Infliximab-induced retrobulbar optic neuritis

Abstract

A 51-year-old woman underwent four cycles of intravenous infliximab for refractory active ulcerative colitis diagnosed 15 years earlier. She had a 1-month history of fever, abdominal pain and bloody diarrhoea, findings consistent with a relapse of her disease. She was also taking oral mesalazine, prednisone and azathioprine. Three weeks later, during the last cycle of infliximab, she developed pain, blurred vision and a loss in the visual field of the right eye. The results of a neurological examination were unremarkable. Laboratory evaluation revealed a white-cell count of 17 200/mm 3 , and initial ocular examination revealed visual acuities of 20/60 in the right eye and 20/20 in the left eye. Fundus fluorescein angiography was normal; findings from automated perimetry were normal in the left eye but showed an ‘arcuate’ scotoma in the right eye (A). Gadolinium-enhanced T1-weighted coronal magnetic resonance imaging of the brain and orbits (B) revealed enhancement of the orbital portion of her right optic nerve (arrow), findings compatible with retrobulbar optic neuritis. There were no other lesions consistent with demyelination within the brain. Retrobulbar optic neuritis associated with infusion of infliximab is rare, but has occasionally been reported in recent years (Arch Ophthalmol 2002; 120:985–7; Ann Intern Med 2004; 140:W34). Within four weeks of treatment with initial intravenous methylprednisolone, followed by a tapering dose of oral prednisone, the symptoms resolved (visual acuity was 20/20).