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Khalique MI, Arjunan M, Wood S, Mackie SL. The spectrum of giant cell arteritis through a rheumatology lens. Eye (Lond) 2024:10.1038/s41433-024-03153-7. [PMID: 38898105 DOI: 10.1038/s41433-024-03153-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 05/14/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Treatment of giant cell arteritis (GCA) aims initially to prevent acute visual loss, and subsequently to optimise long-term quality of life. Initial prevention of acute visual loss in GCA is well-standardised with high-dose glucocorticoid therapy but in the longer term optimising quality of life requires tailoring of treatment to the individual. The licensing of the IL-6 receptor inhibitor tocilizumab combined with advances in vascular imaging have resulted in many changes to diagnostic and therapeutic practice. Firstly, GCA is a systemic disease that may involve multiple vascular territories and present in diverse ways. Broadening of the "spectrum" of what is called GCA has been crystallised in the 2022 GCA classification criteria. Secondly, the vascular inflammation of GCA frequently co-exists with the extracapsular musculoskeletal inflammation of the related disease, polymyalgia rheumatica (PMR). Thirdly, GCA care must often be delivered across multiple specialities and healthcare organisations requiring effective interprofessional communication. Fourthly, both GCA and PMR may follow a chronic or multiphasic disease course; long-term management must be tailored to the individual patient's needs. In this article we focus on some areas of current rheumatology practice that ophthalmologists need to be aware of, including comprehensive assessment of extra-ocular symptoms, physical signs and laboratory markers; advanced imaging techniques; and implications for multi-speciality collaboration.
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Affiliation(s)
| | - Mousindha Arjunan
- Department of Ophthalmology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Samuel Wood
- Department of Rheumatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sarah L Mackie
- Department of Rheumatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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Dentel A, Clavel G, Savatovsky J, Vignal C, Senè T, Charbonneau F, Zuber K, Lecler A, Hage R. Use of Retinal Angiography and MRI in the Diagnosis of Giant Cell Arteritis With Early Ophthalmic Manifestations. J Neuroophthalmol 2022; 42:218-225. [PMID: 35051984 DOI: 10.1097/wno.0000000000001517] [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 Giant cell arteritis (GCA) is a vasculitis often revealed by visual signs. Diagnosis is challenging and urgent. Retinal angiography (RA) and MRI allow effective diagnosis. We compared those and proposed an imaging-based approach to diagnose GCA in ophthalmological practice. METHODS We conducted a retrospective study based on the data collected from patients suspected to have GCA on ophthalmological findings. Fluorescein (FA) and indocyanine green (ICG) RAs and MRI were performed and compared with final diagnosis. RESULTS Among the 41 patients included, 25 were diagnosed with GCA. Sensitivities and specificities of FA and ICG were not different. MRI showed a higher sensitivity and specificity. The approach consisting in performing RA followed by MRI provided a better accuracy. CONCLUSION Our study shows that RA can be supplemented by MRI in a specialized center to provide the most accurate diagnosis in GCA revealed by visual signs.
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Affiliation(s)
- Alexandre Dentel
- Department of Ophthalmology (AD, CV, RH), Foundation Adolphe de Rothschild Hospital, Paris, France; Department of Internal Medicine (GC, TS), Foundation Adolphe de Rothschild Hospital, Paris, France; Department of Neuroradiology (JS, FC, AL), Foundation Adolphe de Rothschild Hospital, Paris, France ; and Department of Clinical Research (KZ), Foundation Adolphe de Rothschild Hospital, Paris, France
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Choroidal arterial watershed zone topography and its relationship with maculopathy in highly myopic eyes. Eye (Lond) 2021; 35:2624-2630. [PMID: 33564136 DOI: 10.1038/s41433-021-01427-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 12/15/2020] [Accepted: 01/20/2021] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To evaluate choroidal arterial watershed zones (CWZ) in highly myopic patients. The relationships between CWZ location and myopic maculopathy location and classification were also examined. METHODS This retrospective study included 102 consecutive patients who had been diagnosed with myopic maculopathy. Indocyanine green videoangiography was used to evaluate CWZ presence, location, and configuration. Maculopathy signs were used to examine the relationship between CWZ and myopic maculopathy. RESULTS Various CWZ types were identified in 102 of 158 eyes. The CWZ patterns were classified as vertical optic nerve head (vertical-ONH) in 30 eyes, stellate in 29 eyes, vertical-ONH extending to the macula in 28 eyes, horizontal fovea in eight eyes, and vertical parafovea in seven eyes. Choroidal neovascularization occurred within CWZs in 35 of 42 eyes, and macular atrophy was located within foveal CWZs in 20 of 23 eyes. The CWZ type was significantly correlated with mCNV presence (OR = 5.652, P = 0.014). CONCLUSIONS Variations in CWZ topography are associated with myopic maculopathy, particularly in eyes with myopic choroidal neovascularization (mCNV) and macular atrophy, and CWZ is a risk factor for mCNV. This suggests that eyes with macular CWZs are vulnerable to developing myopic maculopathy and are predisposed to mCNV because of ischaemic hypoxia.
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Simon S, Ninan J, Hissaria P. Diagnosis and management of giant cell arteritis: Major review. Clin Exp Ophthalmol 2021; 49:169-185. [PMID: 33426764 DOI: 10.1111/ceo.13897] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/06/2020] [Accepted: 12/13/2020] [Indexed: 12/13/2022]
Abstract
Giant cell arteritis is a medical emergency because of the high risk of irreversible blindness and cerebrovascular accidents. While elevated inflammatory markers, temporal artery biopsy and modern imaging modalities are useful diagnostic aids, thorough history taking and clinical acumen still remain key elements in establishing a timely diagnosis. Glucocorticoids are the cornerstone of treatment but are associated with high relapse rates and side effects. Targeted biologic agents may open up new treatment approaches in the future.
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Affiliation(s)
- Sumu Simon
- Department of Ophthalmology and South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jem Ninan
- Department of Rheumatology, Modbury Public Hospital, Modbury, South Australia, Australia
| | - Pravin Hissaria
- Department of Immunology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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[Giant cell arteritis: Ischemic complications]. Presse Med 2019; 48:948-955. [PMID: 31564551 DOI: 10.1016/j.lpm.2019.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
GCA ischemic complications occur generally in patients with a yet undiagnosed or uncontrolled disease. When disease control is fair, ischemic complications may be due mostly to atheromatosis. Ophtalmic complications are most frequent and are dominated by anterior ischemic optic neuropathy. Vasculitic strokes occur essentially in the vertebrobasilar arterial territory. Overt vasculitic coronary disease is exceptional. The diagnosis of upper and lower limbs ischemic complications benefit from advances in echography (halo sign) and positron emission tomography imaging. Treatment relies on corticosteroids (initially 1mg/kg prednisone or more, preceded by intravenous methylprednisolone gigadoses if necessary), the control of cardiovascular risk factors and antiplatelet drugs; heparin may be indicated for threatening limbs ischemia.
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Pellegrini M, Giannaccare G, Bernabei F, Moscardelli F, Schiavi C, Campos EC. Choroidal Vascular Changes in Arteritic and Nonarteritic Anterior Ischemic Optic Neuropathy. Am J Ophthalmol 2019; 205:43-49. [PMID: 30954470 DOI: 10.1016/j.ajo.2019.03.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To compare choroidal vascularity index (CVI) in patients with arteritic anterior ischemic optic neuropathy (A-AION), nonarteritic anterior ischemic optic neuropathy (NA-AION), and control subjects. DESIGN Retrospective cross-sectional study. METHODS This study was conducted at the Ophthalmology Unit of the S.Orsola-Malpighi University Hospital (Bologna, Italy). Macular and optic nerve head optical coherence tomography (OCT) scans of 20 patients with A-AION secondary to giant cell arteritis (biopsy-proven), 20 patients with NA-AION, and 20 control subjects were acquired with Heidelberg Spectralis (Heidelberg Engineering, Heidelberg, Germany). Images were binarized using ImageJ software, and total choroid area (TCA), luminal area (LA), and stromal area (SA) were segmented. The main outcome measure was CVI, defined as the ratio of LA to TCA. RESULTS Patients with A-AION showed a significantly lower macular and peripapillary CVI compared to both patients with NA-AION (respectively, 67.17 ± 2.35 vs 69.66 ± 4.18, P = .048; 63.51 ± 3.29 vs 67.67 ± 3.07, P < .001) and control subjects (respectively, 67.17 ± 2.35 vs 70.00 ± 2.95, P = .021; 63.51 ± 3.29 vs 68.69 ± 3.19, P = .002). Conversely, no significant difference in macular and peripapillary CVI was found between patients with NA-AION and controls (respectively, P = .942 and P = .570). After adjustment for age, the difference of peripapillary CVI among groups remained statistically significant (P < .001), while the difference in macular CVI did not (P = .060). CONCLUSIONS Macular and peripapillary CVI are reduced in patients with A-AION. These parameters may be useful to quantitatively evaluate choroidal vascular dysfunction in A-AION, serving as a new additional diagnostic tool to distinguish A-AION from NA-AION.
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Littlewood R, Mollan SP, Pepper IM, Hickman SJ. The Utility of Fundus Fluorescein Angiography in Neuro-Ophthalmology. Neuroophthalmology 2019; 43:217-234. [PMID: 31528186 DOI: 10.1080/01658107.2019.1604764] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/04/2019] [Accepted: 04/04/2019] [Indexed: 10/26/2022] Open
Abstract
While its use is still widespread within the medical retina field, fundus fluorescein angiography (FFA) is increasingly falling out of favour in the investigation of neuro-ophthalmological disease, with the introduction of new technologies, particularly optical coherence tomography. FFA does, however, provide useful diagnostic and prognostic information in many neuro-ophthalmological diseases including papilloedema, pseudo-papilloedema, optic neuropathies and central retinal artery occlusion to name a few. We aim to summarise the main FFA findings in each of these conditions and highlight where FFA is of most use in providing complementary information to other modes of investigation.
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Affiliation(s)
| | - Susan P Mollan
- Department of Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK
| | - Irene M Pepper
- Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, UK
| | - Simon J Hickman
- Department of Neurology, Royal Hallamshire Hospital, Sheffield, UK
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Ing E, Pagnoux C, Tyndel F, Sundaram A, Hershenfeld S, Ranalli P, Chow S, Le T, Lutchman C, Rutherford S, Lam K, Bedi H, Torun N. Lower ocular pulse amplitude with dynamic contour tonometry is associated with biopsy-proven giant cell arteritis. Can J Ophthalmol 2017; 53:215-221. [PMID: 29784156 DOI: 10.1016/j.jcjo.2017.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 08/29/2017] [Accepted: 10/10/2017] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To determine the role of the ocular pulse amplitude (OPA) from Pascal dynamic contour tonometry in predicting the temporal artery biopsy (TABx) result in patients with suspected giant cell arteritis (GCA). DESIGN Prospective validation study. PARTICIPANTS Adults aged 50 years or older who underwent TABx from March 2015 to April 2017. METHODS Subjects on high-dose glucocorticoids more than 14 days or without serology before glucocorticoid initiation were excluded. The OPA from both eyes was obtained and averaged just before TABx of the predominantly symptomatic side. The variables chosen for the a priori prediction model were age, average OPA, and C-reactive protein (CRP). Erythrocyte sedimentation rate (ESR), platelets, jaw claudication, and eye findings were also recorded. In this study, subjects with a negative biopsy were considered not to have GCA, and contralateral biopsy was performed if the clinical suspicion for GCA remained high. An external validation set (XVAL) was obtained. RESULTS Of 109 TABx, 19 were positive and 90 were negative. On univariate logistic regression, the average OPA had 0.60 odds for positive TABx (p = 0.03), with no statistically significant difference in age, sex, CRP, ESR, or jaw claudication. In suspected GCA, an OPA of 1 mm Hg had positive likelihood ratio 4.74 and negative likelihood ratio 0.87 for positive TABx. Multivariate regression of the prediction model using optimal mathematical transforms (inverse OPA, log CRP, age >65 years) had area under the receiver operating characteristic curve (AUROC) = 0.85 and AUROCXVAL = 0.81. CONCLUSIONS OPA is lower in subjects with biopsy-proven GCA and is a statistically significant predictor of GCA.
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Affiliation(s)
- Edsel Ing
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, Ont.
| | - Christian Pagnoux
- Department of Medicine, Rheumatology, University of Toronto Medical School, Toronto, Ont
| | - Felix Tyndel
- Department of Medicine, Neurology, University of Toronto Medical School, Toronto, Ont
| | - Arun Sundaram
- Department of Medicine, Neurology, University of Toronto Medical School, Toronto, Ont
| | - Seymour Hershenfeld
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, Ont
| | - Paul Ranalli
- Department of Medicine, Neurology, University of Toronto Medical School, Toronto, Ont
| | - Shirley Chow
- Department of Medicine, Rheumatology, University of Toronto Medical School, Toronto, Ont
| | - Tran Le
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, Ont
| | - Carla Lutchman
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, Ont
| | - Susan Rutherford
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, Ont
| | - Kay Lam
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, Ont
| | - Harleen Bedi
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, Ont
| | - Nurhan Torun
- Harvard Medical School, Beth Israel Deaconess Hospital, Boston Department of Ophthalmology, Boston, MA
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