Case report: bilateral simultaneous anterior optic neuropathy associated with golimumab

The authors report the case of a 62-year-old man who developed bilateral simultaneous anterior optic neuropathy while taking the tumor necrosis factor-alpha (TNF-α) inhibitor golimumab for psoriatic arthritis. They conclude that this case represents a rare but well-documented serious adverse event associated with TNF-α inhibitors.

The patient developed bilateral blurred vision associated with bilateral optic disc swelling shortly after receiving his third dose of golimumab. He had begun taking golimumab one year earlier and stopped after one dose (50 mg) to undergo treatment for prostate cancer. He then restarted the drug two months before presentation at the same dose. His last and third dose was taken three days before presentation, coincident with the beginning of his visual symptoms. Although he used tadalafil at times, he had not taken any for at least one month.

An extensive assessment, including magnetic resonance imaging, lumbar puncture and serologies, was negative. He was treated with systemic corticosteroids, after which his vision improved and the disc swelling resolved.

The authors say it is conceivable that his optic neuropathies were ischemic in origin, possibly related to the use of an erectile dysfunction drug, but he had not used that medication recently and had no vascular risk factors. However, given the evidence against alterative diagnoses and considering the published reports of similar cases with other TNF-α inhibitors, they believe the patient most likely had an optic neuropathy related to golimumab therapy.

They say it is unclear from published case reports if the specific agent, cumulative dose or duration of therapy influences the clinical presentation in terms of it being anterior or retrobulbar, unilateral or bilateral. The dose and duration of the current case are similar to those of previously reported cases of bilateral anterior optic neuropathy associated with TNF-α inhibitors. However, unlike four such reported cases in which there was no visual recovery, the current patient did have some improvement. The authors say that whether this improvement was due to stopping golimumab, instituting corticosteroid therapy or both is unclear, although steroid therapy is well known to hasten visual recovery in both demyelinating and idiopathic optic neuritis.