Giant cell arteritis and intravenous methylprednisolone

Letters to the Editor Giant Cell Arteritis and Intravenous Methylprednisolone Dear Editor: Cornblath and Eggenberger concluded in "Progressive Visual Loss from Giant Cell Arteritis Despite High-dose Intravenous Methylprednisolone" ( Ophthahnology 1997; 104:854- 8) that, ' 'The results of intravenous methylprednisolone (IVMP) treatment of patients with visual loss from GCA are similar to the results of treatment with oral corticosteroids, with IVMP treatment being more costly and having a small risk of sudden death." In our neuro-ophthalmology clinic, we use IVMP treatment for patients with giant cell arteritis (GCA) and visual loss who are monocular, have bilateral or severe visual loss, or develop progressive loss or fellow eye involvement despite oral prednisone therapy. I wonder whether the decision to use IVMP (versus oral therapy alone) at other institutions (including the huthors' series) is biased by treating only more severe disease. This selection bias might result in a falsely lower rate of visual recovery for patients treated with IVMP compared with standard oral steroid therapy. As the authors point out, in the literature visual recovery in patients with GCA and visual loss treated with oral steroids or IVMP is not common, and it is not clear that IVMP improves the visual recovery rate or decreases the rate of visual loss. Nevertheless, Liu et ai ~ reported that in 41 patients with visual loss due to GCA treated with oral prednisone alone or IVMP, fellow eye involvement was observed only with oral therapy. Two of the five cases reported by Cornblath and Eggenberger were treated with oral steroids for variable periods of time prior to the initiation of IVMP. The remaining three cases had bilateral symptoms or signs prior to initiation of IVMP. I wonder if the authors could comment on the role of IVMP in the possible prevention of fellow eye involvement. ANDREW G. LEE, MD

Houston, Texas Reference I. Liu GT, Glaser JS, Schatz NJ, Smith JL. Visual morbidity in giant cell arteritis. Clinical characteristics and prognosis for vision. Ophthalmology 1994; 101:1779-85. Authors' reply Dear Editor: As in other areas of medicine in which there is no definitive proven treatment, physicians must use their judgment and weigh the risks and benefits when, deciding on a course of treatment. Dr. Lee presents his criteria for the use of intravenous methylprednisolone (IVMP) in selected cases of giant cell arteritis (GCA). It is quite possible that our group of patients was subject to referral bias

and represented a more severe spectrum of GCA. However, this does not change the point of the paper: there is no proven efficacy to using IVMP for GCA, and as in all treatments with little data, physicians must make a case-by-case decision and weigh the factors of risk, cost, and possible improved outcome. We still use IVMP in select cases. Dr. Lee raises a question of prevention of fellow eye involvement through the use IVMP. In our two cases with visual loss in the uninvolved eye, patients were seen within 3 to 5 days of the onset of visual loss and treated with oral prednisone for 2 to 4 days. The patients then lost vision 48 hours after IVMP had started. It is possible that starting IVMP at the first onset of symptoms might have prevented second eye involvement, but this remains unknown. Liu et al 2 reported no patients losing vision in a previously uninvolved eye when treated with IVMP. However, the numbers in their report were too small to have statistical significance. The role of IVMP treatment in GCA, i.e., if it improves visual outcome or reduces involvement of the uninvolved second eye, remains unclear, and physicians must use individual circumstances when making these treatment decisions. WAYNE T. CORNBLATH, MD ERIC EGGENBERGER, DO

Ann Arbor, Michigan References 1. Cornblath WT, Eggenberger ER. Progressive visual loss from giant cell arteritis despite high-dose intravenous methylprednisolone. Ophthalmology 1997; 104:854-8. 2. Liu GT, Glaser JS, Schatz NJ, Smith JL. Visual morbidity in giant cell arteritis. Clinical characteristics and prognosis for vision. Ophthalmology 1994; 101:1779-85. Histopathologic Confirmation of Cutaneous Eyelid Lesions Dear Editor: Drs. Kersten et al, are to be con~atulated for their prospective study of the accuracy of clinical diagnosis of cutaneous eyelid lesions. ~ Their report emphasizes the high index of suspicion for malignancy one must have for benign-appearing lesions. However, I do not believe their conclusion that all excised eyelid lesions should be submitted for histopathologic confirmation follows from their data. Prior to excision, each lesion was categorized as most likely to represent a benign, malignant, or premalignant process. I believe the lesions in the " m o s t likely benign" category could be further subdivided into two categories: (1) "appears benign but could possibly be malignant"' and (2) "appears benign and could not possibly be malignant." I submit that there are lesions, such as xanthel-

203