INFORMATION FOR CANDIDATE:

You are a resident in a suburban emergency

department and your next patient is a 60 year old
Mr. Bartlett who experienced a sudden loss of
vision in his right eye about 2 hours ago and he
is very concerned about this.
YOUR TASK IS TO:
Take a history
Examine the patient
Organize investigations
Advise the patient regarding the most likely
diagnosis and management

HOPC: Mr. Bartlett notice some general malaise with influenza type symptoms over the
last 2 weeks. He had a low grade fever, anorexia developed a right sided, unilateral
throbbing headache last night. When he woke up this morning he could not see in his right
eye which scared him and so he came to the ED.
He also felt that his right temple area was a bit swollen, red and tender.
PHx,+ FHx.: unremarkable
SHx: married teacher with 2 adult children, no problems, non smoker, little alcohol,
NKA, no medication.
EXAMINATION: somewhat tired looking man. BP 140/85, P 80 + reg., RR 18, Temp.
37.5 degrees.
The right temple area is mildly swollen, tender and red with a throbbing pulsating
temporal artery palplable.
The vision in his right eye is markedly reduced to basically shadows only. Fundoscopy is
normal.
INVESTIGATIONS:
ESR usually > 100
CRP markedly elevated
FBE sometimes normochromic, normocytic anaemia and leucocytosis
LFTs abnormal in 30 % of patients
TEMPORAL ARTERY BIOPSY: changes involve the entire arterial wall,
particularly the media with areas of necrosis which are accompanied by diffuse
infiltration of mononuclear cells and giant cells (granulomatous arteritis!). This
procedure can usually be done under local anaesthesia!
Fundoscopy may show evidence of ischaemic disease present in patients with
symptoms of visual loss.
Angiography can be helpful to demonstrate the presence of arteritis (areas of
constriction and dilation interspersed with areas that appear normal)
Colour duplex ultrasound of the temporal artery
DIAGNOSIS: TEMPORAL (GRANULOMATOUS) ARTERITIS / GIANT CELL
ARTERITIS: is a chronic generalized inflammatory disease of the temporal arteries,
affecting mainly the elderly, features of polymyalgia rheumatic often present caused by
granulomatous inflammation of the intima and inner part of the media (focal and
segmental) with infiltration of lymphocytes, epithelioid and giant cells leading to marked
thickening of the intima with narrowing and occlusion of the lumen.
Headache: recent onset of severe temporal headache, or represents a change in character
from previous headaches, may be worse at night. Sometimes with pronounced scalp
tenderness, making simple tasks such as combing hair, or resting the head on a pillow
extremely painful.
Jaw claudication: particularly prominent when the patient is talking or eating, and is
present in more than half of patients with temporal arteritis.

Visual disturbances: are due to inflammation of the branches of the ophthalmic or retinal
arteries, leading to different problems:
a) ischaemic optic neuritis in around 50% of cases.
b) Central retinal artery thrombosis can also occur.
c) blurred vision
d) amaurosis fugax, transient or permanent visual loss, or diplopia (due to third,
fourth, or sixth cranial nerve palsy).
These symptoms can occur in the absence of, or before the development of headache.
If temporal arteritis remains untreated, the second eye may become affected within 1-2
weeks.
Systemic symptoms:
similar to those of polymyalgia rheumatic,they include: anorexia, weight loss, fever,
sweats, malaise, fatigue and depression, proximal stiffness, soreness and pain.
Signs
Differential diagnosis
Migraine
Tension headache
Trigeminal neuralgia
Takayasu's arteritis
Polyarteritis nodosa
Polymyositis
MANAGEMENT:
Visual disturbances constitute a medical emergency and require immediate treatment with
high doses of corticosteroids, e.g. 1000 mg methyl prednisolone i.v. and 60 mg
prednisolone orally per day for the first week. Response usually occurs within a few days.
A course of 2-4 weeks is advisable tapered gradually but maintenance of 5-10 mg per
day is often necessary for several months, sometimes treatment needs to be provided for
years to prevent relapses! The therapy can be monitored by ESR levels!
Some hospitals have a policy to arrange an urgent (same-day) assessment by an
ophthalmologist.