Visual deterioration in giant cell arteritis patients while on high doses of corticosteroid therapy

To report the incidence and extent of visual deterioration in patients with giant cell arteritis (GCA) on high doses of systemic corticosteroids during the early stages of treatment; the various factors that may influence the outcome; and whether intravenous megadose corticosteroid therapy is more effective than oral therapy.

Noncomparative interventional case series.

One hundred forty-four patients with GCA (271 eyes) seen initially with visual loss (91 patients) and without visual loss (53 patients). All patients had biopsy-confirmed GCA and were followed while on high doses of systemic corticosteroid therapy for at least 2 weeks.

Every patient at the initial visit had an ophthalmic evaluation, including visual acuity, visual fields, intraocular pressure, slit-lamp and ophthalmoscopic evaluation, erythrocyte sedimentation rate (ESR; Westergren) and C-reactive protein (CRP) estimation, and temporal artery biopsy as soon as possible. If GCA was either strongly suspected or confirmed by biopsy, they were immediately started in our clinic on high doses of oral (80-120 mg) prednisone daily or intravenous megadose systemic corticosteroids (usually 150 mg dexamethasone sodium phosphate every 8 hours for 1-3 days) followed by oral prednisone. At each visit they underwent all the initial ophthalmic evaluations and had an ESR and CRP evaluation done. Tapering of steroid therapy was not started until both ESR and CRP had reached their lowest stable levels. These showed marked interindividual variation and usually took approximately 2 weeks to stabilize. Then the steroid therapy was gradually tapered, guided primarily by the levels of ESR and CRP. No generalization is possible regarding the period required to achieve the maintenance dosage, because this also varied markedly from patient to patient.

Visual acuity deterioration.

While on high doses of steroid therapy during the initial stages of the treatment, only 9 (11 eyes) of the 91 patients seen initially with visual loss developed further visual acuity deterioration in one or both eyes within 5 days after the start of therapy (one of the eyes had normal vision initially), but none of the 53 patients initially seen without visual loss developed any visual deterioration. Six of the 48 patients (13%) who were on intravenous steroid therapy had visual deterioration compared with 3 of 97 patients (3%) who were only on oral steroid therapy (P = 0.060).

Our study shows that although a few eyes can develop visual deterioration while on high doses of steroid therapy, early, adequate steroid therapy is effective in preventing further visual loss in most. When further visual deterioration occurred despite high doses of systemic corticosteroids, it almost invariably started within 5 days after the start of the high-dose steroid therapy. There was no evidence that intravenous megadose steroid therapy was more effective than oral therapy in preventing visual deterioration.