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Endgames Case Review

Sequential vision loss in a patient with headache

BMJ 2016; 353 doi: (Published 08 June 2016) Cite this as: BMJ 2016;353:i3055

Rapid Response:

Re: Sequential vision loss in a patient with headache

I was pleased to read the case review on giant cell arteritis (GCA) by Wagner and Jain. It highlighted the important points of what is a potentially devastating condition. I would add, however, that fundus fluorescein angiography (FFA) should also be included as a useful investigation.

By its nature, GCA can be difficult to diagnose, as the ‘gold standard’ temporal artery biopsy is an inherently insensitive test. Occult GCA, in which there are no systemic symptoms, was shown by Hayreh to occur in 21% of biopsy-confirmed GCA patients (1) and multiple cases reports exist of GCA with normal/borderline inflammatory markers (2). In these patients, the presence of delayed retinal filling and choroidal perfusion on FFA is an extremely useful finding as it indicates dual circulation involvement. This increases the likelihood that a vasculitis, and in particular GCA, is the underlying diagnosis (3).

1) Hayreh SS, Podhajsky PA, Zimmerman B. Occult giant cell arteritis: ocular manifestations. Am J Ophthalmol 1998;125:521-526.
2) Poole TRG, Graham EM, Lucas G. Giant cell arteritis with a normal ESR and CRP. Eye 2003;17:92-93.
3) Mack HG, O’Day J, Currie JN. Delayed Choroidal Perfusion in Giant Cell Arteritis. J Clin Neuroophthalmol 1991;11:221-7.

Competing interests: No competing interests

09 June 2016
Andrew H Malem
Ophthalmology Specialist Registrar
Queen Alexandra Hospital
Southwick Hill Road, Portsmouth, PO6 3LY