CORRESPONDENCE

Efficacy of Unilateral Versus BilateralTemporal Artery Biopsies for theDiagnosis of Giant Cell Arteritis

EDITOR:

BOYEV AND ASSOCIATES (AM J OPHTHALMOLOGY 128:211–

215, August 1999) have provided further evidence thatunilateral temporal arteritis can occur.1 As suggested byKlein and associates, however, it is possible that inpatients with differing diagnoses on each side, a normalbiopsy was obtained from an abnormal artery havingfailed to include the skip lesions.2 It would therefore beof interest to know the length of the biopsy specimenstaken from the patients with different diagnoses on eachside. The authors merely described the samples as“adequate.”

We disagree with the authors’ conclusion that bilat-eral temporal artery biopsy should be performed in allpatients in whom giant cell arteritis is suspected whenthe first biopsy is negative on frozen section. Theirresults are in fact consistent with Hayreh’s proposal thata temporal artery biopsy of the contralateral side shouldbe performed if the first biopsy is negative and if thepatient has signs and symptoms of giant cell arteritis orarteritic anterior ischemic optic neuropathy or both.2 Inthe authors’ study, patients with a final clinical diagno-sis of giant cell arteritis had characteristic symptoms ofgiant cell arteritis. The “false-positive” patient with anultimate diagnosis of prostatic carcinoma presented witha fever of unknown origin and a raised erythrocytesedimentation rate. Therefore, with Hayreh’s criteria hewould not have required a second biopsy but referral toan internist for a thorough systemic evaluation.

We suggest that patients suspected of having giantcell arteritis undergo a unilateral biopsy with samplesexamined under frozen section. However, if the firstbiopsy is negative the surgeon may then proceed toperform a biopsy on the contralateral side if the patienthas signs and symptoms of giant cell arteritis or arteriticanterior ischemic optic neuropathy or both.

JAMES BALL, MB BCHIR

RAMAN MALHOTRA, FRCOPHTH

Reading, United Kingdom

REFERENCES

1. Klein RG, Cambell RJ, Hunder GG, Carney JA. Skip lesionsin temporal arteritis. Mayo Clinic Proc 1976;51:504–510.

2. Hayreh SS, Podhasky PA, Reman R, Zimmerman B. Giantcell arteritis: validity and reliability of various diagnosticcriteria. Am J Ophthalmol 1997;123:285–296.

AUTHOR REPLY

THE LENGTHS OF THE TEMPORAL ARTERY BIOPSY SPECI-

mens performed on our six patients with differing diag-noses on each side ranged from 8 to 30 mm, with a meanlength of 16.7 mm. As noted in our paper, all specimenswere cut such that cross-sections were obtained at 0.5 mmintervals. Most skip areas in temporal arteritis are only afew millimeters long.1–4 Indeed, Chambers and Bernardi-no4 concluded that there was a 99% probability of findingsuch an area when a biopsy of at least 4 mm was obtainedand serially sectioned. Because the smallest of our biopsyspecimens was 8 mm in length, it is possible but extremelyunlikely that any of the “negative” results were the resultof only biopsying a skip area.

Drs Ball and Malhotra state that they disagree with ourrecommendation to perform a contralateral temporal ar-tery biopsy in patients with “suspected” giant cell arteritiswhen the first biopsy is negative on frozen section. Theyrecommend contralateral biopsy only in patients with“signs and symptoms of giant cell arteritis or arteriticanterior ischemic optic neuropathy or both.” We believethat their apparent disagreement with our recommenda-tions is really a question of semantics. When we state thatsomeone has “suspected” giant cell arteritis, we mean thathe or she has signs or symptoms consistent with giant cellarteritis, including ocular manifestations such as anterioror retrobulbar ischemic optic neuropathy and doublevision. Thus, we all agree that if one believes that giantcell arteritis is a likely diagnosis, one should consider acontralateral biopsy. One can adjust one’s degree of suspi-cion according to how comfortable one would feel if he orshe missed the diagnosis!

LINNEA R. BOYEV, MD, PHD

NEIL R. MILLER, MD

WILLIAM RICHARD GREEN, MD

Baltimore, Maryland

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