tunnel vision in a patient with polymyalgia rheumatica · artery fibrosis and vision involvement....

155 Milchert and Brzosko: Tunnel vision in PMR Personal non-commercial use only. The Journal of Rheumatology Copyright © 2019. All rights reserved. Images in Rheumatology Tunnel Vision in a Patient with Polymyalgia Rheumatica MARCIN MILCHERT, MD, PhD; MAREK BRZOSKO, MD, PhD, Professor, Department of Rheumatology, Internal Medicine, Geriatrics and Clinical Immunology of Pomeranian Medical University in Szczecin, Poland. Address correspondence to Dr. M. Milchert, Pomeranian Medical University, Department of Rheumatology, Internal Medicine, Geriatrics and Clinical Immunology, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland. E-mail: [email protected]. Ethical approval was not required by the authors’ institution. The patient gave written informed consent to publish the material. J Rheumatol 2020;47:155–6; doi:10.3899/jrheum.190150 Silent vasculitis may accompany polymyalgia rheumatica (PMR), resulting in complications such as vision deterio- ration. Reduced visual field is a possible manifestation. A 66-year-old man was diagnosed with PMR and treated accordingly (prednisone maximum 15 mg/day) at a tertiary center, with resolution of his symptoms. After 18 months, he suddenly experienced right eye vision loss. Visual field of his left eye was peripherally limited (Figure 1). Color Doppler ultrasound of proximal part of temporal arteries revealed halo sign consistent with giant cell arteritis (GCA; Figure 2), and stenotic distal branches with decreased flow velocity. High-dose corticosteroids (methylprednisolone 500 mg/day for 3 days) were immediately introduced. The patient regained central vision in his right eye with minor improvement contralaterally. A subsequently acquired distal branch temporal artery biopsy confirmed only fibrosis of the vessel wall. The patient remains stable after 7 years of followup. He adapted well for his disability. While working as a lecturer, he is able to see a single student at the back of an auditorium with his tunnel vision; however, he admits to having problems in climbing a rostrum because of stumbling over the stairs. Low doses of corticosteroids may not suppress silent GCA, leading to temporal artery fibrosis as well as ocular artery branches involvement. Retrospective analysis revealed that the patient had signs of temporal pain at his first presentation that were masked by dominating PMR manifestations. His GCA might have progressed silently, while undertreated with small cortico- steroid doses that resolved PMR manifestations but were not suppressing vascular inflammation, leading to temporal artery fibrosis and vision involvement. Fast-track ultrasound GCA clinics may reduce the rate of sight loss among patients with GCA 1 . Figure 1. Kinetic perimetry revealing reduced visual field, clinically resulting in tunnel vision. www.jrheum.org Downloaded on September 14, 2020 from

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Page 1: Tunnel Vision in a Patient with Polymyalgia Rheumatica · artery fibrosis and vision involvement. Fast-track ultrasound GCA clinics may reduce the rate of sight loss among patients

155Milchert and Brzosko: Tunnel vision in PMR

Images in Rheumatology

Tunnel Vision in a Patient with PolymyalgiaRheumatica MARCIN MILCHERT, MD, PhD; MAREK BRZOSKO, MD, PhD, Professor, Department of Rheumatology, Internal Medicine, Geriatrics and ClinicalImmunology of Pomeranian Medical University in Szczecin, Poland. Address correspondence to Dr. M. Milchert, Pomeranian Medical University,Department of Rheumatology, Internal Medicine, Geriatrics and Clinical Immunology, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland. E-mail: [email protected]. Ethical approval was not required by the authors’ institution. The patient gave written informed consent to publish thematerial. J Rheumatol 2020;47:155–6; doi:10.3899/jrheum.190150

Silent vasculitis may accompany polymyalgia rheumatica(PMR), resulting in complications such as vision deterio-ration. Reduced visual field is a possible manifestation. A 66-year-old man was diagnosed with PMR and treatedaccordingly (prednisone maximum 15 mg/day) at a tertiarycenter, with resolution of his symptoms. After 18 months,he suddenly experienced right eye vision loss. Visual fieldof his left eye was peripherally limited (Figure 1). ColorDoppler ultrasound of proximal part of temporal arteriesrevealed halo sign consistent with giant cell arteritis (GCA;Figure 2), and stenotic distal branches with decreased flowvelocity. High-dose corticosteroids (methylprednisolone500 mg/day for 3 days) were immediately introduced. Thepatient regained central vision in his right eye with minorimprovement contralaterally. A subsequently acquired distal branch temporal artery biopsy confirmed only fibrosis of the vessel wall. The patient remains stable after

7 years of followup. He adapted well for his disability.While working as a lecturer, he is able to see a singlestudent at the back of an auditorium with his tunnel vision;however, he admits to having problems in climbing arostrum because of stumbling over the stairs. Low doses ofcorticosteroids may not suppress silent GCA, leading totemporal artery fibrosis as well as ocular artery branchesinvolvement. Retrospective analysis revealed that the patient had signsof temporal pain at his first presentation that were masked bydominating PMR manifestations. His GCA might haveprogressed silently, while undertreated with small cortico-steroid doses that resolved PMR manifestations but were notsuppressing vascular inflammation, leading to temporalartery fibrosis and vision involvement. Fast-track ultrasoundGCA clinics may reduce the rate of sight loss among patientswith GCA1.

Figure 1. Kinetic perimetry revealing reduced visual field, clinically resulting in tunnel vision.

www.jrheum.orgDownloaded on September 14, 2020 from

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Page 2: Tunnel Vision in a Patient with Polymyalgia Rheumatica · artery fibrosis and vision involvement. Fast-track ultrasound GCA clinics may reduce the rate of sight loss among patients

REFERENCE 1. Milchert M, Diamantopoulos A, Brzosko M. Atlas of ultrasound

application in large vessel arteritis: giant cell arteritis and Takayasuarteritis. Szczecin: Wydawnictwo Pomorskiej Akademii Medycznej;2016.

156 The Journal of Rheumatology 2020; 47:1; doi:10.3899/jrheum.190150

Figure 2. Color Doppler ultrasound of left temporal artery. Halo sign (arrow) visible as hypoechoic, homogeneousconcentric thickening of vessel wall in transverse plane, well delineated toward the luminal side, filled with color,confirming partially preserved flow.

www.jrheum.orgDownloaded on September 14, 2020 from

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