Bilateral tacrolimus‐associated optic neuropathy after kidney transplant

Purpose Tacrolimus is an immunosuppressant drug which is often used after allogenic transplant to prevent organ rejection. It blocks T-cell development and inhibits cytokine synthesis. We report the case of a patient who developed bilateral optic neuropathy as a suspected complication of tacrolimus therapy. Methods A 75 year-old man who underwent orthotopic kidney transplant in 2013 was treated with tacrolimus since that moment without toxic blood levels at any moment. He had a history of moderate hypertension but neither other atherosclerotic risk factors nor ophthalmological disease associated. He came to the Emergency department for the first time in 2015, when he noticed sudden blurred vision in his left. His best corrected visual acuity (BCVA) in his left eye was 20/30. Dilated fundus examination revealed hyperemia, haemorrhages and swelling of the disc with distended veins. Visual field analyser showed a superior altitudinal defect in the left eye. Complete blood count, erythrocyte sedimentation and C-reactive protein were normal. He underwent oral treatment with prednisone 60 mg in descendent pattern. In the follow-up the visual field worsened, with abolished visual field, BCVA was hand movement at one meter distance and a relative afferent pupillary defect in his right eye was demonstrated. Optic disc showed evidence of atrophy. The right eye examination was unremarkable. Results Two years later in 2017 the patient came back to the Emergency department complaining of severe painless visual loss in his left eye. Fundoscopy revealed an optic disc edema with splinter haemorrhages which was confirmed with the OCT where we could see a diffuse edema of the fibre layer. Conclusions We should be aware of ophthalmological symptoms in patients who have been receiving therapy with tacrolimus, even in the absence of toxic blood levels of that drug.