If a patient over 50 arrives with sudden visual loss and anything suggesting giant cell arteritis — jaw claudication, scalp tenderness, new temporal headache, proximal girdle pain, a raised ESR or CRP — the treatment decision should not wait for the temporal artery biopsy.
Biopsy findings persist for a period after corticosteroids are started, so treating first does not destroy the diagnosis. What waiting does destroy is the fellow eye, and bilateral involvement in untreated arteritic disease can follow within days. The correct sequence is: take the bloods, start high-dose corticosteroid, then arrange the biopsy and the ophthalmology and rheumatology referrals.
The corollary is to document why. A patient started on steroids on clinical suspicion, with the features listed in the notes, is a defensible decision that the next team can continue or stop. A patient started without that record tends to have the steroid discontinued by whoever inherits them at the weekend.
- Bloods first, steroid immediately, biopsy arranged afterwards
- Do not let an appointment for temporal artery biopsy delay treatment
- Write the specific features that prompted the decision in the notes
- Normal inflammatory markers do not exclude it where the clinical picture is strong
- Warn the patient explicitly about symptoms in the other eye and what to do
Why it matters
The window in which the second eye can be saved is shorter than the wait for a biopsy slot.
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