Sudden Vision Loss in an Older Woman with Scalp Tenderness
A 74-year-old woman presents with sudden painless loss of vision in the right eye 3 days ago. She describes a curtain over the upper field. Visual acuity is 20/200 OD and 20/25 OS; there is a right relative afferent pupillary defect and a swollen, pale optic disc. She reports jaw pain when chewing and scalp tenderness. ESR is 62 mm/h and CRP is 28 mg/L. She takes aspirin 81 mg daily and amlodipine. She has had no temporal artery biopsy yet and no previous diagnosis of giant cell arteritis. The fellow eye is normal. She is systemically well and afebrile, with platelets 410 × 10^9/L and blood pressure 152/84 mmHg. She has no diplopia, eye pain, or preceding visual symptoms. She is awaiting outpatient rheumatology review in 2 weeks.
1. What is the first-hour management, and why is waiting for a biopsy dangerous?
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This is giant cell arteritis with arteritic anterior ischaemic optic neuropathy until proven otherwise. The fellow eye is at high risk within days, so I would start high-dose systemic corticosteroid immediately: IV methylprednisolone 1 g daily for 3 days, then oral prednisone 1 mg/kg/day (maximum 60–80 mg/day), or oral prednisone 1 mg/kg/day if IV access is delayed. I would not wait for temporal artery biopsy or rheumatology review. I would check capillary glucose, blood pressure, electrolytes, and infection risk; add aspirin 81 mg daily if no contraindication, gastric protection, and bone protection. The affected eye's vision may not recover, but the purpose is to protect the fellow eye and reduce systemic vascular risk. I would also involve rheumatology urgently and arrange biopsy within days.
2. How should the temporal artery biopsy be timed and interpreted if negative?
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Arrange biopsy urgently, ideally within 1–2 weeks. Corticosteroids do not reliably obscure histology for at least 2 weeks, so treatment must not be delayed. A long segment (2–3 cm) increases yield because of skip lesions; if the first side is negative and suspicion remains high, a contralateral biopsy can be considered. A negative biopsy does not exclude GCA when the clinical picture is strong-age over 50, new headache or scalp tenderness, jaw claudication, ESR/CRP elevation, and typical visual loss. In that situation I would continue steroids and treat clinically, then taper guided by symptoms and inflammatory markers. I would not stop steroids solely because of a negative biopsy.
3. Outline the maintenance plan and the main harms to monitor.
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After the IV pulse, continue oral prednisone 1 mg/kg/day and taper slowly over 12–18 months, guided by symptoms, ESR/CRP, and relapse. Relapse is common, so the taper should not be forced. Monitor blood pressure, glucose/HbA1c, electrolytes, bone density, cataract, mood, and infection. Add calcium/vitamin D and consider a bisphosphonate; add gastric protection if needed. Aspirin 81 mg daily unless contraindicated. If relapsing or steroid-dependent, consider tocilizumab or methotrexate with rheumatology. I would also counsel about smoking cessation and cardiovascular risk. The patient needs clear safety-net advice for recurrent jaw claudication, headache, or fellow-eye visual symptoms.