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A Vision Care Community Outreach Publication
Eye Contact
Winter 2009 • Twenty-Third Edition
In This Issue
Temporal Arteritis:
Headaches With A Risk
For Sudden Blindness
•
IntraLase – Brand New
LASIK Technology
•
New Eye Clinic Opens
in Riverside
Temporal Arteritis: Headaches With A
Risk For Sudden Blindness
GCA is a rheumatologic condition
associated more commonly with
other general systemic symptoms,
such as malaise, unintentional
Temporal arteritis (TA), also called
weight loss, proximal muscle aches
Giant-Cell Arteritis (GCA), is a
(polymyalgia rheumatica), loss of
condition that is a true ophthalmic
appetite, weakness, and anemia.
emergency. Even though it is a
Symptoms of involvement in the
chronic inflammatory disease,
Kelly Shannon Keefe, MD
head and neck can include jaw
involving many blood vessels of
claudication (pain with repeated chewing),
the body (thus the term “arteritis”), most
temporal headaches, temporal scalp
notably TA/GCA has a predilection for
tenderness, scalp dysesthesias (tingling
affecting the blood vessels of the head and
or numbness, especially when touching
neck. There is a distinct risk of sudden
the hair), and possibly double vision or,
blindness or stroke, if the inflammation
more worrisome, a transient loss of vision
involves the vasculature to the eye or brain.
(amaurosis). The goal for doctors is to make
the diagnosis and treat the disease before
TA occurs in patients usually older than
irreversible visual loss or stroke occurs.
70 yrs of age, affecting women more
Kelly Shannon Keefe, MD
Ophthalmic Pathology and
Oculoplastic Surgery
often than men. A 50-year retrospective
study out of the Mayo clinic of 173 cases
had a 79% female incidence, and the
mean age of diagnosis was 74.8 years.
Even though clinical suspicion is raised when
an adult presents with temporal headaches,
only about half of patients with biopsy-proven
disease actually complain of headaches. TA/
11370 Anderson Street
Suite 1800
Loma Linda, CA 92354
909-558-2154
909-558-2020 LASIK
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Unilateral headaches in patients over age 70, with
scalp tenderness or “tingling” dysesthesias.
The diagnosis is established by a constellation
of clinical symptoms (it is considered highly
suspect if three or more of the above-listed
symptoms are present). Laboratory tests
which may aid in making the diagnosis
include elevated serum acute-phase reactants
(ESR and CRP), thrombocytosis, and mild to
moderate anemia. But there are many cases of
TA/GCA that have a very low, normal ESR.
Some studies have shown that an elevated
CRP is more likely to be seen with this
disease. And keep in mind that an elevated
ESR may be found in many other diseases
besides TA (infection, occult malignancy, etc).
The gold standard for making the diagnosis
is still tissue biopsy. And the superficial
temporal artery on the scalp is an easilyobtainable specimen under local anesthesia. It
is important to obtain an adequately
long specimen (at least 2 cm is
Continued on page 3
1
Grand
Rounds
If you plan to attend one of the
Grand Rounds, please call
909-558-2182 to confirm
the date and location.
First Wednesday of the Month
7:00 - 8:30 am
Faculty Medical Offices
11370 Anderson Street, Suite 1800
Loma Linda, CA 92354
Second Friday of the Month
7:00 - 8:30 am
VA Medical Center, Ophthalmology Clinic
11201 Benton Road
Loma Linda, CA 92354
Third Wednesday of the Month
7:00 - 8:30 am
Faculty Medical Offices
11370 Anderson Street, Suite 1800
Loma Linda, CA 92354
Fourth Wednesday of the Month
7:00 - 8:30 am
Fluorescein Angiography Conference
Faculty Medical Offices
11370 Anderson Street, Suite 1800
Loma Linda, CA 92354
Physicians and Optometrists are invited to
attend these sessions. Attendees can earn up
to 1.5 hours of Category 1 CME Credits.
Attendance is free.
2
Temporal Arteritis, continued from page 1
preferred), since TA/GCA is well-known for having “skip areas” of involvement
of vessels, meaning that there may be patchy areas of vessel engulfed with
the inflammation, next to very normal areas of uninvolved vessel. Surgical
pathology preparation should be done with 3 mm serial cross-sectional
segments, to avoid false negative results, since a pathologic study looking at
many specimens found the shortest area of inflamed vessel was 3.2 mm.
The dilemma is that the treatment for this disease (high dose
immunosuppressives, long term tapering regimens) is sometimes worse
than the disease itself for an elderly patient. The complications from
steroids are numerous, and many of these patients already have fragile
health (osteoporosis, diabetes, GI bleeding risk, etc). So tissue biopsy
proof of the disease is very important. In patients who are very highly
suspect, bilateral temporal artery biopsy should be considered.
Treatment regimens are controversial. How high should the initial dose
of Prednisone be (60, 80, or 100 mg)? Some neuro-ophthalmogists even
advocate IV pulse steroids as the initial regimen. And how slowly should
you taper? Can some patients eventually be tapered off completely?
Review of the literature reveals no “right answers” to these questions.
But multicenter trials have looked at appropriate initial oral dosing of
between 0.5-1.0 mg/kg of Prednisone (I personally use 1.0 mg/kg), or IV
Solumedrol between 250 mg to 1 gm initial bolus (I personally consider
using 1 gm bolus treatment in suspicious cases with amaurosis symptoms).
Also steroid-sparing agents may be used in diabetics or patients in
whom steroids are contraindicated, but keep in mind that their onset of
action is delayed (a week or more). So high dose steroids initially are still
recommended. Most clinicians initiate treatment immediately in patients
who are highly clinically suspicious, even before the biopsy can be obtained,
and maintain the high dose steroids until the biopsy results are known.
The biopsy will be most useful (more easily interpreted if showing classic
inflammation) if it is performed within 1-2 weeks of initiating treatment.
There is still a lot of new information being learned about TA/GCA. It has
been long suggested that this inflammatory disease might be triggered by an
infectious agent. Definite cyclical variations in incidence have been shown in
studies out of Minnesota, Scotland, France, and Israel, with peaks in incidence
being simultaneous to respiratory infections. (I personally noted that most
of my positive biopsy cases occur between November and February!) And
a group out of UCLA recently isolated gene fragments from cells in GCA
temporal arteries with high homology to microbial genes. And much research
is being done to compare the relative significance of the different laboratory
abnormalities in predicting the diseases (questions such as: is CRP better than
Importance of timely temporal artery biopsy in highly-suspect patients,
with experienced pathologist’s interpretation. Histology reveals a transmural
vessel granulomatous inflammation, with luminal narrowing.
ESR? Is thrombocytosis a risk factor for vision loss? Is IL-6 a more-sensitive
marker?). And clinical trials are underway to investigate if regimens of steroidsparing agents might be useful in the tapering phase to lessen the relapse rate
of the disease. And there was a promising study (however with small numbers)
which showed a possible future role for duplex ultrasonography to aid in the
diagnosis of TA/GCA (the presence of a hyperechoic halo around the temporal
artery, indicating signs of edema and vessel stenosis, was highly correlated with
subsequent positive temporal artery biopsies). This may or may not prove to be
useful diagnostically, however, since the negative consequences of the high-dose
steroid treatment, as well as the risk of not treating an unknown patient whom
may have the disease, will most likely still rely on the results of a tissue biopsy.
TA/GCA is a high risk disease, presenting with a constellation of symptoms
and frequently abnormal labs, and the clinician can determine a high
rate of suspicion for the disease in any one patient. Yet still this is one
disease where truly “the tissue is the issue” for clinching the diagnosis.
Dr. Keefe received her medical degree from Case Western University, School of Medicine.
She completed an Internal Medicine residency at the National Naval Medical Center,
Bethesda MD, and her Ophthalmology residency at the Naval Medical Center in
San Diego, CA. Dr. Keefe did her Fellowship on Ophthalmic Pathology at the Armed
Forces Institute of Pathology (AFIP), Washington DC. Her areas of expertise include
Oculoplastic and Orbital Surgery, Ocular Pathology, and Cataract Surgery.
Specialties
& Staff
Cataract Surgery
Howard V. Gimbel, MD, MPH, FRCSC, Chair
Michael Rauser, MD, Residency Program Director,
Vice Chair for Clinical Affairs
Wayne Isaeff, MD
Kelly Keefe, MD
Julio Narváez, MD
Richard Tamesis, MD
Donald G. Tohm, MD
Cornea & External Disease
John Affeldt, MD, MPH
Julio Narváez, MD
Mark Sherman, MD
Dobli Srinivasan, MD
Medical Ophthalmology
Ernest Zane, MD, Vice Chair for Academic Affairs
William Clegg, MD
Harvey Lashier, MD
Dr. Keefe is board-certified in Ophthalmology by the American Board of Ophthalmology,
and holds a membership with the American Association of Ophthalmic Pathologists.
IntraLase – Brand New
LASIK Technology
The world’s most advanced LASIK vision
correction technology — the 100 percent
blade-free IntraLase Method™ — is now
available at Loma Linda University Health
Care Ophthalmology. This advanced
technology enhances the safety of the LASIK
procedure, and represents the emerging
standard of care in LASIK worldwide. With
its excellent safety profile and superior
precision, the IntraLase Method is among the
fastest-growing refractive surgical techniques.
Dr. Howard Gimbel with
In addition, the IntraLase has many important
a LASIK patient.
applications beyond refractive surgery. This
advanced femtosecond laser has made possible revolutionary advances in
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the most significant advance in corneal transplantation in four decades.
Same precise femtosecond laser technology is applied to penetrating corneal
transplantation surgery enabling the surgeon an infinite number of possible
designs of the size, shape, and side cut configuration of the host and donor
corneas so as to make them fit with hand-in-glove precision. There is a
consensus that IEK is likely to become the gold standard for keratoplasty in
the 21st century.
Patrick McCaffery, MD
James Sharp, MD
Neuro-Ophthalmology
& Adult Strabismus
Madhu R. Agarwal, MD
Ocular Pathology
Kelly Keefe, MD
Oculoplastics & Orbital Surgery
Madhu R. Agarwal, MD
Kelly Keefe, MD
Optometry
William Kiernan, OD
Roselynn Nguyen, OD
Pediatric Ophthalmology
Jennifer Dunbar, MD
Leila Khazaeni, MD
Refractive Surgery
Howard V. Gimbel, MD, MPH, FRCSC
Julio Narváez, MD
Uveitis
Mark Sherman, MD
Richard Tamesis, MD
Vitreoretinal Diseases & Surgery
Joseph Fan, MD
Michael Rauser, MD
Mukesh B. Suthar, MD
Riverside County Regional Medical Center
Larry Bowes, MD, Vice Chair
Wayne Isaeff, MD
Patrick McCaffery, MD
Gerald Schultz, MD
Laura Teasley, MD
3
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Loma Linda University Health Care
Ophthalmology Department • 11370 Anderson Street, Suite 1800 • Loma Linda, CA 92354
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New Eye Clinic Opens in Riverside
The staff and surgeons at Loma Linda University Health Care (LLUHC) Ophthalmology are pleased to announce their
expansion to Riverside in the form of a new office entitled Loma Linda University Ophthalmology at Riverwalk. This new
office, which will be open in late February 2009, is located at the new Medical Park at Riverwalk.
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Ophthalmology
at Riverwalk
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The eye clinic is located at 4244 Riverwalk Parkway, Suite 100 in Riverside.
For appointments, call 909-558-2154.
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LLUHC Ophthalmology is known for its leadership in research and technology,
as well as its excellence in patient care. They have been recruiting new and
dynamic physicians in a wide variety of sub-specialty areas within the field of
ophthalmology such as Oculoplastics and Retinal Disorders. Five such physicians
will be at Loma Linda University Ophthalmology at Riverwalk. In addition, the
new office will have state-of-the-art equipment, and the ophthalmologists will
treat a number of eye diseases, including Glaucoma and Cataracts. Laser vision
correction will also be available.
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