Uveitis is the most common extra-articular manifestation in patients with spondyloarthritis, and is present in 23% of patients with ankylosing spondylitis, and 15.9% of patients with non-radiographic spondyloarthritis,1 with a greater risk for HLA-B27-allele-positive patients with an OR of 4.2 (3.3–5.3).2 It presents in up to 41% as a first manifestation of spondyloarthritis, and the 2 key characteristics to aid diagnosis are the presence of anterior recurring uveitis, and back or joint pain.3 The most common presentation of uveitis is acute in 88.7%, it is anterior in 90.5%, and unilateral in 87.3%.2 Its management includes topical mydriatic agents, sulfasalazine and methotrexate to reduce recurrence.4 Treatment with tumor necrosis factor blockers (anti-TNFα) is effective in improving the signs and symptoms of spondyloarthritis and uveitis,5 and there are recommendations on the use of monoclonal antibodies such as infliximab and adalimumab as first-line anti-TNFα agents to treat uveitis associated with spondyloarthritis.6,7 However, there are no recommendations on the management of patients for whom this strategy fails.

We present the case of a 37-year-old woman who presented with a 2-year history of inflammatory lumbar pain; she had a history of an episode of anterior uveitis 8 years earlier in the left eye, which improved with topical management, within extension studies with the presence of HLA-B27, high acute phase reactants, and grade 2 bilateral sacroiliitis found on conventional radiography; a diagnosis was made of ankylosing spondylitis. Management with NSAIDs, methotrexate and sulfasalazine was started, presenting liver and skin toxicity. Due to persistent inflammatory lumber pain with a BASDAI score of 7, and elevated acute phase reactants, the patient was started on etanercept; two years later she presented with uveitis in the right eye and recurrence of her inflammatory lumbar pain. Following the therapeutic failure of infliximab and adalimumab due to recurrence of the uveitis episodes, the patient is being managed with monthly subcutaneous golimumab; clinical improvement of joint disease activity has been achieved and she has had no further episodes of uveitis.

For patients with spondyloarthritis with episodes of refractory uveitis (as in the case we present), the guidelines of the American College of Rheumatology (ACR)7 recommend the use of anti-TNFα monoclonal antibodies (infliximab, adalimumab) versus fusion proteins (etanercept)to reduce the recurrence of uveitis. Similarly, the guidelines of the European League Against Rheumatism (EULAR) on axial spondyloarthritis6 mention that infliximab, adalimumab and certolizumab are effective in preventing uveitis recurrence, while the results with etanercept remain contradictory; to date there have been no published cases on the effectiveness of golimumab for refractory uveitis associated with spondyloarthritis. Likewise on the management of anti-TNFα agents, opthalmology8 continue to recommend infliximab and adalimubab rather than etanercept, as second-line immunomodulatory agents for inflammatory eye disorders, including posterior uveitis, panuveitis and severe uveitis associated with spondyloarthritis. A recent study by Calvo-Rio et al.,9 in which golimumab was used for 15 patients with uveitis associated with spondyloarthritis refractory to least one immunosuppressive drug, reported an improvement in intraocular inflammatory parameters using this therapeutic strategy. On reviewing the study, only one patient shared similar characteristics with our patient, namely, failure of the same anti-TNFα agents (infliximab, adalimumab and etanercept). The study by Yazgan et al.,10 which assessed the use of golimumab for patients with HLA-B27-positive ankylosing spondylitis and recurrent anterior uveitis found complete remission of the ocular involvement, and significantly increased visual acuity (P=.002). None of the patients described in this study had similar characteristics to our patient. Therefore our case reinforces the efficacy of golimumab for patients with refractory and recurrent uveitis associated with spondyloarthritis who have already been treated with other anti-TNFα drugs.