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• Response to 'Impact of delayed diagnoses at the time of COVID-19: increased rate of preventable bilateral blindness in giant cell arteritis' by Monti et. al.
  Charles Oshinsky, Alison M Bays, Ingeborg Sacksen, Elizabeth Jernberg, R Eugene Zierler and P Scott Pollock
  Published on: 14 October 2021

• Published on: 14 October 2021

  Response to 'Impact of delayed diagnoses at the time of COVID-19: increased rate of preventable bilateral blindness in giant cell arteritis' by Monti et. al.

  • Charles Oshinsky, Rheumatology Fellow University of Washington
  • Other Contributors:
    • Alison M Bays, Rheumatologist
    • Ingeborg Sacksen, Rheumatologist
    • Elizabeth Jernberg, Rheumatologist
    • R Eugene Zierler, Vascular Surgeon
    • P Scott Pollock, Rheumatologist

  Monti et. al. reported a decrease in Fast Track Clinic (FTC) assessments for Giant Cell Arteritis (GCA) during the COVID-19 pandemic and an increase in irreversible visual loss; other groups have found increased incidence of GCA during the COVID-19 pandemic.1,2,3 We created an FTC in 2017 to rapidly evaluate and treat patients with possible GCA using vascular ultrasound and also noticed an increase in permanent vision loss. We conducted a medical records review study during two time periods of patients referred to the FTC with concern for GCA to evaluate how many had permanent visual loss.4 The “COVID-19 period” was defined as 3/1/2020-8/31/2020 the “pre-COVID-19 period was 3/1/2019-8/31/2019. Patients received an ultrasound for GCA performed by a specially trained vascular sonographer. A positive ultrasound for GCA had either halo sign with compression in the temporal arteries and branches or increased intima-media thickness (IMT) in the large vessels. Patients were referred for temporal artery biopsy (TAB) at the discretion of the rheumatologist.

  25 patients were referred to the FTC during both the COVID-19 period and pre-COVID-19 period and nine diagnosed with GCA in each group. 52% of patients experienced symptoms for less than two weeks prior to presenting to medical care during the COVID-19 period, 48% pre-COVID-19. The median number of days from the time first seen in the medical system until referral to the FTC was 7 days during COVID-19 compared to 8.5 day...

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  Monti et. al. reported a decrease in Fast Track Clinic (FTC) assessments for Giant Cell Arteritis (GCA) during the COVID-19 pandemic and an increase in irreversible visual loss; other groups have found increased incidence of GCA during the COVID-19 pandemic.1,2,3 We created an FTC in 2017 to rapidly evaluate and treat patients with possible GCA using vascular ultrasound and also noticed an increase in permanent vision loss. We conducted a medical records review study during two time periods of patients referred to the FTC with concern for GCA to evaluate how many had permanent visual loss.4 The “COVID-19 period” was defined as 3/1/2020-8/31/2020 the “pre-COVID-19 period was 3/1/2019-8/31/2019. Patients received an ultrasound for GCA performed by a specially trained vascular sonographer. A positive ultrasound for GCA had either halo sign with compression in the temporal arteries and branches or increased intima-media thickness (IMT) in the large vessels. Patients were referred for temporal artery biopsy (TAB) at the discretion of the rheumatologist.

  25 patients were referred to the FTC during both the COVID-19 period and pre-COVID-19 period and nine diagnosed with GCA in each group. 52% of patients experienced symptoms for less than two weeks prior to presenting to medical care during the COVID-19 period, 48% pre-COVID-19. The median number of days from the time first seen in the medical system until referral to the FTC was 7 days during COVID-19 compared to 8.5 days pre-COVID-19. The median number of days from referral until ultrasound was completed was 1 day during COVID-19 and 2 days pre-COVID-19, and the median number of days on prednisone prior to ultrasound for GCA was 1 during COVID-19 and 2 pre-COVID-19. During the COVID-19 period, 7 patients received TAB compared to 13 patients pre-COVID-19. Median days to temporal artery biopsy was increased in during COVID-19 group at 21 days compared to 7 in the pre-COVID-19 group. All TABs were negative.

  During the COVID-19 period, seven patients had a positive ultrasound for GCA, and two patients were diagnosed based on clinical history. During the pre-COVID-19 period five patients had positive ultrasound findings for GCA, and four patients were diagnosed based on clinical history.

  Permanent vision loss due to GCA during the COVID-19 period occurred in four patients, and none in the pre-COVID-19 period. Vision loss improved somewhat but did not resolve entirely with treatment in 3 patients (one with bilateral anterior ischemic optic neuropathy (AION), one with unilateral AION and one with bilateral optic nerve edema), and 1 patient experienced permanent vision loss without any improvement due to unilateral retinal ischemia.

  We found no change in referral rates during the COVID-19 pandemic but found alarming rates of permanent vision loss compared to historical controls. One notable difference between the two groups was the time from FTC activation to TAB, which was prolonged during the COVID-19 period; it seems unlikely to have contributed to negative outcomes as all TABs were negative and vision impairment occurred prior to FTC activation. This may indicate that complications arose as a result of either delayed presentation or delayed FTC activation, but this is not supported by our analysis. Patients in both groups were referred to the FTC quickly, and underwent workup within 1-2 days. Despite similarities, outcomes were worse during the COVID-19 period. Further research is necessary to elucidate the etiology of the increase in permanent vision loss in patients with GCA during the COVID-19 pandemic.

  References
  1. Monti, S. et al. Impact of delayed diagnoses at the time of COVID-19: increased rate of preventable bilateral blindness in giant cell arteritis. Ann. Rheum. Dis. 79, 1658–1659 (2020).
  2. Lecler, A., Villeneuve, D., Vignal, C. & Sené, T. Increased rather than decreased incidence of giant-cell arteritis during the COVID-19 pandemic. Ann. Rheum. Dis. 80, e89–e89 (2021).
  3. Luther, R. et al. Increased number of cases of giant cell arteritis and higher rates of ophthalmic involvement during the era of COVID-19. Rheumatol. Adv. Pract. 4, rkaa067 (2020).
  4. Harris, P. A. et al. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J. Biomed. Inform. 42, 377–381 (2009).

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  Conflict of Interest:
  None declared.

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