Department of Ophthalmology, Addenbrookes, Hospital, Cambridge, UK; John Van Geest Centre for Brain Repair, Cambridge, UK; MRC Mitochondrial Biology Unit, Keith Peters Building, Cambridge Biomedical Campus, Cambridge, UK.
Department of Ophthalmology, Addenbrookes, Hospital, Cambridge, UK.
Surv Ophthalmol. 2020 Mar-Apr;65(2):218-226. doi: 10.1016/j.survophthal.2019.11.004. Epub 2019 Nov 24.
Giant cell arteritis is the most common systemic vasculitis in the elderly and is a potentially life-threatening ophthalmic emergency that can result in irreversible blindness. Blindness is most commonly associated with acute onset, irreversible arteritic ischemic optic neuropathy. Without treatment, second eye involvement may occur, resulting in bilateral blindness. Patients with established visual loss are treated with high-dose steroids and generally undergo a temporal artery biopsy to confirm their diagnosis. A significant number of patients are, however, referred for urgent ophthalmology assessment from concerns about "incipient" arteritic ischemic optic neuropathy. Before visual loss, patients may experience a range of ocular symptoms related to ischemia. This generally leads to treatment with high-dose systemic steroid and an urgent request for a temporal artery biopsy. Temporal artery biopsy is considered as the standard investigation for confirmatory diagnosis. It is generally arranged as soon as possible, although it is often not carried out for several days, and there may also be delays in histopathological reporting. It is often perceived that the patient is "safe" while on corticosteroids, in that they are being treated to avoid visual loss. What is not acknowledged, however, is that, if patients do not have giant cell arteritis and are being treated "just in case," they will often require a tapering of oral steroids over several weeks, exposing them to unnecessary and significant side effects. In the rheumatology setting, vascular ultrasound has emerged as a safe and reliable alternative to temporal artery biopsy as a point of care diagnostic tool in the management of giant cell arteritis. Given an experienced sonographer and optimal equipment, a rapid diagnosis can be established in a fast-track clinic setting, taking into consideration clinical assessment, scoring, and ultrasound findings. A huge advantage of ultrasound is that it provides immediate information that can be used to inform treatment decisions. We explore the evidence that supports the incorporation of vascular ultrasound into the ophthalmology repertoire to make a more efficient diagnosis that is cost-effective and associated with better patient outcomes, including a potential reduction in loss of sight and avoidance of unnecessary long-term steroid treatment by early exclusion of mimics.
巨细胞动脉炎是老年人中最常见的系统性血管炎，是一种潜在的危及生命的眼科急症，可导致不可逆转的失明。失明最常见于急性发作、不可逆的动脉炎性缺血性视神经病变。如果不治疗，第二只眼睛可能会受累，导致双眼失明。已经出现视力丧失的患者接受大剂量类固醇治疗，通常会进行颞动脉活检以确认诊断。然而，由于对“初期”动脉炎性缺血性视神经病变的担忧，大量患者被转介到眼科进行紧急评估。在视力丧失之前，患者可能会出现一系列与缺血相关的眼部症状。这通常会导致大剂量全身类固醇治疗，并紧急要求进行颞动脉活检。颞动脉活检被认为是确诊的标准检查。尽管通常会尽快安排，但活检通常需要几天时间才能进行，组织病理学报告也可能会延迟。人们通常认为患者在接受皮质类固醇治疗时是“安全的”，因为他们正在接受治疗以避免视力丧失。然而，人们没有认识到，如果患者没有巨细胞动脉炎，并且正在接受“以防万一”的治疗，他们通常需要在数周内逐渐减少口服类固醇剂量，这会使他们面临不必要的严重副作用。在风湿病学领域，血管超声已作为一种安全可靠的替代方法，替代颞动脉活检，作为巨细胞动脉炎管理中的一种即时诊断工具。如果有经验丰富的超声技师和最佳设备，在快速通道诊所环境中可以快速建立快速诊断，同时考虑临床评估、评分和超声发现。超声的一个巨大优势是它可以提供即时信息，用于告知治疗决策。我们探讨了将血管超声纳入眼科诊断的证据，以实现更有效的诊断，这种诊断既具有成本效益，又能改善患者结局，包括通过早期排除模拟疾病来降低失明风险和避免不必要的长期类固醇治疗。
