To the Editor:

Giant cell (temporal) arteritis (GCA) is a common vasculitis of unknown etiology. GCA usually involves medium and large-sized vessels with a predisposition for the cranial arteries, 1 or more branches of the carotid artery, and particularly the temporal artery in the elderly (1). Vision loss is one of the most serious sequela of this disease. Permanent vision loss has been recently estimated to occur in 8–22% of patients with GCA (2, 3). The incidence of this arteritis varies widely among different geographic regions.

We recently analyzed data from the first nationwide survey and found that the prevalence of GCA in Japan was low (approximately 1/140 of that reported in the US) (4), and we investigated the ocular involvement in Japanese patients with GCA. The method of survey and the questionnaire have been previously described in detail (4). In 34 (51.5%) of the 66 GCA patients, the presence of ocular manifestations was identified. Impaired vision was recorded in 29 (43.9%) of 66 patients, opthalmalgia in 14 (21.2%) of 66 patients, ischemic optic neuritis in 14 (21.2%) of 66 patients, optic nerve atrophy in 12 (18.2%) of 66 patients, diplopia in 5 (7.7%) of 65 patients, and permanent complete vision loss in 4 (6.5%) of 62 patients (2 with vision loss in the right eye and 1 each with vision loss in the left and in both eyes) (4).

Clinical features and laboratory findings among 34 GCA patients with ocular involvement were compared with those in 32 patients without ocular involvement (Table 1). There was no statistical difference in age and sex distribution between the 2 groups. The mean (SD) duration of apparent clinical disease activity prior to diagnosis was not significantly different between the patients with ocular involvement (5.9 ± 15.5 months) and those without ocular involvement (6.7 ± 13.2 months) (P > 0.05). Therefore, the development of ocular involvement was not attributable to diagnostic delay because the time required for diagnosis was somewhat shorter among patients with ocular involvement. Only 2 (5.9%) of 34 patients with ocular involvement compared with 12 (35.3%) of 32 patients without ocular involvement were found to have weight loss (P < 0.005). Polymyalgia rheumatica was identified in 4 patients with ocular involvement (11.8%) and in 16 patients without ocular involvement (50.0%) (P < 0.005), other musculoskeletal pain was observed in 5 patients with ocular involvement (14.7%) and 13 patients without (40.6%), respectively (P < 0.005), and temporary artery region pain was observed in 21 patients with ocular involvement (61.8%) and in 30 patients without (93.8%), respectively (P < 0.01). Only 18 patients with ocular involvement (52.9%) demonstrated elevated levels of C-reactive protein (CRP) (> 2.0 mg/dl) compared with 31 patients without ocular involvement (96.9%) (P < 0.01) (Table 1). However, the percentage of abnormalities of the white blood cell and platelet counts, and the erythrocyte sedimentation rates (ESR) were not significantly different between the 2 groups.

Table 1. Difference in clinical manifestations of patients with giant cell arteritis associated with or without ocular involvements*
Clinical manifestations and laboratory findingsOcular involvementsP
Present (n = 34)Absent (n = 32)
  • *

    Values are number (%) unless noted otherwise. NS = not significant.

Estimated onset age, years (mean ± SD)71.5 ± 10.870.6 ± 9.4NS
Sex (male/female)14/2010/22NS
Months from onset to diagnosis (mean ± SD)5.9 ± 15.56.7 ± 13.2NS
Weight loss2 (5.9%)12 (35.3%)< 0.005
Polymyalgia rheumatica4 (11.8)16 (50.0)< 0.005
Other musculoskeletal pains5 (14.7)13 (40.6)< 0.005
Pain in temporal artery region21 (61.8)30 (93.8)< 0.01
Cranial nerve symptoms3 (8.8)3 (9.4)NS
Jaw claudication6 (17.6)4 (12.5)NS
C-reactive protein >2.0 mg/dl18 (52.9)31 (96.9)< 0.01
White blood count 10,000/μL16 (47.1)16 (50.0)NS
Platelet >40 × 105/μL12 (35.3)10 (31.3)NS
Erythrocyte sedimentation rate >50 mm/hour27 (79.4)28 (87.5)NS

Cid et al (3) pointed out that some GCA patients with irreversible cranial ischemic events tended to have less evidence of systemic inflammatory reaction (as evaluated by clinical manifestations and laboratory markers) than previously reported, and termed these features as “occult GCA” by ophthalmologists (5–8). The incidence of fever, weight loss, headache, myalgia, elevation of the ESR and/or the CRP level was reported to be low in the patients with ocular involvement compared with those without ocular involvement (2). Hayreh et al (8) reported that myalgia was much less frequent in patients with ocular involvement compared with those without ocular involvement (14% versus 45%; P < 0.0001); these values are very analogous with our results.

In conclusion, Japanese patients with GCA have a heterogeneous spectrum of clinical manifestations, especially with respect to ocular involvement, similar to those observed in Western countries. Poor systemic and/or focal manifestations associated with laboratory findings of less inflammation were revealed among GCA patients with ocular involvement.

Shigeto Kobayashi MD, PhD*, Tetsuro Yano MD, PhD*, Yutaka Inaba MD, PhD*, Hiroshi Hashimoto MD, PhD*, Yoshifuji Matsumoto MD, PhD†, Akiko Tamakoshi MD, PhD‡, Takashi Kawamura MD, PhD‡, Yoshiyuki Ohno MD, PhD‡, * Juntendo University School of Medicine Tokyo, Japan, † Toyokawa City Hospital, Nagoya, Japan, ‡ Nagoya University Graduate School of Medicine Nagoya, Japan.