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A. Barak, L. S. Morse, I. Schwab, Leflunomide (Arava®)-induced cystoid macular oedema, Rheumatology, Volume 43, Issue 2, February 2004, Pages 246–248, https://doi.org/10.1093/rheumatology/keh005
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1Department of Ophthalmology, UC Davis, Sacramento, CA, USA and 2Tel Aviv Medical Center, Tel Aviv, Israel.
Sir, Leflunomide (Arava®), an immunomodulatory agent, was the first oral agent for active rheumatoid arthritis labelled for slowing the progression of the disease, slowing structural damage to joints and relieving arthritis symptoms [1]. While it has potent immunosuppressive and anti-inflammatory activity, its use has not been studied in uveitis, yet it clearly is a potential anti-uveitic agent [2]. We report a case of bilateral cystoid macular oedema which developed recently after initiation of leflunomide treatment.
RS is a 57-yr-old white male who started on leflunomide owing to severe rheumatoid arthritis. His current medical problems included rheumatoid arthritis, which was diagnosed 7 yr ago, and his medications included 5 mg of prednisone (taken for 2 yr, with no change in steroid regimen during the last 6 months), Arthroteck (voltarin + cytotec to protect the gastrointestinal tract) and leflunomide. He was taking no ocular medications, had no previous eye problems and had no previous ocular surgery or any fundoscopic examination that he recalled. Two weeks after initiation of leflunomide treatment he developed blurring of the vision in both eyes. On examination he was 20/20 in the right eye and 20/25 in the left eye with refraction. His skin was within normal limits. His conjunctiva was quiet. His anterior segment examination was completely normal and the intraocular pressures were 12 and 14 mmHg. His funduscopic examination showed mild cystoid macular oedema on the right and mild but more prominent cystoid macular oedema on the left. No vitreitis or any other signs of scleritis were found. His angiogram, taken at the UC Davis medical centre 2 weeks after initiation of ocular symptoms, confirmed the diagnosis of cystoid macular oedema in both eyes, more in the left eye than in the right eye, with disk hyperfluorescence and no perivascular leakage (Fig. 1). He was diagnosed as having cystoid macular oedema, and was advised to stop the leflunomide. Four weeks after cessation of the leflunomide treatment, subjective visual improvement was noted, but his vision continues to be somewhat blurred. Three months later, visual acuity was 20/20 VA in both eyes, with no further symptoms. On clinical examination no cystoid macular oedema was seen. No additional angiograms were taken.
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