
| | - Ari Aharon Shemesh
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont
| | - Edward Margolin
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont.
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20
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Basu N, Karabayas M, Pusey C. Prognosis and future developments in vasculitis. Best Pract Res Clin Rheumatol 2018; 32:148-165. [PMID: 30526894 DOI: 10.1016/j.berh.2018.08.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 08/07/2018] [Accepted: 08/24/2018] [Indexed: 12/11/2022]
Abstract
The prognosis of ANCA-associated vasculitis has been transformed in recent years. Once it was a set of invariably acute and fatal conditions, but these disorders are currently considered to be chronic diseases. This change is largely attributable to earlier diagnosis and the careful application of immunotherapeutics. However, patients still experience premature mortality, relapse, comorbid ill health and poor quality of life. Mortality rates in large-vessel vasculitis are not comparable; however, morbidity and poor patient outcomes prevail. Toxicity secondary to glucocorticoids represents a common driver of poor outcomes across systemic vasculitis. The main thrust of future treatment strategies is to reduce if not eliminate exposure to these agents.
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Affiliation(s)
- N Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, United Kingdom.
| | - M Karabayas
- Department of Rheumatology, NHS Grampian, United Kingdom
| | - C Pusey
- Department of Medicine, Imperial College London, United Kingdom
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21
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Anti-Interleukin-6 Antibody as Treatment for Giant Cell Arteritis. J Neuroophthalmol 2018; 38:558-560. [PMID: 30199508 DOI: 10.1097/wno.0000000000000712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Giant cell arteritis of the breast: A case report. DERMATOL SIN 2018. [DOI: 10.1016/j.dsi.2017.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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23
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Vodopivec I, Rizzo JF. Ophthalmic manifestations of giant cell arteritis. Rheumatology (Oxford) 2018; 57:ii63-ii72. [DOI: 10.1093/rheumatology/kex428] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ivana Vodopivec
- Department of Neurology, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Joseph F Rizzo
- Neuro-Ophthalmology Service, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Neuro-Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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24
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Karti O, Karti DT, Kilic İH, Gokcay F, Celebisoy N. Baseline demographics, clinical features, and treatment protocols of 240 patients with optic neuropathy: experiences from a neuro-ophthalmological clinic in the Aegean region of Turkey. Int Ophthalmol 2017; 39:155-166. [PMID: 29260500 DOI: 10.1007/s10792-017-0799-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 12/11/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To analyze the demographic patterns, clinical characteristics, and treatment protocols of optic neuropathies. MATERIALS AND METHODS The hospital data of patients with optic neuropathy admitted to the Department of Neuro-ophthalmology in a tertiary referral center in Turkey between January 2010 to January 2017 were retrospectively analyzed. Demographic patterns, clinical features, treatment protocols, and the natural disease courses were assessed. RESULTS The total number of patients with optic neuropathy seen over this period was 240, which consist of 43 with idiopathic optic neuritis (17.9%), 40 with multiple sclerosis-related optic neuritis (16.7%), 12 with chronic relapsing inflammatory optic neuritis (5.0%), 12 with atypical optic neuritis (5.0%), 11 with neuromyelitis optica spectrum disorders-related optic neuritis (4.6%), 90 with non-arteritic ischemic optic neuropathy (37.5%), 4 with arteritic ischemic optic neuropathy (1.7%), 10 with traumatic optic neuropathy (4.1%), 6 with compressive optic neuropathy (2.5%), and 12 with mitochondrial optic neuropathy [9 with toxic optic neuropathy (3.7%) and 3 with Leber's hereditary optic neuropathy (1.2%)]. There were 101 males (42%) and 139 females (58%). The mean age was 43.34 ± 15.86 years. CONCLUSION This study reported the demographics, clinical characteristics, and treatment protocols of optic neuropathies in a neuro-ophthalmology specialty clinic at a tertiary referral center in Turkey during the past decade. The data may be useful in assessing the global status of optic neuropathies.
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Affiliation(s)
- Omer Karti
- Department of Ophthalmology, Bozyaka Training and Research Hospital, Saim Cıkrıkcı cad. No: 59, Bozyaka, Izmir, Turkey.
| | - Dilek Top Karti
- Department of Neurology, Bozyaka Training and Research Hospital, Izmir, Turkey
| | - İlay Hilal Kilic
- Department of Neurology, Ege University Medical Faculty, Izmir, Turkey
| | - Figen Gokcay
- Department of Neurology, Ege University Medical Faculty, Izmir, Turkey
| | - Nese Celebisoy
- Department of Neurology, Ege University Medical Faculty, Izmir, Turkey
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25
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26
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Wirth M, Schirmer L, Hofauer B, Lenschow M, Loos D, Thuermel K, Knopf A. Head and neck giant cell arteritis: an autoimmune disease with many faces. Acta Otolaryngol 2017; 137:986-991. [PMID: 28440088 DOI: 10.1080/00016489.2017.1314010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
CONCLUSION A high rate of infrequent presentations of giant cell arteritis were seen in the ENT department and should be anticipated as a differential diagnosis in every older patient with odynophagia with high CRP values without cause in thorough ENT examination. OBJECTIVE To describe the clinical manifestation of head and neck giant cell arteritis and to derive a diagnostic pathway covering atypical cases. METHOD Single-center, retrospective analysis of cases with GCA in the head and neck region (HN-GCA) (2002-2012) to describe the clinical presentation and to derive a diagnostic pathway covering manifestations presenting to an ENT department. RESULTS Sixty-five patients were newly diagnosed with HN-GCA in the department of otolaryngology, ophthalmology and neurology. The most frequent symptoms were loss of vision (83%) and new onset headache (63%). Eight patients (12%) presented with infrequent manifestations, predominantly in the department of otorhinolaryngology. The most common atypical presentation (50%) was odynophagia in conjunction with high CRP values misleading to an infectious cause and delaying diagnosis. A diagnostic pathway for GCA was derived based on the ACR classification criteria and the clinical findings.
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Affiliation(s)
- Markus Wirth
- Department of Otolaryngology – Head and Neck Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Lucas Schirmer
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Benedikt Hofauer
- Department of Otolaryngology – Head and Neck Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Magdalena Lenschow
- Department of Otolaryngology – Head and Neck Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Daria Loos
- Department of Ophthalmology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Klaus Thuermel
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas Knopf
- Department of Otolaryngology – Head and Neck Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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27
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Giant Cell Arteritis: Current and Future Treatment Options. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017. [DOI: 10.1007/s40674-017-0071-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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28
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Abstract
Giant cell arteritis (GCA) is the most common form of vasculitis in individuals aged 50 years and over. GCA typically affects large and medium-sized arteries, with a predilection for the extracranial branches of the carotid artery. Patients with GCA usually present with symptoms and signs that are directly related to the artery that is affected, with or without constitutional manifestations. The most dreaded complication of GCA is visual loss, which affects about one in six patients and is typically caused by arteritis of the ophthalmic branches of the internal carotid artery. Before the advent of glucocorticoid treatment, the prevalence of visual complications was high. Increasing awareness by physicians of the symptoms of GCA and advances in diagnostic techniques over the past twenty years have also contributed to a substantial decline in the frequency of permanent visual loss. Ischaemic brain lesions are less common than visual lesions, and mostly result from vasculitis of the extradural vertebral or carotid arteries. In the case of both the eye and the brain, ischaemic damage is thought to result from arterial stenosis or occlusion that occurs secondary to the inflammatory process. The inflammatory response at the onset of arteritis, its role as a predictor of complications and the role of traditional cardiovascular risk factors have been extensively investigated in the past decade. In this Review, the epidemiology, risk factors, clinical presentation and current therapeutic approach of GCA-related ischaemic events are discussed, with a particular emphasis on visual loss.
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29
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Espino Barros A, Amram AL, Derham AM, Smith SV, Lee AG. Management of ischemic optic neuropathies. EXPERT REVIEW OF OPHTHALMOLOGY 2017. [DOI: 10.1080/17469899.2017.1291341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Angelina Espino Barros
- Department of Ophthalmology, Centro Médico Zambrano Hellion, San Pedro Garza García, México
| | - Alec L. Amram
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX, USA
| | - Angeline Mariani Derham
- Department of Ophthalmology, University of Texas Health Science Center San Antonio School of Medicine, San Antonio, TX, USA
| | - Stacy V. Smith
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Andrew G. Lee
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX, USA
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
- Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York City, NY, USA
- Section of Ophthalmology, UT MD Anderson Cancer Center, Houston, TX, USA
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA
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30
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31
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Bei L, Lee I, Lee MS, Van Stavern GP, McClelland CM. Acute vision loss and choroidal filling delay in the absence of giant-cell arteritis. Clin Ophthalmol 2016; 10:1573-1578. [PMID: 27695279 PMCID: PMC5028095 DOI: 10.2147/opth.s112196] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Giant-cell arteritis (GCA) is a visually devastating disease that often progresses to severe bilateral vision loss if untreated. Diagnosis of GCA is made challenging by the protean nature of the disease and the lack of a simple test that is both highly sensitive and specific. Choroidal filling delay on fluorescein angiography (FA) has been touted as a highly characteristic feature of GCA-related vision loss, although knowledge of both the sensitivity and specificity of this finding remains unproven. We report our experience of delayed choroidal filling on FA in a series of seven patients referred to an academic neuro-ophthalmology practice due to concern for GCA. Despite the FA findings, our examination, diagnostic testing, and long-term follow-up excluded the diagnosis of GCA in all cases, suggesting that choroidal perfusion abnormalities may occur in the absence of GCA. When evaluating a patient for acute vision loss, the astute clinician must remain cognizant of the limitations of FA in the diagnosis of GCA.
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Affiliation(s)
- Ling Bei
- Department of Ophthalmology and Visual Neurosciences, Washington University School of Medicine, St Louis, MO
| | - Iris Lee
- Casey Eye Institute, Oregon Health and Science University, Portland, OR
| | - Michael S Lee
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN, USA
| | - Greg P Van Stavern
- Department of Ophthalmology and Visual Neurosciences, Washington University School of Medicine, St Louis, MO
| | - Collin M McClelland
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN, USA
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32
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Saleh M, Turesson C, Englund M, Merkel PA, Mohammad AJ. Visual Complications in Patients with Biopsy-proven Giant Cell Arteritis: A Population-based Study. J Rheumatol 2016; 43:1559-65. [PMID: 27252424 DOI: 10.3899/jrheum.151033] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To study the clinical and laboratory characteristics of patients with biopsy-proven giant cell arteritis (GCA) with visual complications, and to evaluate the incidence rate of visual complications in GCA compared to the background population. METHODS Data from 840 patients with GCA in the county of Skåne, Sweden, diagnosed between 1997 and 2010, were used for this analysis. Cases with visual complications were identified from a diagnosis registry and confirmed by a review of medical records. The rate of visual complications in patients with GCA was compared with an age- and sex-matched reference population. RESULTS There were 85 patients (10%) who developed ≥ 1 visual complication after the onset of GCA. Of the patients, 18 (21%) developed unilateral or bilateral complete visual loss. The mean age at diagnosis was 78 years (± 7.3); 69% were women. Compared with patients without visual complications, those with visual complication had lower C-reactive protein levels at diagnosis and were less likely to have headache, fever, and palpable abnormal temporal artery. The use of β-adrenergic inhibitors was associated with visual complications. The incidence of visual complications among patients with GCA was 20.9/1000 person-years of followup compared to 6.9/1000 person-years in the reference population, resulting in a rate ratio of 3.0 (95% CI 2.3-3.8). CONCLUSION Ten percent of patients with GCA developed visual complications, a rate substantially higher than that of the general population. Patients with GCA who had visual complications had lower inflammatory responses and were more likely to have been treated with β-adrenergic inhibitors compared with patients without visual complications.
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Affiliation(s)
- Muna Saleh
- From the Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital, Helsingborg; Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; Department of Clinical Sciences, Orthopaedics and Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden; Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts; Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.M. Saleh, MD, Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital; C. Turesson, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; M. Englund, MD, PhD, Department of Clinical Sciences, Orthopaedics, Lund University, and the Clinical Epidemiology Research and Training Unit, Boston University School of Medicine; P.A. Merkel, MD, MPH, Division of Rheumatology, University of Pennsylvania; A.J. Mohammad, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, and the Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Carl Turesson
- From the Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital, Helsingborg; Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; Department of Clinical Sciences, Orthopaedics and Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden; Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts; Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.M. Saleh, MD, Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital; C. Turesson, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; M. Englund, MD, PhD, Department of Clinical Sciences, Orthopaedics, Lund University, and the Clinical Epidemiology Research and Training Unit, Boston University School of Medicine; P.A. Merkel, MD, MPH, Division of Rheumatology, University of Pennsylvania; A.J. Mohammad, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, and the Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Martin Englund
- From the Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital, Helsingborg; Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; Department of Clinical Sciences, Orthopaedics and Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden; Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts; Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.M. Saleh, MD, Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital; C. Turesson, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; M. Englund, MD, PhD, Department of Clinical Sciences, Orthopaedics, Lund University, and the Clinical Epidemiology Research and Training Unit, Boston University School of Medicine; P.A. Merkel, MD, MPH, Division of Rheumatology, University of Pennsylvania; A.J. Mohammad, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, and the Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Peter A Merkel
- From the Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital, Helsingborg; Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; Department of Clinical Sciences, Orthopaedics and Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden; Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts; Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.M. Saleh, MD, Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital; C. Turesson, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; M. Englund, MD, PhD, Department of Clinical Sciences, Orthopaedics, Lund University, and the Clinical Epidemiology Research and Training Unit, Boston University School of Medicine; P.A. Merkel, MD, MPH, Division of Rheumatology, University of Pennsylvania; A.J. Mohammad, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, and the Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Aladdin J Mohammad
- From the Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital, Helsingborg; Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; Department of Clinical Sciences, Orthopaedics and Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden; Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts; Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.M. Saleh, MD, Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital; C. Turesson, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; M. Englund, MD, PhD, Department of Clinical Sciences, Orthopaedics, Lund University, and the Clinical Epidemiology Research and Training Unit, Boston University School of Medicine; P.A. Merkel, MD, MPH, Division of Rheumatology, University of Pennsylvania; A.J. Mohammad, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, and the Vasculitis and Lupus Clinic, Addenbrooke's Hospital.
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Chacko JG, Chacko JA, Salter MW. Review of Giant cell arteritis. Saudi J Ophthalmol 2014; 29:48-52. [PMID: 25859139 DOI: 10.1016/j.sjopt.2014.10.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 09/16/2014] [Accepted: 10/01/2014] [Indexed: 11/26/2022] Open
Abstract
Giant-cell arteritis (GCA) is a systemic autoimmune disease affecting primarily the elderly. Giant cell arteritis can cause sudden and potentially bilateral sequential vision loss in the elderly. Therefore, it is considered a medical emergency in ophthalmology and a significant cause of morbidity in an increasingly aging population. Ophthalmologists need to be able to recognize the classic symptoms and signs of this disease, and then be able to work-up and treat these patients in an efficient manner. An in-depth review of GCA from the literature as well as personal clinical experience follows.
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Affiliation(s)
- Joseph G Chacko
- Jones Eye Institute, Department of Ophthalmology, University of Arkansas for Medical Sciences, 4301 W. Markham, #523, Little Rock, AR 72205, USA
| | | | - Michael W Salter
- Jones Eye Institute, Department of Ophthalmology, University of Arkansas for Medical Sciences, 4301 W. Markham, #523, Little Rock, AR 72205, USA
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De Smit E, Palmer AJ, Hewitt AW. Projected Worldwide Disease Burden from Giant Cell Arteritis by 2050. J Rheumatol 2014; 42:119-25. [DOI: 10.3899/jrheum.140318] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To estimate and project the number of people affected worldwide by giant cell arteritis (GCA) by 2050. Modeling the number of people visually impaired as a result of this disease will help establish the projected morbidity and resource burden.Methods.A systematic literature review up to December 2013 was conducted using PubMed and ISI Web of Science. Studies reporting an incidence rate for GCA were used to model disease incident cases at regional and national levels. United Nations Population Prospect data were used for population projections. Morbidity burden was established through rates of visual impairment. The associated financial implications were calculated for the United States.Results.The number of incident cases of GCA will increase secondary to an aging population. By 2050, more than 3 million people will have been diagnosed with GCA in Europe, North America, and Oceania. About 500,000 people will be visually impaired. By 2050, in the United States alone, the estimated cost from visual impairment due to GCA will exceed US$76 billion. Inpatient care for patients with active GCA will total about US$1 billion. Management of steroid-related adverse events will increase costs further, with steroid-induced fractures estimated to total US$6 billion by 2050.Conclusion.Projecting disease burden for GCA on a global scale allows for optimization of healthcare planning and prioritization of research domains. Additional population-based studies are required to more accurately project worldwide disease burden. Our work highlights the future global disease burden of GCA, and illustrates the associated financial implications.
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Affiliation(s)
- Jonathan H. Smith
- Kentucky Neuroscience Institute; University of Kentucky; Lexington KY USA
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Liao YJ, Hwang JJ. Treatment of anterior ischemic optic neuropathy: Clues from the bench. Taiwan J Ophthalmol 2014. [DOI: 10.1016/j.tjo.2013.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Liozon E, Ly KH, Robert PY. Manifestations ophtalmologiques de la maladie de Horton. Rev Med Interne 2013; 34:421-30. [DOI: 10.1016/j.revmed.2013.02.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 02/15/2013] [Indexed: 10/27/2022]
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Abstract
UNLABELLED ABSTRACT.: PURPOSE Malfunction of retinal blood flow or oxygenation is believed to be involved in various diseases. Among them are retinal vessel occlusions, diabetic retinopathy and glaucoma. Reliable, non-invasive technology for retinal oxygen measurements has been scarce and most of the knowledge on retinal oxygenation comes from animal studies. This thesis describes human retinal oximetry, performed with novel retinal oximetry technology. The thesis describes studies on retinal vessel oxygen saturation in (1) light and dark in healthy volunteers, (2) central retinal vein occlusion, (3) branch retinal vein occlusion, (4) central retinal artery occlusion, (5) diabetic retinopathy, (6) patients undergoing glaucoma surgery and (7) patients taking glaucoma medication. METHODS The retinal oximeter (Oxymap ehf., Reykjavik, Iceland) is based on a fundus camera. An attached image splitter allows the simultaneous capture of four images of the same area of the fundus. Two images are used for further analysis, one acquired with 586 nm light and one with 605 nm light. Light absorbance of retinal vessels is sensitive to oxygen saturation at 605 nm but not at 586 nm. Measurement of reflected light at these wavelengths allows estimation of oxygen saturation in the main retinal vessels. This is performed with custom-made analysis software. RESULTS LIGHT AND DARK: After 30 min in the dark, oxygen saturation in retinal arterioles of healthy volunteers was 92 ± 4% (mean ± SD, n = 15). After 5 min in 80 cd/m(2) light, the arteriolar saturation was 89 ± 5%. The decrease was statistically significant (p = 0.008). The corresponding values for retinal venules were 60 ± 5% in the dark and 55 ± 10% in the light (p = 0.020). Similar results were found after alternating 5 min periods of darkness and light. In a second experiment (n = 19), a significant decrease in retinal vessel oxygen saturation was found in 100 cd/m(2) light compared with darkness but 1 and 10 cd/m(2) light had no significant effect. CENTRAL RETINAL VEIN OCCLUSION: In patients with central retinal vein occlusion, the mean saturation in affected retinal venules was 49 ± 12%, while the mean value for venules in the fellow eye was 65 ± 6% (mean ± SD, p = 0.003, n = 8). The retinal arteriolar saturation was the same in affected (99 ± 3%) and the unaffected (99 ± 6%) eyes. The venous oxygen saturation showed much variation between affected eyes. BRANCH RETINAL VEIN OCCLUSION: Median oxygen saturation in venules affected by branch retinal vein occlusion was 59% (range, 12-93%, n = 22), while it was 63% (23-80%) in unaffected venules in the affected eye and 55% (39-80%) in venules in the fellow eye. The difference was not statistically significant (p > 0.05). There was a significant difference between affected arterioles (median 101%; range, 89-115%) and unaffected arterioles (95%, 85-104%) in the affected eye (p < 0.05, n = 18). CENTRAL RETINAL ARTERY OCCLUSION: In a patient with a day's history of central retinal artery occlusion due to temporal arteritis, the mean arteriolar saturation was 71 ± 9% and 63 ± 9% in the venules. One month later, after treatment with prednisolone, the mean arteriolar saturation was 100 ± 4% and the venous saturation 54 ± 5%. DIABETIC RETINOPATHY: When compared with healthy volunteers (n = 31), patients with all categories of diabetic retinopathy had on average 7-10 percentage points higher saturation in retinal arterioles (p < 0.05 for all categories, n = 6-8 in each category). In venules, the saturation was 8-12 percentage points higher (p < 0.05 for all categories). GLAUCOMA SURGERY: Oxygen saturation in retinal arterioles increased by 2 percentage points on average (p = 0.046, n = 19) with surgery, which lowered intraocular pressure from 23 ± 7 mmHg (mean ± SD) to 10 ± 4 mmHg (p < 0.0001). No other significant changes were found (p ≥ 0.35). DORZOLAMIDE: A significant reduction of 3 percentage points was found in arterioles (p < 0.01) and venules (p < 0.05) when patients with glaucoma or ocular hypertension changed from dorzolamide-timolol combination eye drops to timolol alone (n = 6). No change was found in patients, who started on timolol and switched to the combination therapy (p > 0.05, n = 7). CONCLUSIONS Dual wavelength oximetry can be used to non-invasively measure retinal vessel oxygen saturation in health and disease. The results indicate that retinal vessel oxygen saturation is (1) increased in the dark, (2) lower in venules affected by central retinal vein occlusions, (3) variable in branch retinal vein occlusion, (4) lower in retinal arterioles in central retinal artery occlusion, (5) increased in diabetic retinopathy, (6-7) mildly affected by glaucoma surgery or dorzolamide.
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Treatment of acute visual loss in giant cell arteritis: should we prescribe high-dose intravenous steroids or just oral steroids? J Neuroophthalmol 2013; 32:278-87. [PMID: 22914694 DOI: 10.1097/wno.0b013e3182688218] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Temporal arteritis, also termed giant cell arteritis, is one of the vasculitides affecting large and medium sized cranial arteries, particularly of the carotid tree. Clinical manifestations may vary from the classic constellation of temporal headache in the elderly accompanied by constitutional signs, jaw claudication, and visual symptoms; therefore, a high index of clinical suspicion may be necessary to identify the disorder. Once suspected, immediate treatment is crucial while exploring any number of diagnostic tools to confirm or refute the diagnosis, since morbidity from untreated temporal arteritis can be devastating. At the same time, achieving a definitive diagnosis is paramount, as treatment can be toxic with significant morbidity of its own. Temporal artery biopsy remains the gold standard, but noninvasive diagnostic approaches are being refined. Corticosteroids remain the cornerstone of treatment, but are ineffective for, not tolerated by, or contraindicated in some individuals, necessitating the exploration of alternatives.
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Affiliation(s)
- Stephanie J Nahas
- Department of Neurology, Thomas Jefferson University Hospital, Jefferson Headache Center, Philadelphia, PA 19107-5092, USA.
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Steigerwalt RD, Cesarone MR, Belcaro G, Pascarella A, De Angelis M, Gattegna R, Nebbioso M. Arteritic anterior ischemic optic neuropathy treated with intravenous prostaglandin E(1) and steroids. Int J Angiol 2012; 19:e113-5. [PMID: 22477619 DOI: 10.1055/s-0031-1278380] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Arteritic anterior ischemic optic neuropathy (AAION) is an acute ischemia of the posterior ciliary arteries and/or ophthalmic artery due to inflammation. Therapy is immediate intervention with systemic steroids, especially to protect against vision loss in the other eye. The addition of a potent vasodilator to the steroids could help restore ocular blood flow and improve visual acuity. The objective of the current report was to present the use of prostaglandin E(1) (PGE(1)) - a powerful vasodilator of the microcirculation - in the treatment of AAION. Two patients with AAION were treated with intravenous steroids and PGE(1). The visual acuity improved from 4/50 (less than 20/200) to 6/10 (20/35) in one patient and from 1/50 (20/400) to 1/10 (20/200) in the second patient. The visual fields in both patients maintained small central islands of vision. No complications due to the use of PGE(1) were seen. Intravenous PGE(1) should be considered in addition to steroids in cases of AAION to immediately restore blood flow to the optic nerve and improve visual acuity while the steroids reduce the inflammation.
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Dubey R, Bhardwaj G, Sanli E, Kalapesi F, Francis IC. Temporal Arteritis—Reversal of Blindness Using Anticoagulation and Steroids. Neuroophthalmology 2011. [DOI: 10.3109/01658107.2011.611275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Scheurer RA, Harrison AR, Lee MS. Treatment of vision loss in giant cell arteritis. Curr Treat Options Neurol 2011; 14:84-92. [PMID: 22037998 DOI: 10.1007/s11940-011-0152-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OPINION STATEMENT If giant cell arteritis is suspected as a cause of visual loss, emergent management is necessary. Clinical suspicion should prompt the practitioner to obtain laboratory studies and initiate treatment prior to establishing the diagnosis. The evaluation includes immediate erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood count (CBC). Treatment begins with high-dose intravenous corticosteroids. We recommend intravenous methylprednisolone (250 mg every 6 h) for 3 to 5 days. During that time, a temporal artery biopsy should be performed for pathologic diagnosis. We also begin daily adjunctive aspirin orally. After the initial bolus of intravenous corticosteroids, therapy transitions to oral prednisone administered at 1 mg/kg per day until the activity of the disease process attenuates, as demonstrated by improvement in systemic symptoms and normalization of both ESR and CRP. This change usually occurs in the first 3 to 4 weeks. The patient should be followed closely, with therapy tapered as guided by systemic symptoms, ESR, and CRP. To maximize the use of remaining vision, appropriate patients should be referred to specialists for help with low-vision therapies, assistive devices, and precautions to protect the better-seeing eye.
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Affiliation(s)
- Ryan A Scheurer
- Department of Ophthalmology, University of Minnesota, Minneapolis, MN, USA
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Gonzalez-Gay MA, Martinez-Dubois C, Agudo M, Pompei O, Blanco R, Llorca J. Giant cell arteritis: epidemiology, diagnosis, and management. Curr Rheumatol Rep 2011; 12:436-42. [PMID: 20857242 DOI: 10.1007/s11926-010-0135-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Giant cell arteritis (GCA), also called temporal arteritis, is a vasculitis that affects large and middle-sized blood vessels--with predisposition to the involvement of cranial arteries derived from the carotid artery--in individuals older than 50 years of age. Familial aggregation of GCA has been observed. Incidence of GCA is higher in white individuals than those of other ethnicities, particularly those of Scandinavian background. A temporal artery biopsy is the gold standard test for the diagnosis of GCA. Several imaging modalities, in particular ultrasonography, are useful in the diagnosis of GCA. Corticosteroids are the cornerstone of treatment in GCA. Alternative, steroid-sparing drugs, particularly methotrexate, should be considered in GCA patients with severe corticosteroid-related side effects and/or in those who require prolonged corticosteroid therapy due to relapses of the disease.
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Affiliation(s)
- Miguel A Gonzalez-Gay
- Rheumatology Division, Hospital Universitario Marques de Valdecilla, Avenida de Valdecilla s/n, 39008, IFIMAV, Santander, Cantabria, Spain.
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Chew S, Kerr N, Danesh-Meyer H. Giant cell arteritis. J Clin Neurosci 2009; 16:1263-8. [DOI: 10.1016/j.jocn.2009.05.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2009] [Accepted: 05/06/2009] [Indexed: 10/20/2022]
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Braun N, Fritz P, Rieth A, Schroth W, Kimmel M, Biegger D, Zakim D, Alscher MD. Predictors for treatment success and expression of glucocorticoid receptor in giant cell arteritis and polymyalgia rheumatica. J Rheumatol 2009; 36:2269-76. [PMID: 19684157 DOI: 10.3899/jrheum.090075] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) generally respond well to treatment with glucocorticoids (GC). We sought to determine the value of clinical, histopathologic, immunohistochemical, and genetic findings and the expression of the glucocorticoid receptor (GR) for discriminating between patients who achieve complete remission, or partial remission, or who do not improve with glucocorticoid treatment. METHODS We examined biopsies of the temporal artery from 60 patients, of whom 27 had GCA, 13 PMR, and 20 arteriosclerosis. RESULTS Of the clinical variables evaluated, jaw claudication was correlated with the histologic classification of the biopsies (p < 0.0001). Erythrocyte sedimentation rate was significantly higher in patients with PMR and GCA than in patients with arteriosclerosis (p < 0.0001). There were significant differences between patients with GCA versus PMR in the numbers of CD3-, CD8-, and CD4-positive T cells, in CD68-positive monocytes (p < 0.0001), and antigen-presenting cells (p < 0.0001). CD138-positive and CD20-positive cells were absent in patients with PMR but present in patients with GCA (p < 0.0001). In GCA and chronic inflammation most monocytes and lymphocytes expressed GR (88.9%). The number of CD68-positive cells and the extent of GR-staining in chronic inflammation reflected the success of treatment in logistic regression analysis (p < 0.05). GR polymorphism showed that more than 90% of patients had the wild-type (homozygote) of the R23K or N363S polymorphism. There was no evidence that this polymorphism influenced response to treatment with GC (Fisher's exact test 1.0). CONCLUSION Expression of GR and the presence of CD20-, CD3-, CD4-, CD8-, CD68-, CD138-positive cells and antigen-presenting cells differ between GCA and PMR. The presence of CD68-positive cells and the extent of GR-staining in chronic inflammation are suitable to predict complete remission in GCA.
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Affiliation(s)
- Niko Braun
- Division of General Internal Medicine and Nephrology, Department of Internal Medicine, Robert-Bosch Hospital Stuttgart, 70376 Stuttgart, Germany.
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Cid MC, Prieto-González S, Arguis P, Espígol-Frigolé G, Butjosa M, Hernández-Rodríguez J, Segarra M, Lozano E, García-Martínez A. The spectrum of vascular involvement in giant-cell arteritis: clinical consequences of detrimental vascular remodelling at different sites. APMIS 2009:10-20. [PMID: 19515134 DOI: 10.1111/j.1600-0463.2009.02471.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Although repeatedly reported in the literature, the extracranial involvement by giant-cell arteritis has been considered anecdotal until recent years. The emergence of new or improved imaging techniques along with a closer follow-up of these patients and their increase in life expectancy are beginning to underline that the clinical impact of extracranial involvement by GCA may be more relevant than previously thought. This review focuses on the extent of vascular involvement in GCA as reported by pathology and imaging studies as well as the clinical consequences of imperfect vascular remodelling in various vascular territories.
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Affiliation(s)
- Maria C Cid
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, and IDIBAPS, University of Barcelona, Barcelona, Spain.
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Yamauchi Y, Cruz JMC, Kaplan HJ, Goto H, Sakai JI, Usui M. Suspected Simultaneous Bilateral Anterior Ischemic Optic Neuropathy in a Patient with Behçet's Disease. Ocul Immunol Inflamm 2009; 13:317-25. [PMID: 16159724 DOI: 10.1080/09273940590950945] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AIM To report a 47-year-old Japanese woman with a one-year history of Behçet's disease who complained of sudden bilateral visual loss with concurrent anterior ischemic optic neuropathy (AION). CASE REPORT The patient's Snellen visual acuity was 0.1 (OD) and 0.3 (OS) of onset. There was bilateral mild anterior chamber inflammation. Bilateral optic disc pale swelling was observed without retinal exudates and edema. Fluorescein angiography demonstrated bilateral hypofluorescence of the optic disc in early frames but with no distinct retinal vasculitis. Visual field showed bilateral relative central scotoma and right altitudinal hemianopsia. Laboratory examination revealed an ESR of 26 mm in the first hour with a C-reactive protein level of < 0.3 mg/dl. Periocular injection of triamcinolone acetonide in both eyes without systemic corticosteroid administration improved her visual acuity to 0.7 (OD) and 1.2 (OS) within 45 days of onset. Bilateral optic disc swelling gradually resolved. In the early stages, fluorescein angiography demonstrated normal optic disc filling in both eyes. There was a residual right central scotoma on visual field. CONCLUSION We observed an extremely rare case of simultaneous bilateral AION with Behçet's disease with marked visual recovery within 45 days of onset.
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Affiliation(s)
- Yasuyuki Yamauchi
- Department of Ophthalmology, Tokyo Medical University Hospital, Tokyo, Japan.
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Borg FA, Dasgupta B. Treatment and outcomes of large vessel arteritis. Best Pract Res Clin Rheumatol 2009; 23:325-37. [DOI: 10.1016/j.berh.2009.04.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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