OCULAR MANIFESTATIONS OF GCA

As mentioned above, visual loss is the most feared and irreversible complication of GCA. Therefore, ophthalmologists are likely to be the first physicians consulted by GCA patients with visual loss, especially those with occult GCA³ who have no associated systemic symptoms at all.

Of a total of 170 GCA patients in our study, 50% presented in our clinic with ocular symptoms.² Of the 85 patients with ocular symptoms, both eyes were involved in 45% of the patients.

1. Ocular symptoms: These were amaurosis fugax in 26%, visual loss of varying severity in 92%, diplopia in 7% and eye pain in 7%. These occurred in various combinations. Amaurosis fugax was the only presenting visual symptom in 10%. That indicates that amaurosis fugax in persons aged >50 years is a red flag for GCA.
2. Visual acuity: It was 20/40 or better in 21%, 20/50 - 20/100 in 17%, 20/200 - 20/400 in 8%, count fingers in 15%, hand motion in 10%, light perception in 13% and no light perception in 15% (see Table below).
3. Ocular ischemic lesions: These were AION in 76.4%, central retinal artery occlusion in 13%, cilioretinal artery occlusion in 25%, posterior ischemic optic neuropathy in 6% and ocular ischemia in 1%. Cotton-wool spots were seen in one third of the eyes. Peripheral triangular chorioretinal ischemic lesions were seen in 10 eyes. The various ocular ischemic lesions were seen in a variety of combinations.
4. Fluorescein fundus angiography: This is an extremely helpful test in diagnosis of GCA during the early stages of visual loss (see below) and also as a source of information about the cause of visual loss. In almost every patient with GCA in our series, it revealed occlusion of one or more of the posterior ciliary arteries.^2,11-14 (see Figure 1-b) When central retinal artery occlusion was present, there was almost always associated posterior ciliary artery occlusion as well; this is because the central retinal artery and posterior ciliary artery often arise by a common trunk from the ophthalmic artery,^2,13 and when that common trunk is involved by GCA, the eye presents with evidence of occlusion of both central retinal and posterior ciliary arteries.

Figure 1b: Fluorescein fundus angiogram. Left eye with arteritic AION, showing choroidal filling defects (dark areas) during the early stages of AION. (Reproduced from Hayreh^`)

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