Diplopia at diagnosis of giant cell arteritis should prompt corticosteroids use
Click Here to Manage Email Alerts
Key takeaways:
- Binocular diplopia was not an exceptional feature at GCA diagnosis.
- Diplopia resolution tends to be faster in patients treated with IV vs. oral corticosteroids.
Diplopia should raise clinician suspicion for giant cell arteritis when associated with cephalic symptoms and prompt the use of corticosteroids to prevent ocular ischemic complications, according to researchers.
“International guidelines recommend the use of IV corticosteroids in [the] case of ocular involvement in GCA, but there are no specific guidelines for patients with binocular diplopia,” Thibaud Chazal, MD, and colleagues from the Adolphe de Rothschild Foundation Hospital in Paris wrote in the Journal of Neuro-Ophthalmology. “Our study was designed to describe the characteristics of patients with binocular diplopia related to GCA in a tertiary ophthalmologic center and evaluate the prognosis of diplopia after treatment initiation.”
Chazal and colleagues conducted a retrospective study of 111 patients (mean age, 74 years; 70% women) diagnosed with giant cell arteritis (GCA) from January 2015 to April 2021; GCA diagnosis was based on a positive temporal artery biopsy or high-definition MRI.
The researchers defined transient binocular diplopia as a diplopia lasting less than 24 hours and persistent as a diplopia lasting more than 24 hours. Cephalic symptoms included headaches of recent onset, jaw claudication and scalp tenderness.
Furthermore, the researchers defined polymyalgia rheumatica as the presence of moderate to severe pain lasting for at least 2 weeks and morning stiffness in at least two of the following areas: neck, shoulder and pelvic girdles.
According to results, 30 patients (27%) had binocular diplopia, which was transient in three patients (10%) and persistent in 27 patients (90%).
“We showed that binocular diplopia was not an exceptional feature at GCA diagnosis, accounting for 27% of our patients in our tertiary ophthalmologic French center,” the researchers wrote.
Most patients with diplopia had cephalic symptoms (87%), with associated polymyalgia rheumatica reported in seven patients (23%).
The researchers attributed diplopia to cranial nerve palsy in 21 out of 24 patients (88%), especially third (46%) and sixth (42%) cranial nerve.
Ocular ischemic complications occurred in 11 patients (37%) with diplopia, of whom five had bilateral visual impairment and two developed vision loss after initiation of corticosteroids.
“These results indicate that diplopia is not associated with a better visual prognosis and should raise clinicians’ awareness of the need to rapidly start an adequate treatment if GCA is suspected,” the researchers wrote.
The median duration of diplopia was 6 days in patients treated intravenously vs. 11 days in patients treated orally, according to the researchers.
The resolution rate of diplopia at 7 days was quicker in patients treated intravenously (67%) vs. patients treated orally (33%), although both groups had similar resolution rates at 1 month (66% vs. 78%, respectively).
The researchers noted that two patients had relapse of diplopia at 4 weeks and 6 weeks after an initial treatment course of 18 months and 24 months.
“Larger prospective studies are needed to better define patients with diplopia at risk of visual complication and study the impact of anti-IL6 receptor agents on preventing ocular ischemic complications in these patients,” the researchers wrote.
Perspective
Back to Top
Most optometrists are keenly aware of the most common ocular manifestation of GCA — anterior ischemic optic neuropathy (AION) and its associated vision loss. However, this study discusses the prevalence of diplopia in patients with GCA. While this manifestation is less common, it is still important to be aware and include GCA in the differential diagnosis for a sudden-onset diplopia, especially in older adults.
In this particular study, 27% of patients who were eventually diagnosed with GCA had diplopia as a presenting symptom. While the vast majority (87%) of these patients also had the familiar cephalic symptoms associated with GCA — headache, jaw claudication and scalp tenderness — only 37% went on to experience ocular ischemia with vision loss.
While this study does have admitted limitations, including small sample size from one clinic location, it does highlight the importance of remembering that not all GCA patients will present with the classic vision loss from AION that most clinicians are familiar with. For this reason, it is important to conduct a thorough history on patients with new diplopia to ensure there are no other associated GCA signs or symptoms, as rapid treatment improves the prognosis of patients with this condition.
Collapse
Read more about
Click Here to Manage Email Alerts