Giant cell arteritis and the eye: treat before the biopsy
- Emergency
Giant cell arteritis can cut the optic nerve's blood supply and blind one eye, then the other. Corticosteroids start the same day, before the biopsy.
See it in 3D: Optic disc · Optic nerve · Ophthalmic artery
What it is
Arteritic anterior ischaemic optic neuropathy is the main cause of blindness in giant cell arteritis, a vasculitis of medium and large arteries in people over 50. The posterior ciliary arteries close, and the optic nerve head infarcts: vision is lost suddenly and the disc is pale and swollen. Without treatment the other eye is often affected within days. The non-arteritic form, much more common, affects a small crowded disc and has no proven treatment.
How to recognise it
- Over 50 with new headache, scalp tenderness, jaw pain on chewing, fever, weight loss or shoulder and hip stiffness.
- Transient visual loss or double vision in the days before.
- Sudden severe visual loss with a chalky white swollen disc.
- Very high ESR and CRP, often with a high platelet count.
- Visual loss in one eye: the other eye is at risk within days.
What to do at once
- In any patient over 50 with sudden visual loss, ask the symptoms of giant cell arteritis.
- Feel the temporal arteries: thickened, tender or pulseless.
- Order ESR, CRP and a blood count the same day.
- Start high-dose corticosteroids at once if the diagnosis is suspected; with visual loss, intravenous treatment is often used.
- Arrange temporal artery ultrasound or biopsy within one to two weeks; the biopsy stays positive after steroids are started.
- Refer to ophthalmology and rheumatology.
Mistakes that cost sight
- Waiting for the biopsy before treating risks blindness in the other eye.
- Non-arteritic ischaemic optic neuropathy happens in a small disc with no cup, with hypertension, diabetes or sleep apnoea, and with normal ESR and CRP.
- Vision lost from arteritic optic neuropathy rarely recovers; the aim of treatment is to protect the other eye.
Next step / Initial management
- Suspected giant cell arteritis with visual symptoms: corticosteroids the same day and emergency referral.
- Confirm with temporal artery ultrasound (halo sign) or biopsy, without delaying treatment.
- Long tapering steroid course under rheumatology, with bone protection; steroid-sparing drugs in selected patients.
- Non-arteritic form: control vascular risk factors, assess for sleep apnoea, and follow up with ophthalmology.
Test yourself
Think of the answer, then tap the question to see it.
When should corticosteroids be started in suspected giant cell arteritis with visual loss?
The same day, as soon as the diagnosis is suspected, without waiting for the biopsy.
Why can treatment start before the temporal artery biopsy?
Because the biopsy remains diagnostic for one to two weeks after starting corticosteroids.
How does the non-arteritic form differ?
It is more common, affects a small crowded disc, has normal ESR and CRP and no proven treatment.
Connections
See it in 3D3
The structures of Durgical's 3D anatomy where it is found.
In Pharmacology2
Educational content; not a clinical guideline and no substitute for assessment by a health professional. For sudden visual loss, severe eye pain, a chemical burn or an eye injury, go to an emergency department at once.
Sources: Giant Cell Arteritis (Temporal Arteritis) (StatPearls Publishing (NCBI Bookshelf), 2024); Nonarteritic Anterior Ischemic Optic Neuropathy (StatPearls Publishing (NCBI Bookshelf), 2025).
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Representative model, for educational purposes only.