An 81-year-old white female presented with headache and visual loss. The past medical history was significant for type 2 diabetes, nonalcoholic fatty liver disease, diverticulosis, and asthma. The patient reported a 3-day history of “pixelated vision” in the left eye (OS) with shadows and a 2-month history of bilateral temporal headaches, jaw claudication, and scalp tenderness.
External exam demonstrated cord-like, tender, vessels on both temples. The visual acuity was 20/25 OD and 20/40 OS. The pupils measured 5 mm in the dark and 3 mm in the light with a relative afferent pupillary defect OS. The motility exam was full, and the patient was orthophoric in primary gaze. Slit lamp exam showed 2+ nuclear sclerosis OU. Direct fundus examination was normal OD and showed +1 optic disc edema OS.
The patient was started on oral prednisone and underwent a temporal artery biopsy. The surgical bed was completely dry with minimal to no bleeding at time of incision and on dissection of the temporal artery. A firm, cord-like temporal artery with intraluminal thrombus was identified (Fig. A). There was marked intimal thickening with fibromyxoid changes and luminal occlusion (Fig. B), consistent with the diagnosis of giant cell arteritis.
Giant cell arteritis is a disease of medium to large vessels and inflammation and intimal thickening could lead to occlusion of vessels like posterior ciliary artery, ophthalmic artery or central retinal artery leading to permanent vision loss. Chatelain et al mention in his article a strong correlation of permanent vision loss in patients with the degree of arterial wall obstruction, with the odds ratio around 5 for 75% obstruction of vessel lumen as compared to a 25% obstruction and this corelates to the intimal thickening. Interestingly they do not find a thrombus of the vessel lumen to corelate with permanent vision loss. A completely dry surgical field during a temporal artery biopsy is an ominous sign of more extensive disease including possible occlusion of the temporal artery and other branches of the external carotid artery supplying the surgical field. The absence of bleeding at the time of surgery should increase the suspicion for giant cell arteritis.