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Retrospective, Multicenter Comparison of the Clinical Presentation of Patients Presenting With Diplopia From Giant Cell Arteritis vs Other Causes

Ross, Ahmara, G., MD, PhD; Jivraj, Imran, MD; Rodriguez, Geoffrey, MD; Pistilli, Maxwell, MS, Med; Chen, John, J., MD, PhD; Sergott, Robert, C., MD; Moster, Mark, MD; Sheldon, Claire, A., MD, PhD; Liu, Grant, T., MD; Foroozan, Rod, MD; Ko, Melissa, W., MD; Francis, Courtney, E., MD; Williams, Zoë, R., MD; Lee, Andrew, G., MD; McClelland, Collin, M., MD; Shindler, Kenneth, S., MD, PhD; Yalamanchili, Sushma, MD; Osborne, Benjamin, MD; Hedges, Thomas, R., III, MD; Van Stavern, Gregory, P., MD; Puckett, Ernest, MD; Rigi, Mohammed, MD, Msc; García-Basterra, Ignacia, MD; Tamhankar, Madhura, A., MD

doi: 10.1097/WNO.0000000000000656
Original Contribution: PDF Only

Background: Although giant cell arteritis (GCA) is a well-known cause of transient and permanent vision loss, diplopia as a presenting symptom of this condition is uncommon. We compared symptoms and signs of patients presenting with diplopia from GCA to those from other causes.

Methods: This was a multicenter, retrospective study comparing the clinical characteristics of patients presenting with diplopia from GCA with age-matched controls. Demographic information, review of symptoms, ophthalmic examination, and laboratory data of biopsy-proven patients with GCA were compared with those of age-matched controls presenting with diplopia.

Results: A total of 27 patients presented with diplopia from GCA, 19 with constant diplopia, and 8 with transient diplopia. All patients with constant diplopia from GCA were matched with 67 control subjects who had diplopia from other etiologies. Patients with GCA were more likely to describe other accompanying visual symptoms (58% vs 25%, P = 0.008), a greater number of systemic GCA symptoms (3.5, GCA vs 0.6, controls, P < 0.001) such as headache (94% [17/18] vs 39% [23/67]; P < 0.001), jaw claudication (80% [12/15] vs 0% [0/36]; P < 0.001), and scalp tenderness (44% [7/16] vs 7% [3/43]; P < 0.001). Ocular ischemic lesions (26% vs 1%, P < 0.001) were also common in patients with diplopia from GCA. Inflammatory markers were elevated significantly in patients with GCA vs controls (erythrocyte sedimentation rate: 91% [10/11] vs 12% [3/25], P < 0.001; C-reactive protein: 89% [8/9] vs 11% [2/19], P < 0.001).

Conclusions: GCA is a rare but serious cause of diplopia among older adults and must be differentiated from other more common benign etiologies. Our study suggests that most patients with diplopia from GCA have concerning systemic symptoms and/or elevated inflammatory markers that should trigger further work-up. Moreover, careful ophthalmoscopic examination should be performed to look for presence of ocular ischemic lesions in older patients presenting with acute diplopia.

Department of Ophthalmology (AGR, MP, GTL, KSS, MAT), Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Ophthalmology (IJ), University of Toronto, Toronto, Ontario, Canada; Department of Ophthalmology (GR), Cornell Medical Center, New York, New York; Department of Ophthalmology and Neurology (JJ-WC), Mayo Clinic, Rochester, New York; Department of Ophthalmology (RCS, MM), Wills Eye Hospital, Philadelphia, Pennsylvania; Department of Ophthalmology & Visual Sciences (CAS), University of British Columbia, Vancouver, British Columbia, Canada; Department of Ophthalmology (RF), Baylor College of Medicine, Houston, Texas; Department of Neurology (MWK), SUNY Upstate Medical University, Syracuse, New York; Department of Ophthalmology (CEF), University of Washington, Seattle, Washington; Department of Ophthalmology (ZRW), Flaum Eye Institute, University of Rochester Medical Center, Rochester, New York; Houston Methodist Ophthalmology Associates (AGL, SY, EP, MR), Houston, Texas; Department of Ophthalmology and Visual Neurosciences (CMM), University of Minnesota, Minneapolis, Minnesota; Department of Neurology and Ophthalmology (BO), Georgetown University, Washington DC; New England Eye Center (TRH), Tufts University, Boston, Massachusetts; Department of Ophthalmology and Neurology (GPVS, IG-B), Washington University, St. Louis, Missouri; and Department of Ophthalmology, University Hospital Virgen de la Victoria, Campus Teatinos, Málaga, Spain.

Address correspondence to Madhura A. Tamhankar, MD, Scheie Eye Institute, 51 N. 39th Street, Philadelphia PA 19104; E-mail: madhura.tamhankar@uphs.upenn.edu

The authors report no conflicts of interest.

© 2018 by North American Neuro-Ophthalmology Society