Statistics from Altmetric.com
Editor,—I have read with interest the article by Dr Karseras, entitled “Ophthalmology and general medicine”.1 The author states that “Prepresentation constitutional malaise, tenderness of temporal arteries, raised erythrocyte sedimentation rate (ESR) and rarely, biopsy will usually exclude this potentially blinding and lethal condition”. I would like to emphasise some salient points particularly regarding the ESR and biopsy. A more specific and accepted description of the disease is “giant cell (temporal) arteritis” to distinguish it from Takayasu's arteritis. It is important to maintain a high index of suspicion of the disease when seeing patients aged 50 years or older. The condition is an ophthalmic emergency. The condition can cause permanent total blindness unless urgent treatment with corticosteroids is provided. Treatment should not be delayed while awaiting results of the ESR or biopsy. Blindness can result from ischaemic optic neuropathy or retinal artery occlusion.2 Death from myocardial infarction or stroke can occur. The ESR is raised in about 90% of cases.3 Hence a normal ESR does not exclude the disease.
Most authorities recommend that temporal artery biopsy should be performed in all cases regardless of the presence of a firm clinical diagnosis and raised ESR. Treatment involves the long term use of oral prednisolone. The establishment of a biopsy proved diagnosis can be helpful particularly in cases where significant side effects from prednisolone occur.
The biopsy should be ipsilateral to the side of the visual symptoms or headache. Contralateral biopsy can be considered in cases where the histology of the ipsilateral biopsy is negative. The biopsy should preferably be performed within one week of the start of steroid treatment.
The biopsy is positive in about 70% of cases of giant cell (temporal) arteritis.4
Skip lesions may be present along the course of large and medium sized arteries. In addition, vasculitis may affect the ophthalmic artery but not necessarily the temporal artery. Hence negative histology does not necessarily exclude the diagnosis.
Dr Karseras responds:
I thank David Infeld for his interest in my article. There is not much in his letter of commentary that I would disagree with. Certainly where there is a high index of suspicion and symptoms fit the clinical picture I would personally start treatment on systemic steroids before the results of the ESR or biopsy. I am not too sure about undertaking a temporal artery biopsy in all cases, regardless of the presence of firm clinical diagnosis. Possible side effects from prednisolone do not seem to me to be a good reason to subject patients to this less than easy procedure in all circumstances.
I usually have not needed to resort to temporal artery biopsy in cases that have come clinically to the ophthalmic department. A balanced clinical view would be to assess the likelihood of temporal arteritis being present in a patient who has possible impending blindness. The decision for biopsy is based on clinical acumen and wisdom. Some patients may be treated unnecessarily but others may well be saved from the blindness that can come on so quickly and bilaterally.
I am pleased to see that Dr Infeld recognises the presence of difficult cases, which can still have drastic consequences despite a normal ESR and biopsy.
I suppose 40 years of personal clinical experience of the occasional case of temporal arteritis gives one the confidence to advocate “better safe than sorry” and accept that it is better to have some side effects, which may be unnecessary, rather than some irreversible loss of sight. But I agree with most of Dr Infeld's comments.