Ophthalmic Complications in Patients With Inflammatory Bowel Disease During Anti-TNF Treatment
BACKGROUND: The main ophthalmologic extraintestinal manifestations (EIM) in inflammatory bowel disease (IBD) patients are episcleritis, uveitis and scleritis. Uncommon ophtalmic involvement can occur and may be related to adverse events of anti-TNF therapy. As the signs and symptoms are similar, differentiating these changes becomes a challenge for the physician. The aim of this report is to describe 3 cases of ophthalmologic complications (2 opportunistic infections and 1 adverse effect) during anti-TNF treatment.
METHODS: Data from patients from the IBD Unit of Gastroenterology Division of the Clinics Hospital of the University of São Paulo was retrospectively collected based on medical records.
RESULTS: Case 1: Female, 61 yo, diagnosed with Crohn's disease (CD) since 2004 (ileal and stenosing). Previous treatments with infliximab and adalimumab. Certolizumab pegol (CZP) monotherapy was started due to clinical and endoscopic activity. After the second dose of the medication, she had right eye pain, conjunctival hyperemia, photophobia, visual blurring and tearing. She was evaluated by the ophthalmologist: diagnosis of corneal ulcer by Herpes zoster. She was treated with Valaciclovir for 14 days and discontinued treatment with CZP. The patient had good ocular improvement. Case 2: Female, 23 yo, with ulcerative colitis (pancolitis) diagnosed 5 years ago currently under combination therapy with Azathioprine and Infliximab every 4 weeks. At the last outpatient evaluation, she still had clinical and endoscopic activity. She complained of loss of eyesight and scotoma. She also had maculopapulous and non-itching exanthema on the abdomen, palms and soles of the feet. After ophthalmic examination, posterior uveitis was detected and the patient underwent the following examinations: tuberculin skin test (17 mm), non-treponemal test (VDRL 1:32) and treponemal test (chemiluminescence immunoassay positive). As the pattern of fundus could be compatible with tuberculosis and syphilis in addition to clinical and laboratory findings, the diagnosis of ocular tuberculosis and secondary syphilis as well were made. Other serologies were negative. Following cessation of IBD therapy, treatment with oral prednisolone, intravenous ceftriaxone for syphilis (21 days) and antituberculosis drugs (rifampicin, isoniazid, ethambutol and pyrazinamide) were started. The patient showed great improvement in visual acuity and skin lesions. Case 3: Female, 51 yo, diagnosed with CD (penetrating) since 2012. Submitted to an ileum-rectum anastomosis in 2015. After surgery, she started treatment with infliximab monotherapy. After 1 year, she began to have symptoms of irritated eyes. Her symptoms worsened after infliximab dose optimization for every 4 weeks. The patient had decreased visual acuity, conjunctival hyperemia, pruritus, photophobia and pain around both eyes. She was evaluated by the ophthalmologist and diagnosed with cornea with punctate keratitis, eyelid edema, diffuse conjunctival hyperemia, decreased eyelashes and blepharitis. Infliximab treatment was discontinued. Eye drops prescribed with dexamethasone and lubricant. Patient had progressive ocular improvement.
CONCLUSION(S): Unusual eye involvement may occur in IBD patients during anti-TNF therapy as adverse events. Careful evaluation with a multidisciplinary team (including the ophthalmologist) is required for proper and early diagnosis with suitable treatment in order to reduce ophthalmic morbidity.
