Clinical study
Risk factors for visual loss in giant cell (temporal) arteritis: a prospective study of 174 patients

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Abstract

Objective

To determine the risk factors—especially the effects of thrombocytosis—for permanent visual loss in patients with temporal arteritis.

Methods

One hundred seventy-four patients with temporal arteritis (147 biopsy proven) were prospectively observed for the development of permanent visual loss. We used multivariate logistic regression analysis to determine which of 17 pretreatment characteristics were associated with visual loss.

Results

Visual ischemic manifestations occurred in 48 (28%) patients, including permanent visual loss in 23 (13%) patients. The independent predictors associated with an increased risk of permanent visual loss were a history of transient visual ischemic symptoms (odds ratio [OR] = 6.3; 95% confidence interval [CI]: 1.4 to 29; P = 0.02) and a higher platelet count (OR = 3.7 per SD; 95% CI: 1.8 to 7.9; P = 0.001). The presence of constitutional symptoms (OR = 0.14; 95% CI: 0.02 to 0.77, P = 0.01), polymyalgia rheumatica (OR = 0.04; 95% CI: 0.01 to 0.48, P = 0.02), and C-reactive protein level (OR = 0.35 per SD; 95% CI: 0.13 to 0.92, P = 0.03) were associated with a reduced risk. Upper limb artery involvement was excluded from the multivariate model, as no patients with that problem developed permanent visual loss. Of the 87 patients who presented with thrombocytosis (platelet count >400 × 109/L), 32 (37%) developed ischemic visual symptoms, compared with 16 (18%) of those without thrombocytosis.

Conclusions

An elevated platelet count is a risk factor for permanent visual loss in temporal arteritis. The finding of thrombocytosis in a patient with suspected temporal arteritis should emphasize the need for urgent treatment, with consideration of using inhibitors of platelet aggregation or anticoagulation therapy.

Section snippets

Patients

Between January 1978 and November 2000, 192 consecutive patients were diagnosed with temporal arteritis in the Department of Internal Medicine of Dupuytren Hospital, Limoges, France. Patients who had not had a platelet count performed before glucocorticoid treatment (18 patients) were excluded from the study. Of the 174 remaining patients, 147 (84%) had biopsy-proven giant cell arteritis (9). In the other 27 cases, the diagnosis was based on standard criteria (10).

Measurements

Pretreatment clinical,

Results

The patients were mainly elderly; 63% were women (Table 1). Constitutional symptoms with an increased erythrocyte sedimentation rate were the sole manifestations of temporal arteritis in 13 biopsy-proven cases. All but 1 patient had a temporal artery biopsy performed.

Discussion

In this large sample of patients with temporal arteritis, 28% had visual ischemic symptoms and 13% had permanent visual loss. The rate of irreversible blindness is similar to those previously reported 1, 2, 3, 4, 15. These complications occurred before treatment in most patients. Signs or symptoms suggesting temporal arteritis heralded the ophthalmic complication for weeks in a majority of patients. Amaurosis itself as an initial manifestation of giant cell arteritis 16, 17 was rare in our

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