Certolizumab-Induced Uveitis: A Case Report and Review of the Literature
A 64-year-old woman was referred to our clinic due to bilateral reduced visual acuity (VA), mainly in her left eye. The patient's medical history was significant for seropositive RA, which had been well controlled for the previous 3 years under treatment with methotrexate and certolizumab (Cimzia). The patient had no previous ocular history.\nThe patient complained of a mild reduction in VA in both eyes during the previous year and noticed a significant reduction in her left eye (which occurred 1 week prior to her presentation). Initial examination revealed a VA of 20/32 in the right eye and 20/100 in the left eye. Anterior segment examination revealed no corneal keratic precipitates, mild (+1) flare in the anterior chambers and posterior synechiae bilaterally (fig. ). Dilated fundus examination revealed vitreal cells and haze, which were present bilaterally, but more distinct in the left eye. Macular edema (fig. ) and peripheral retinal punched-out lesions were visible (fig. ). Intraocular pressure (IOP) was 21 mm Hg in the right eye and 30 mm Hg in the left eye.\nThe integration of the clinical signs at presentation led to a working diagnosis of ocular sarcoidosis, possibly associated with anti-TNFα treatment. Workup included normal complete blood count, chemistry and C-reactive protein. Angiotensin-converting enzyme (ACE) levels were mildly elevated (61 U/l, normal range 10–51 U/l). Physical examinations and chest X-rays were normal, and so was the pulmonary function test. The patient was also examined by an expert pulmonologist who ruled out any lung disease.\nShe was treated with topical steroid drops as well as anti-glaucoma medication. By doing so, an improvement of the anterior uveitis and a normalization of the IOP were achieved. In coordination with the rheumatologist, the certolizumab was discontinued and the methotrexate dosage was increased. The topical steroidal treatment was tapered down and discontinued. Two months after the discontinuation of certolizumab, the uveitis had decreased and VA had improved to 20/32 in both eyes. Nevertheless, the macular edema persisted and the patient underwent periocular injections of 40 mg triamcinolone acetonide (Triesence; Alcon Inc.) in both eyes, with a partial resolution of the macular edema (fig. ).\nOne year after her initial presentation, the patient's RA is well controlled, and the change in systemic treatment did not result in any exacerbation. Her VA remains 20/32 in both eyes, and IOP is 17 mm Hg in both eyes (under topical treatment). The macular edema has improved, but still remains significant and is likely the cause of her impaired VA (fig. ).