Correspondence

Giant-Cell Arteritis

N Engl J Med 2003; 348:1497-1498April 10, 2003

Article

To the Editor:

In their review of polymyalgia rheumatica and giant-cell arteritis, Salvarani and colleagues (July 25 issue)1 describe the ocular manifestations of giant-cell arteritis, including funduscopic findings. We believe there is an important omission because uveitis is not mentioned.

Visual involvement occurs in 25 to 50 percent of patients with giant-cell arteritis. Loss of vision due to ischemia of the optic nerve is the most well known of these complications.2 Uveitis is an uncommon presenting feature of giant-cell arteritis and is due to ischemia of the posterior ciliary arteries and their branches.3,4 Posterior uveitis is manifested as choroidal ischemic lesions that later appear as peripheral chorioretinal degenerative patches. They frequently have a triangular pattern, with the base toward the periphery and the apex toward the posterior pole. Anterior uveitis due to anterior-segment ischemia is manifested as keratic edema and precipitates, with cells in the anterior chamber. A pupillary abnormality is often present, with a relative afferent pupillary defect. Combined, the lesions of anterior and posterior uveitis usually develop into panuveitis, and they are usually associated with ischemic lesions of the optic nerve.

These unusual ocular manifestations can occur as a presenting feature of giant-cell arteritis and, if unrecognized, can delay the diagnosis. Early recognition and diagnosis are important for preventing blindness.

Lionel Védrine, M.D.
Jean-Pierre Algayres, M.D., Ph.D.
Gilles Coutant, M.D., Ph.D.
Hôpital du Val-de-Grâce, 75005 Paris, France
lmvt@wanadoo.fr

4 References

1. 1

   Salvarani C, Cantini F, Boiardi L, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. N Engl J Med 2002;347:261-271
   Full Text | Web of Science | Medline

2. 2

   Hayreh SS, Podhajsky PA, Zimmerman B. Ocular manifestations of giant cell arteritis. Am J Ophthalmol 1998;125:509-520
   CrossRef | Web of Science | Medline

3. 3

   Dasgupta B, Pitzalis C, Panayi GS. Inflammation of the uveal tract as a presenting feature of temporal arteritis. Ann Rheum Dis 1989;48:964-965
   CrossRef | Web of Science | Medline

4. 4

   Rajesh CV, Cole M. Panuveitis as a presenting feature of giant cell arteritis. Br J Ophthalmol 2000;84:340-340
   CrossRef | Web of Science | Medline

Author/Editor Response

We thank Dr. Védrine and colleagues for their comments. Vision loss in giant-cell arteritis is related to the occurrence of ocular ischemic lesions, which consist mainly of arteritic, anterior, ischemic optic neuropathy and occlusion of the central retinal artery (identified in one study in 81 percent and 14 percent of patients with ocular involvement, respectively).1 In our experience, anterior and posterior uveitis is a very rare presenting feature of giant-cell arteritis. The two cases cited by Dr. Védrine and colleagues are the only two cases that have been reported in the literature. In one of these cases, biopsy-proven giant-cell arteritis developed one year after the occurrence of panuveitis.2 In the other case, a temporal-artery biopsy specimen did not show any evidence of arterial inflammation.3 Furthermore, in our own clinical practice, we have not observed panuveitis as an ocular manifestation of giant-cell arteritis. It is possible that panuveitis could occur as a chance association with giant-cell arteritis.

Carlo Salvarani, M.D.
Luigi Boiardi, M.D.
Arcispedale S. Maria Nuova, 42100 Reggio Emilia, Italy
salvarani.carlo@asmn.re.it

Gene G. Hunder, M.D.
Mayo Clinic, Rochester, MN 55905

3 References

1. 1

   Hayreh SS, Podhajsky PA, Zimmerman B. Ocular manifestations of giant cell arteritis. Am J Ophthalmol 1998;125:509-520
   CrossRef | Web of Science | Medline

2. 2

   Rajesh CV, Cole M. Panuveitis as a presenting feature of giant cell arteritis. Br J Ophthalmol 2000;84:340-340
   CrossRef | Web of Science | Medline

3. 3

   Dasgupta B, Pitzalis C, Panayi GS. Inflammation of the uveal tract as a presenting feature of temporal arteritis. Ann Rheum Dis 1989;48:964-965
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Hiromasa Tsuda, Kozue Tanaka, Shuji Kishida. (2011) Anterior Uveitis as an Initial Manifestation of Polymyalgia Rheumatica. Case Reports in Medicine 2011, 1-3
   CrossRef

2. 2

   Fabio Bandini, Luana Benedetti, Paola Ceppa, Guido Corallo. (2005) Uveitis as a Presenting Sign of Giant Cell Arteritis. Journal of Neuro-Ophthalmology 25:3, 247-248
   CrossRef