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    Oral vs. IV steroids for giant cell arteritis

    Intravenous steroids may be key to saving sight, achieve visual recovery for patients with GCA

     

    Take Home

    Intravenous methylprednisolone may prevent visual loss and occasionally achieve visual recovery in patients with giant cell arteritis.

     

     

    Philadelphia—Treating giant cell arteritis (GCA) requires rapid recognition of the disease, which may appear without the usual systemic symptoms. When vision is affected, immediate treatment is needed to prevent further vision loss and occasionally achieve some visual recovery. Intravenous steroids administered during a period of hospitalization may be key to saving vision, according to Mark L. Moster, MD.

    Case report

    Dr. Moster—professor of neurology and ophthalmology, Wills Eye Hospital, Thomas Jefferson University School of Medicine, Philadelphia—related the case of an 82-year-old man with intermittent flashes and rust-colored vision in the right eye that lasted for seconds to minutes but persisted over 9 days. On the day of presentation, the vision went black, cleared, and was followed by a grey blur over the central visual field. None of the classic symptoms of GCA—such as headache, jaw claudication, decreased appetite, polymyalgia rheumatica, or malaise—were present. The patient had a past medical history of hypertension and hyperlipidemia, coronary artery disease, prostate and colon cancers, and myelodysplastic syndrome.

    At presentation, the visual acuity (VA) in the right eye was 20/400 with dyschromatopsia, an afferent pupillary defect, and a superior visual field defect. The optic nerves appeared normal.

    Laboratory evaluation showed a markedly elevated erythrocyte sedimentation rate (119 mm/hr) and C-reactive protein (6.9 mg/dl, normal <0.8 mg/dl)  and a normal platelet count. Orbital color Doppler ultrasonography showed severely decreased flow in the ophthalmic artery circulation (Figure 1).

    Treatment was started immediately with intravenous methylprednisolone 250 mg every 6 hours for 3 days. Biopsy of the temporal artery showed chronic vasculitis with intimal fibrosis consistent with GCA.

    Two days after the start of treatment, his symptoms improved, and the VA was 20/40. The patient was discharged and 60 mg of oral prednisone/day was prescribed with vitamin D, calcium, and esomeprazole (Nexium, AstraZeneca). At a follow-up visit at week 4, the vision was 20/25+ with a trace afferent pupillary defect and a minor visual field defect in the right eye. Laboratory tests returned to normal levels, according to Dr. Moster.

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