Sudden, painless visual loss. Initially unilateral, but may rapidly become bilateral. Occurs in patients ≥55 years of age. Antecedent or simultaneous headache, jaw claudication (pain with chewing), scalp tenderness especially over the superficial temporal arteries (e.g., tenderness with hair combing), proximal muscle and joint aches (polymyalgia rheumatica), anorexia, weight loss, or fever may occur.
(See Figure 10.17.1.)
Critical
Afferent pupillary defect; visual loss (often counting fingers or worse); pale, swollen disc, at times with flame-shaped hemorrhages. Later, optic atrophy and cupping occur as the edema resolves. The ESR, CRP, and platelet count may be markedly increased.
Other
Visual field defect (commonly altitudinal or involving the central field); a palpable, tender, and often nonpulsatile temporal artery; and a central retinal artery occlusion or a cranial nerve palsy (especially a sixth cranial nerve palsy) may occur.
NOTE: |
The biopsy should be performed within 1 week after starting systemic steroids, but a positive result may be seen up to 1 month later. Biopsy is especially important in patients in whom steroids are relatively contraindicated (e.g., diabetics). |
NOTE: |
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Tocilizumab, a novel humanized IL-6 receptor antagonist, has been recently approved by the FDA for long-term management of GCA. Addition of subcutaneous tocilizumab to standardized steroid regimens helps achieve remission faster and significantly reduces the dose and toxicity of corticosteroids.