Acute anterior uveitis after discontinuation of tocilizumab in a patient with rheumatoid arthritis
A 72-year-old woman presented with sudden loss of vision without pain in the left eye. Bilateral cataract surgery has been performed 6 months prior. At around 4 months before presentation, she was diagnosed with RA and had started tocilizumab monotherapy at a dose of 8 mg/kg every 4 weeks. However, the tocilizumab was discontinued after the third infusion, due to severe malaise and dizziness. Five weeks after the third infusion, she experienced a sudden decrease of vision. At presentation, the best corrected visual acuity (BCVA) was less than 2/200 in her left eye. An ophthalmological examination revealed severe anterior uveitis with hypopyon () and anterior vitritis but no apparent retinal lesion. There were no symptoms related to Behçet’s disease or human leukocyte antigen (HLA)-B27-associated acute anterior uveitis, and serologic tests for HLA typing were negative for HLA-A26, A29, B27, and B51. Because of the recent history of cataract surgery, the inflammatory symptoms led to a strong suspicion of delayed postoperative endophthalmitis. In addition to intravenous antibiotics, a diagnostic and therapeutic vitrectomy was performed. The obtained aqueous humor and vitreous samples were subjected to culture for bacteria and fungus, as well as multiplex polymerase chain reaction (PCR) for detection of human herpes viruses 1–8, bacterial 16S ribosomal ribonucleic acid (rRNA), and fungus 28S rRNA. However, no pathogens were detected from any ocular samples by these tests. Intravenous infusions of betamethasone 4 mg/day were initiated in addition to antibiotics, and the ocular inflammation improved gradually. After treatment with antibiotics and betamethasone was terminated on the eleventh postoperative day, cell infiltration into the anterior chamber increased on the next day, and the intravenous infusions of betamethasone 4 mg/day was restarted. Subsequently, the uveitis was ameliorated, and the anti-inflammatory treatment with intravenous betamethasone 4 mg/day was replaced by oral prednisolone 20 mg/day, on the 18th postoperative day.\nHowever, the uveitis recurred again in the left eye on the 43rd postoperative day despite the ongoing treatment with prednisolone 20 mg/day, and the IL-6 level in the aqueous humor was 46,100 pg/mL. The recurrent uveitis was improved by an additional subconjunctival injection of 2 mg of betamethasone. The patient has since remained relapse-free, with BCVA maintained at 20/20 (). No symptom of inflammation was observed in the right eye during the follow-up period.\nThis case report did not require Institutional Review Board/Ethics Committee approval.