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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 LLUeyes.com 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 corneal transplantation surgery. IntraLase Enabled Keratoplasty: IEK is 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 Nonprofit Organization US Postage PAID San Bernardino, CA Permit No. 1272 11234 Anderson Street Loma Linda, California 92350 LLUMCMKTG#UHC-055-09/0209/4200 Do you or your staff have any questions about Eye Contact? Please write or call us, we would be happy to hear from you. Loma Linda University Health Care Ophthalmology Department • 11370 Anderson Street, Suite 1800 • Loma Linda, CA 92354 909-558-2154 • Fax 909-558-2180 • LLUeyes.com 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. Ontario Hole A ve e Av ra ier S La Map Not To Scale ve tA let l Co ia ol wy ley Kin Mc o eg LA alk Pk Riverw Pierce St LLU Ophthalmology at Riverwalk 15 Di St The eye clinic is located at 4244 Riverwalk Parkway, Suite 100 in Riverside. For appointments, call 909-558-2154. N n Sa 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. 91 n ag e Av M o rnardin San Be