Diplopia may be first sign of giant cell arteritis

Chicago-A number of pathologies can be confused with giant cell arteritis, Anthony Arnold, MD, explained Monday at the American Academy of Ophthalmology annual meeting. Patients with a painful ophthalmoplegia might have an isolated cranial neuropathy, a skull-based or cavernous sinus process such as a tumor, or an inflammatory or infiltrative process, an orbital process, a brainstem process, or a vasculitic process.

“The tip-offs to giant cell arteritis are patient age over 70, systemic symptoms such as malaise, anorexia, fever, weight loss, arthralgias, and myalgias, and temporal artery induration. If the patient presents with pain and ophthalmoplegia and evidence of central retinal artery occlusion or ischemic retinopathy, he or she has giant cell arteritis until proven otherwise,” Dr. Arnold emphasized. He is from the Jules Stein Eye Institute, Los Angeles.

Diplopia may be the first sign of giant cell arteritis most commonly secondary to ischemic cranial neuropathy and the third nerve is the most commonly affected. Either one or multiple nerves may be affected. Occasionally, other patterns are seen; the brainstem can be affected, which produces intranuclear ophthalmoplegia and diplopia from limited adduction. Skew deviation is diplopia from a vertical imbalance. There may also be cases of isolated extraocular muscle dysfunction, he explained.

Pathologies that mimic giant cell arteritis are cavernous sinus and skull-based processes. The presence of numbness suggests the involvement of the trigeminal nerves, unusual in giant cell arteritis. Acute bitemporal visual field loss with diplopia suggests pituitary apoplexy.

Steroids are the treatment for giant cell arteritis, and the patients, most of whom are elderly, must be monitored closely.