The spectrum of Vogt-Koyanagi-Harada disease in Turkey

The Incidence and Presentation Features of Glaucoma in Vogt-Koyanagi-Harada Syndrome: A Systematic Review and Meta-Analysis

TOPIC

To determine the cumulative incidence and features of glaucoma in Vogt-Koyanagi-Harada (VKH) syndrome patients compared to non-glaucoma patients.

CLINICAL RELEVANCE

Knowing the exact burden of secondary glaucoma in VKH could guide its screening and management in clinical practice as a part of the regular follow-up for VKH patients.

METHODS

The review protocol was pre-registered on PROSPERO [CRD42023462794]. PubMed, Scopus, Web of Science, EBSCOhost, and Google Scholar were searched for studies reporting the cumulative incidence and features of glaucoma presentation in VKH. A manual search was also conducted to supplement the primary search. Subgroup analyses based on glaucoma type, VKH stage, and patients' age were conducted. All analyses were conducted using STATA. Fixed- and random-effects models were selected according to the observed heterogeneity. Studies' methodological quality was determined using the NIH tool.

RESULTS

The analysis of 7084 eyes revealed a progressive increase in the cumulative incidence of secondary glaucoma over time. The cumulative incidence was lowest at VKH onset (7%) and highest at 15 years (26%). Open-angle (12%; 95%CI: 9-14%) is more common than angle-closure glaucoma (7%; 95%CI: 3-13%). Glaucoma cumulative incidence is highest in the chronic recurrent stage of VKH (33%; 95%CI: 12-59%) and among children <18 years of age (26%; 95%CI: 16-37%). Features associated with glaucoma occurrence in VKH showed comparable rates to non-glaucoma cases. However, a meta-analysis to determine risk factors of glaucoma development in VKH was not feasible secondary to the lack of adjusted risk measures in included studies. Studies' quality was questionable in 5 studies. The certainty of evidence was moderate-to-high.

CONCLUSION

The cumulative incidence of glaucoma increases throughout VKH's course, with a higher tendency in children, chronic recurrent stages, and long-term follow-up. Future research should focus on examining risk factors of glaucoma development in VKH through adjusted multivariable regression models.

A Novel Risk Stratification-Based Immunomodulatory Treatment Strategy for Vogt-Koyanagi-Harada Disease

PURPOSE

To develop a more tailored immunomodulatory treatment (IMT) strategy based on a novel 2-arm risk stratification system in Vogt-Koyanagi-Harada (VKH) patients.

DESIGN

A retrospective clinical cohort study.

METHODS

Seventy-nine VKH patients in the acute stage were stratified into low- (n = 58) and high-risk (n = 21) groups based on their exposure to risk factors. They were treated with oral glucocorticoids (GCs) plus as-needed (PRN) or first-line IMT. Best corrected visual acuity (BCVA), sunset glow fundus (SGF) occurrence, relapse rate, and systemic adverse events were evaluated during follow-up.

RESULTS

Compared with the low-risk group, the high-risk group showed poorer BCVA at baseline (estimated difference 0.51, 95% CI 0.30-0.78; P < .001) and 6-month follow-up (estimated difference 0.08, 95% CI 0.00-0.08; P = .006), higher incidence of SGF at 12 months (52% vs 28%; RR 1.9, 95% CI 1.1-3.4; P = .040), and higher relapse rate at 6 months (24% vs 5%; RR 4.6, 95% CI 1.2-17.5; P = .028) and 12 months (52% vs 12%; RR 4.4, 95% CI 1.9-9.7; P < .001). In the low-risk cohort, no significant difference between the 2 IMT strategies was observed in primary outcomes. In the high-risk cohort, patients with the immediate IMT showed better BCVA (estimated difference -0.20, 95% CI -0.3 to -0.08; P = .007), lower incidence of SGF (27% vs 80%; RR 0.3, 95% CI 0.1-0.9; P = .030), and lower relapse rate (27% vs 80%; RR 0.3, 95% CI 0.1-0.9; P = .030) compared with the PRN regimen. Moreover, the immediate IMT regimen had a higher frequency of systemic adverse events than the PRN regimen (47% vs 7%; RR 7.1, 95% CI 2.5-20.4; P < .001).

CONCLUSIONS

High-risk stratification at baseline was associated with poor prognosis. The immediate IMT regimen was only beneficial for high-risk VKH patients regarding visual outcome, SGF, and relapse rate. This study suggests a potential need for a customized IMT strategy for VKH patients.

Vogt-Koyanagi-Harada Disease in Pre-school Children

PURPOSE

To report the management and outcome of VKH disease in a 4-year-old boy with a review of literature on VKH in preschool children (3 to 5 years).

METHOD

Retrospective chart and literature review.

RESULT

A 4-year-old boy presented with visual acuity of light perception in both eyes with panuveitis, secondary cataracts and intraocular pressure (IOP) of ≥40 mmHg in both eyes. He was started on oral corticosteroid, immunosuppressive and underwent glaucoma filtering surgery and lensectomy with vitrectomy after adequate control of intraocular inflammation. Over time his IOP was again uncontrolled even with maximum anti-glaucoma medications, and he underwent Ahmed glaucoma valve (AGV) implantation, and he gained a visual acuity of 20/60 in both eyes with aphakic correction at the last visit.

CONCLUSION

Paediatric VKH follows an aggressive disease phase and requires a comprehensive multispeciality management approach.

Epidemiology of Pediatric Uveitis

Uveitis is uncommon in children and its diagnosis and treatment are challenging. Little is known of the epidemiology of pediatric uveitis. Indeed, population-based studies in the literature are rare. However, there are many tertiary referral center reports that describe the patterns of uveitis in childhood, although few are from developed countries, and their comparison presents some issues. Anterior uveitis is the most frequent entity worldwide, especially in Western countries, where juvenile idiopathic arthritis is diffuse. Most cases of intermediate uveitis do not show any association with infectious or noninfectious systemic diseases. In low- and middle-income countries, posterior uveitis and panuveitis are prevalent due to the higher rates of infectious etiologies and systemic diseases such as Behçet disease and Vogt-Koyanagi-Harada disease. In recent decades, idiopathic uveitis rate has decreased thanks to diagnostic improvements.

Therapeutic window of opportunity in the acute uveitic phase of Vogt-Koyanagi-Harada disease: Prevention of late autoimmune complications by early intervention

PURPOSE

To determine relationship between timing of treatment initiation and disease outcomes and whether a therapeutic window of opportunity exists in initial-onset acute uveitis associated with Vogt-Koyanagi-Harada disease.

METHODS

Retrospective analysis of 112 patients (224 eyes). Main outcome measures were final visual acuity, progression to chronic recurrent evolution, development of complications, particularly 'sunset glow fundus', and drug-free remission cure of uveitis.

RESULTS

Forty-six patients (92 eyes) presented in the phase preceding anterior segment (AS) inflammation (early presentation) and 66 patients (132 eyes) had AS inflammation at presentation (late presentation). In significantly more eyes in the early presentation group (85.9%), final visual acuity of 20/20 was achieved compared with those in the late presentation group (66.7%) (p = 0.001). None of the eyes in the early presentation group progressed to chronic recurrent evolution and none developed 'sunset glow fundus', whereas in the late presentation group, 28.8% of the eyes progressed to chronic recurrent evolution (p < 0.001) and 56.1% developed 'sunset glow fundus' (p < 0.001). Patients in the early presentation group were able to discontinue treatment without relapse of inflammation at significantly shorter time intervals compared to patients in the delayed presentation group (p < 0.001). In the late presentation group, logistic regression analysis demonstrated that presenting clinical features predicting unfavourable outcomes were posterior synechiae (odds ratio = 4.03; 95% confidence interval [CI] = 1.29-12.23), bullous exudative retinal detachment extending to the periphery (odds ratio = 3.35; 95% CI = 1.53-7.32) and female gender (odds ratio = 2.05; CI = 1.08-3.90).

CONCLUSIONS

Our findings suggest that the window of opportunity lies in the phase preceding AS inflammation and initiation of effective treatment during this phase results in cure of uveitis and prevents blinding complications.

Clinical and multimodal imaging characteristics of eyes with Vogt–Koyanagi–Harada disease: An Egyptian experience

BACKGROUND

Vogt-Koyanagi-Harada (VKH) disease is a vision-threatening inflammatory disorder that is challenging in diagnosis and management.

METHODS

Retrospective, record-based analysis of 54 eyes belonging to 27 adult patients that fulfilled the revised diagnostic criteria for VKH between January 2018 and January 2021. Demographic, clinical, and imaging data on presentation and during follow-up visits were collected for each patient. Available imaging studies included B-scan ultrasonography (B-scan US), spectral domain optical coherence tomography (OCT), fundus fluorescein angiography (FFA), and OCT angiography (OCT-A).

RESULTS

The female-to-male ratio was 2.38:1. Nineteen patients (70.37%) presented during an initial attack, while eight patients (29.63%) presented during recurrence. The most commonly presenting sign in the posterior segment was exudative retinal detachment (44 eyes, 81.48%). B-scan US was utilized in 4 eyes (7.41%), OCT was utilized in 48 eyes (88.89%) with the most common finding being subretinal fluid (43 eyes, 89.58%), FFA was performed in 39 eyes (72.22%) with the most common finding being punctate hyperfluorescence and late dye pooling (33 eyes, 84.62%), and OCT-A was performed in 30 eyes (55.56%), in which choriocapillaris flow deficit that correlated with disease activity was detectable in 25 eyes (83.33%). Improved visual acuity was noted in 85% of the eyes that were followed up.

CONCLUSION

Early diagnosis and treatment of VKH result in favorable visual outcome. Multimodal imaging, with the recent addition of OCT-A, provides complementary data that could serve in diagnosis and monitoring.

New Perspectives on the Immunopathogenesis and Treatment of Uveitis Associated With Vogt-Koyanagi-Harada Disease

Uveitis associated with Vogt-Koyanagi-Harada (VKH) disease is a bilateral, chronic, granulomatous autoimmune disease associated with vitiligo, poliosis, alopecia, and meningeal and auditory manifestations. The disease affects pigmented races with a predisposing genetic background. Evidence has been provided that the clinical manifestations are caused by a T-lymphocyte-mediated autoimmune response directed against antigens associated with melanocytes in the target organs. Alongside of T lymphocytes, autoreactive B cells play a central role in the development and propagation of several autoimmune diseases. The potential role of B lymphocytes in the pathogenesis of granulomatous uveitis associated with VKH disease is exemplified within several studies. The early initial-onset acute uveitic phase typically exhibits granulomatous choroiditis with secondary exudative retinal detachment and optic disc hyperemia and swelling, subsequently involving the anterior segment if not adequately treated. The disease eventually progresses to chronic recurrent granulomatous anterior uveitis with progressive posterior segment depigmentation resulting in "sunset glow fundus" appearance and chorioretinal atrophy if not properly controlled. Chronically evolving disease is more refractory to treatment and, consequently, vision-threatening complications have been recognized to occur in the chronic recurrent phase of the disease. Conventional treatment with early high-dose systemic corticosteroids is not sufficient to prevent chronic evolution. Addition of immunomodulatory therapy with mycophenolate mofetil as first-line therapy combined with systemic corticosteroids in patients with acute initial-onset disease prevents progression to chronic evolution, late complications, vitiligo, and poliosis. Furthermore, patients under such combined therapy were able to discontinue treatment without relapse of inflammation. These findings suggest that there is a therapeutic window of opportunity for highly successful treatment during the early initial-onset acute uveitic phases, likely because the underlying disease process is not fully matured. It is hypothesized that early and aggressive immunosuppressive therapy will prevent remnant epitope generation in the initiation of the autoimmune process, the so-called primary response. B cell depleting therapy with the anti-CD20 monoclonal antibody rituximab is effective in patients with refractory chronic recurrent granulomatous uveitis. The good response after rituximab therapy reinforces the idea of an important role of B cells in the pathogenesis or progression of chronic recurrent uveitis associated with VKH disease.

Comparison of combination therapy of prednisolone and cyclosporine with corticosteroid pulse therapy in Vogt-Koyanagi-Harada disease

PURPOSE

To compare the efficacy and safety of a combination therapy of prednisolone and cyclosporine and corticosteroid pulse therapy in Vogt-Koyanagi-Harada (VKH) disease.

STUDY DESIGN

A prospective, multicenter, randomized, non-inferiority trial.

METHODS

Patients of new-onset acute VKH disease at 11 centers in Japan between 2014 and 2018 were randomized to a combination (oral prednisolone 60 mg daily with gradual taper-off to 35 mg/day and cyclosporine 3 mg/kg/day) and corticosteroid (methylprednisolone 1000 mg for 3 days followed by oral prednisolone) groups, and were followed for 1 year.

RESULTS

Thirty-four were assigned to the combination and thirty-six patients to the corticosteroid group. Recurrence/worsening risk was 0.15 (95% confidence-interval [CI] 0.03-0.27) in the combination group and 0.25 (95% CI 0.11-0.39) in the corticosteroid group, with a risk difference of - 0.10 (90% CI - 0.27 to 0.06), demonstrating non-inferiority of the combination group with a non-inferiority margin of 0.20 (P = 0.0013). Serious adverse events occurred in three patients (two with hyponatremia and one with severe headaches) in the combination group and none in the corticosteroid group. Sunset glow fundus grades and cataract rates at 1 year were 0.57 (95% CI 0.42-71) and 4.3% in the combination group and 0.91 (95% CI 0.78-1.04) and 34.0% in the corticosteroid group, respectively.

CONCLUSIONS

Combination therapy was noninferior to corticosteroid therapy with respect to recurrence/worsening risk. Notably, the recurrence/worsening risk, sunset glow fundus grade, and cataract rate were lower in the combination group than in the corticosteroid group.

Vogt Koyanagi Harada Disease In Paediatric Age Group: Clinical Characteristics, Remission, Recurrences and Complications in Asian Indian Population

PURPOSE

To describe disease characteristics and outcomes of Vogt-Koyanagi-Harada (VKH) syndrome in paediatric patients.

STUDY DESIGN

Retrospective chart analysis.

METHODS: A RETROSPECTIVE

Analysis of all patients ≤16 years with VKH syndrome was done. Clinical presentations, complications, recurrences and outcomes in cases of paediatric VKH were reviewed.

RESULTS

72 eyes of 36 patients with a mean age at presentation of 13.7 ± 2.34 years were assessed. Mean duration of symptoms and follow up were 9.88 ± 17.3 weeks and 55 months respectively. Clinical signs at presentation included anterior chamber cells >2+(34/72eyes, 47.2%), granulomatous keratic precipitates (6 eyes, 8.3%), posterior synechiae (35 eyes,48.6%), disc edema (46 eyes, 63.8%), neurosensory retinal detachments (44 eyes, 61.1%) and 'sunset-glow' fundus (9 eyes, 12.5%). Best corrected visual acuity (BCVA) at the time of presentation was 1.3logMAR or a Snellens equivalent of 20/400 which improved to 0.51logMAR (Snellens equivalent of 20/63) at last follow up. Remission was achieved in 61.1% cases. More than half of our patients developed one or more complications.

CONCLUSION

VKH in paediatric patients poses a challenge due to a delayed presentation and paediatric VKH patients have a worse visual acuity at the time of presentation as compared to adult age groups. Rates of remission may be low along with high risk of complications and hence there is a need for prolonged immunosuppression.

Vogt-Koyanagi-Harada is a Curable Autoimmune Disease: Early Diagnosis and Immediate Dual Steroidal and Non-Steroidal Immunosuppression are Crucial Prerequisites

Purpose:

It is crucial to subdivide Vogt–Koyanagi–Harada (VKH) disease into two subentities, initial-onset disease versus chronically evolving disease. For early diagnosis and precise follow-up of VKH choroiditis, the “Revised criteria for VKH” are no more sufficient for the appraisal of VKH and new biomarkers for disease activity are needed. It has been shown that, if initial-onset disease is treated promptly within the “therapeutic window of opportunity” and long enough with dual steroidal and non-steroidal immunosuppression, the disease can be cured in a large proportion of cases, an approach still contested. The proportion of chronic evolution and/or sunset-glow fundus (SGF) following steroidal monotherapy versus dual steroidal and non-steroidal immunosuppression was compared.

Methods:

A literature search was performed, identifying studies on initial-onset VKH treated either by steroidal monotherapy or dual immunosuppression. Evolution toward chronicity and/or SGF was compared in both groups.

Results:

Twenty studies were identified with reported long-term outcomes. In 16 studies, 802 patients received steroidal monotherapy, while in 4 studies, 172 patients received dual steroidal and non-steroidal immunosuppression. Chronic evolution and SGF occurred, respectively, in 44% and 59% in the corticosteroid-alone group versus 2.3% and 17.5% in the dual therapy group with no chronic evolution in three studies and no SGF in two studies.

Conclusions:

Chronic evolution and SGF are significantly less frequent in initial-onset VKH when treated with immediate dual steroidal and non-steroidal immunosuppression with a high proportion of healed cases. This combined approach seems recommended in the management of initial-onset VKH disease.

Paediatric autoimmune and autoinflammatory conditions associated with uveitis

Childhood uveitis comprises a collection of heterogenous ocular phenotypes which are associated with a diverse range of childhood autoimmune and autoinflammatory disorders. Of these genetic and/or acquired disorders, juvenile idiopathic arthritis is the most common, affecting 30-80% of children with uveitis. Up to a third of children with uveitis have 'isolated' idiopathic disease and do not have an associated systemic disease which manifests in childhood. However, uveitis may be the presenting manifestation of disease; thus, the apparently well child who presents with uveitis may have isolated idiopathic disease, but they may have an evolving systemic disorder. The diagnosis of most of the associated disorders is reliant on clinical features rather than serological or genetic investigations, necessitating detailed medical history taking and systemic examination. Adequate control of inflammation is key to good visual outcomes, and multidisciplinary care is key to good broader health outcomes.

Bilateral acute angle closure glaucoma as an initial presentation of Vogt-Koyanagi-Harada syndrome: A clinical case report

PURPOSE

Vogt-Koyanagi-Harada (VKH) is an autoimmune disease with bilateral granulomatous uveitis and various systemic manifestations. Bilateral acute angle closure glaucoma (AACG) can be a rare initial manifestation of VKH that may be misdiagnosed as primary angle closure glaucoma (PACG).

CASE REPORT

A 62-year-old woman with bilateral painless loss of vision referred to Qingdao Municipal Hospital. She had been diagnosed as PACG before admission and prescribed with anti-glaucoma treatment which did not improve her symptom. She had severe bilateral uveitis, optic disk swelling, and serous retinal detachment in both eyes. Intraocular pressure (IOP) was 20 mmHg in the right eye and 23 mmHg in the left eye, and her best corrected visual acuities (BCVAs) were 0.02 in both eyes. She was treated with oral corticosteroid therapy on a tapering schedule. One month after the therapy, the IOP remained well-controlled with deepened anterior chamber. Her visual acuity and symptom were improved.

CONCLUSIONS

We experienced a case of VKH disease with an unusual presentation of bilateral secondary AACG. It is important for ophthalmologists to know about this rare cause of painless loss of vision so that it could be treated properly.

Vogt-Koyanagi-Harada disease: recurrence rates after initial-onset disease differ according to treatment modality and geographic area

Background/Purpose Vogt-Koyanagi-Harada (VKH) disease is a primary autoimmune stromal choroiditis producing a spill-over panuveitis. For initial-onset VKH disease, it is increasingly thought that corticosteroid therapy is not sufficient and additional non-steroidal immunosuppressive therapy is needed. At the 11th workshop on VKH, the disease was said to be well controlled with corticosteroids alone in Japanese patients. The aim of this study was to review the literature to determine whether different levels of severity exist in different geographical areas.

METHODS

Literature was reviewed for studies on the evolution of initial-onset VKH disease, looking at treatment modalities and proportion of cases with chronic evolution and/or sunset-glow fundus (SGF).

RESULTS

PubMed search yielded 1249 references containing the term of Vogt-Koyanagi-Harada. Twenty references (15 from outside of Japan and 5 from Japan) contained information on the evolution of treated initial-onset disease. For the "international" group, percentage of chronic evolution after systemic corticosteroid monotherapy was 61%, and after combined steroidal and non-steroidal therapy it fell to 2% (0% in 3/4 studies). In the Japanese studies where all patients received systemic corticosteroids alone, chronic evolution was reported in 25%; however, SGF amounted to 61%.

CONCLUSION

In the world at large, chronic evolution of initial-onset VKH disease treated with corticosteroids alone concerned two-thirds of patients. Japanese studies showed that chronic evolution was substantially less frequent, indicating possibly less severe disease in Japan. This proportion fell to almost zero when dual steroidal and non-steroidal immunosuppression was given at onset.

Role of Optical Coherence Tomography in the Prognosis of Vogt-Koyanagi-Harada Disease

Purpose: To evaluate the prognostic value of OCT in acute VKH diseaseMethods: Retrospective series of consecutive VKH patients seen with the first presentation, a minimum follow-up of 1 year and serial OCT imaging. The primary outcome was the clinical activity phase at 1, 2 and 3 years.Results: Among 29 subjects, 7 resolved, 17 became chronic, and 5 developed chronic recurrent VKH. Median RNFL measurement obtained 2 months post-treatment was higher among subjects who developed chronic VKH (p-value = 0.03) and chronic recurrent disease (p-value = 0.04). Median CRT 1-week post-treatment was lower among subjects who developed PPA (p-value = 0.03). CRT 2 months post-treatment was higher among subjects who developed vitiligo (p-value = 0.02).Conclusion: OCT is helpful in early recognition of the predominantly optic disc swelling variant which carries a poorer prognosis. Lower CRT reading at 1 week and persistently raised CRT at 2 months post-treatment correlated with chronic recurrent disease.

Case Report of a 4-Year-Old Child with Complicated Vogt-Koyanagi-Harada at a Tertiary Eye Hospital

Vogt-Koyanagi-Harada (VKH) disease is a chronic, bilateral, granulomatous panuveitis associated with cutaneous, neurologic, and auditory manifestations. We report a 4-year-old Saudi boy who developed severe ocular complications by 5 years of age. He presented to King Khalid Eye Specialist Hospital at the age of 4 years and was previously operated on elsewhere for cataract with intraocular lens implantation in his right eye at the age of 3 years. He consecutively had iris capture and membrane formation around the intraocular lens. Examination revealed band keratopathy, posterior synechiae, and fundus depigmentation in both eyes with cataract formation in his left eye. At the age of 5.5 years, he developed subretinal neovascular membrane formation in the left eye. To the best of our knowledge, this patient is youngest VKH case that manifested most of the major complications at a young age as 5 years old.

Initial misdiagnosis of Vogt-Koyanagi-Harada disease

Purpose

To report the initial misdiagnosis of patients with Vogt–Koyanagi–Harada (VKH) disease.

Methods

The medical records of 76 consecutive patients diagnosed with VKH disease were reviewed retrospectively at The Eye Center, Riyadh, Saudi Arabia. Patients were referred to The Eye Center from Saudi Arabia and other Middle Eastern countries. The initial diagnosis was made by an ophthalmologist or neurologist. The main outcome measure was to evaluate cases with VKH disease who were initially misdiagnosed.

Results

In 7 (9.2%) out of the 76 patients the initial diagnosis was incorrect. Patients were initially misdiagnosed as optic neuritis (1.3%), intracranial hypertension (1.3%), brain tumor (1.3%), Susac disease (1.3%), migraine (1.3%), rhegmatogenous retinal detachment (1.3%) or anterior granulomatous uveitis of unknown etiology (1.3%). Patients underwent unnecessary tests including MRI and invasive procedures including CSF analysis and anterior chamber paracentesis.

Conclusion

The initial diagnosis of patients with VKH disease was incorrect in 9 % of the cases. Delay in the diagnosis of VKH disease may lead to delay in management and may cause irreversible damage to the photoreceptors with poor visual outcome.

Catching the therapeutic window of opportunity in early initial-onset Vogt-Koyanagi-Harada uveitis can cure the disease

PURPOSE

Vogt-Koyanagi-Harada (VKH) disease is a primary autoimmune granulomatous choroiditis that begins in the choroidal stroma. The aim of this review was to gather a body of evidence for the concept of a window of therapeutic opportunity, defined as a time interval following initial-onset disease during which adequate treatment will substantially modify the disease outcome and possibly even lead to cure, similar to what has been described for rheumatoid arthritis.

METHODS

We reviewed the literature and consulted leading experts in VKH disease to determine the consensus for the notion of a therapeutic window of opportunity in VKH disease.

RESULTS

We found a substantial body of evidence in the literature that a therapeutic window of opportunity exists for initial-onset acute uveitis associated with VKH disease. The disease outcome can be substantially improved if dual systemic steroidal and non-steroidal immunosuppressants are given within 2-3 weeks of the onset of initial VKH disease, avoiding evolution to chronic disease and development of "sunset glow fundus." Several studies additionally report series in which the disease could be cured, using such an approach.

CONCLUSIONS

There is substantial evidence for a therapeutic window of opportunity in initial-onset acute VKH disease. Timely and adequate treatment led to substantial improvement of disease outcome and prevented chronic evolution and "sunset glow fundus," and very early treatment led to the cure after discontinuation of therapy in several series, likely due to the fact that the choroid is the sole origin of inflammation in VKH disease.

Longitudinal observation of subretinal fibrosis in Vogt-Koyanagi-Harada disease

Background

Subretinal fibrosis (SRF) is a vision-threatening complication of Vogt-Koyanagi-Harada disease (VKH). It has long been recognized as a sequela of chronic inflammation. The developmental process of SRF, however, has not been described. The purpose of this study is to provide longitudinal observations of SRF in VKH.

Methods

Retrospective chart review of 10 VKH patients referred to our group between January 2008 and September 2015 at acute uveitic stage with SRF at presentation or who developed SRF during follow up.

Results

Ten patients (6 males and 4 females) with a median age of 39.0 (range, 23 to 58) years old were included. The median disease duration at presentation and median duration of follow up were 25.5 (range 5 to 60) days and 32.5 (range 13 to 61) months respectively. At presentation, all patients except one had been inappropriately treated with glucocorticosteroid (insufficiently dosed or tapered too fast) for longer than 2 weeks. Despite large dose oral glucocorticosteroid (1 mg/kg/d prednisone or equivalent) with slow tapering in combination with at least one immunomodulatory agent (cyclosporin A, cyclophosphamide or azathioprine) after presentation, all patients developed bilateral SRF within the first 4 months of disease course and 7 patients within the first 2 months. In 8 patients, shape-change/migration and progressive proliferation/pigmentation of SRF was observed over a period of several months after its formation, and then became quiescent but may further underwent depigmentation or pigmentation. SRF involved macula in 12 eyes (7 patients) and caused treatment resistant macular detachment and severe visual impairment in 6 eyes (4 patients). At the last visit, eyes with macular involvement were more common to had worse final best corrected visual acuity (≤20/50) than those without (9/12 vs. 0/8, p = 0.001).

Conclusions

SRF usually develop early in the disease course in VKH patients who are not adequately controlled; it usually undergoes a highly dynamic process within the subretinal space and may involve the macula and resulted in poor final visual outcome.

Vogt-Koyanagi-Harada Syndrome in a Group of Patients in Two Ophthalmology Referral Centers in Bogotá, Colombia

PURPOSE

To describe the clinical presentation of Vogt-Koyanagi-Harada (VKH) syndrome in a group of patients in Colombia.

METHODS

Retrospective review of 2638 medical records of patients with uveitis in two centers during 17 years.

RESULTS

A total of 25 patients with uveitis were diagnosed with VKH syndrome (0.95%), 23 patients were included in the data analysis (0.87%), 78.3% females, and mean age of diagnosis was 37 years (SD ± 29). Main complaints: blurred vision (87%), headaches (47.8%), tinnitus (26.1%), and hearing impairments (21.7%). Ophthalmic findings: bilateral serous retinal detachment (73.9%) and non-granulomatous uveitis (52.3%). Most of the patients were diagnosed with probable disease (56.5%). Mean duration of follow-up was 14 months; disease relapse was encountered in 26% of patients despite treatment.

CONCLUSION

Patients in Colombia with VKH had clinical features similar to those reported in other Hispanic populations, except for the non-granulomatous uveitis. This disease may be considered as having variation of clinical manifestations across population groups.

Clinical spectrum and management options in Vogt-Koyanagi-Harada disease

Purpose

The aim of this study was to describe the clinical features, treatment options, and visual outcome of Vogt–Koyanagi–Harada (VKH) disease patients over a 9-year period.

Method

A retrospective chart analysis of 32 patients with VKH, from January 2007 to December 2015, at a tertiary care government medical college eye hospital in South India.

Results

A total of 32 patients were diagnosed with VKH. The mean age at diagnosis was 32.03±8.8 years. There were 24 patients (42 eyes) with acute VKH and eight patients (16 eyes) with recurrent/chronic VKH. The mean baseline best-corrected visual acuity on presentation in the acute VKH group was 5/60 (1.114±0.565) and at last follow-up it was 6/9 (0.225±0.157). Intravenous methyl prednisolone (IVMP) was administered for 3 days to all patients with acute and recurrent VKH, followed by posterior subtenon triamcinolone (40 mg/mL) and oral azathioprine.

Conclusion

VKH-related uveitis is more common in the female gender in this South Indian population. Posterior uveitis is the most common initial manifestation. Initial aggressive treatment with IVMP, peribulbar long-acting corticosteroids, and immunosuppressives, avoiding side effects of systemic steroids, gives a good visual outcome without recurrences. Cases of unilateral VKH, seen in six patients, are the initial manifestations in the natural course of the disease, which if managed aggressively at the acute stage prevents recurrence in the other eye.

Spectrum and visual outcomes of Vogt-Koyanagi-Harada disease in Argentina

AIM

To review all cases of Vogt-Koyanagi-Harada (VKH) disease in an Inflammatory Eye Disease Service in Argentina and to describe the clinical profile and outcomes of treatment.

METHODS

The records from patients with VKH disease between January 1980 and December 2008 were retrospectively analyzed for clinical profile, complications, and treatment. Patients were classified according to their initial treatment in group 1: high corticosteroid dose [≥1 mg/(kg·d)] within 2wk of illness onset; group 2: high corticosteroid dose, 2 to 4wk of onset and group 3: patients who received the high dose after 1mo of illness onset, patients who received lower oral doses than 1 mg/(kg·d) without regarding the time of beginning of the disease.

RESULTS

A total of 210 eyes of 105 patients were included. The mean age at presentation was 32.6±13y (range: 10-74y), and 86.7% were female. The mean duration of follow up was 144±96.6mo. Patients in the group 1 had significantly higher visual acuity than the other groups (P<0.0001), none had (loss of, or no) light perception at the end of follow up, whereas 24.7% patients in group 3 ended in light perception (P<0.004).

CONCLUSION

Patients with early high dose corticosteroid treatment have better visual acuity and fewer complications. Proper timing in referral and treatment is critical for better visual outcome in VKH disease.

Vogt-Koyanagi-Harada syndrome - current perspectives

Vogt–Koyanagi–Harada syndrome is a cause of noninfectious panuveitis, leading to significant vision loss in many patients. It is an autoimmune disease occurring in genetically susceptible individuals and clinically presents as bilateral panuveitis with serous retinal detachments and hyperemic, swollen optic discs, which are associated with neurological and auditory manifestations. Early diagnosis and prompt and adequate treatment with immunosuppressive agents (corticosteroids and other immunosuppressive drugs) may halt disease progression and prevent recurrences and vision loss. This review summarizes the current knowledge on the variable clinical aspects of this disease, highlighting diagnostic and treatment strategies.

Surgical Treatment of Subretinal Fibrosis Caused Macular Detachment in Vogt-Koyanagi-Harada Disease: A Pioneer Study

PURPOSE

To describe surgical outcomes of macular detachment caused by subretinal fibrosis (SRF) in Vogt-Koyanagi-Harada disease (VKH).

METHODS

Retrospective review of VKH patients who underwent SRF removal surgery.

RESULTS

Seven eyes of six VKH patients with preoperative BCVA ranging from light perception to 20/250 were included. Six eyes underwent uncomplicated SRF removal with C3F8 or silicone oil (SO) tamponade and the following optional primary or subsequent procedures: intravitreal injection of triamcinolone acetonide, SO removal, lensectomy, or phacoemulsification with intraocular lens (IOL) implantation. All six eyes had attached macula and improved BCVA at the last visit (ranging from 20/2000 to 20/67) compared to baseline; the other eye, however, showed no light perception after surgery due to optic nerve injury.

CONCLUSIONS

In VKH patients, macular detachment caused by SRF can be treated with surgery with generally favorable outcomes. Extreme caution should be taken to avoid optic nerve injury.

Vogt-Koyanagi-Harada disease: Novel insights into pathophysiology, diagnosis and treatment

Vogt-Koyanagi-Harada (VKH) disease is one of the major vision-threatening diseases in certain populations, such as Asians, native Americans, Hispanics and Middle Easterners. It is characterized by bilateral uveitis that is frequently associated with neurological (meningeal), auditory, and integumentary manifestations. Although the etiology and pathogenesis of VKH disease need to be further elucidated, it is widely accepted that the clinical manifestations are caused by an autoimmune response directed against melanin associated antigens in the target organs, i.e. the eye, inner ear, meninges and skin. In the past decades, accumulating evidence has shown that genetic factors, including VKH disease specific risk factors (HLA-DR4) and general risk factors for immune mediated diseases (IL-23R), dysfunction of immune responses, including the innate and adaptive immune system and environmental triggering factors are all involved in the development of VKH disease. Clinically, the criteria of diagnosis for VKH disease have been further improved by the employment of novel imaging techniques for the eye. For the treatment, early and adequate corticosteroids are still the mainstream regime for the disease. However, immunosuppressive and biological agents have shown benefit for the treatment of VKH disease, especially for those patients not responding to corticosteroids. This review is focused on our current knowledge of VKH disease, especially for the diagnosis, pathogenesis (genetic factors and immune mechanisms), ancillary tests and treatment. A better understanding of the role of microbiome composition, genetic basis and ongoing immune processes along with the development of novel biomarkers and objective quantitative assays to monitor intraocular inflammation are needed to improve current management of VKH patients.

Clinical Outcomes of Patients with Vogt-Koyanagi-Harada Disease Over 12 Years at a Tertiary Center

PURPOSE

To describe the clinical characteristics and treatment outcomes of Vogt-Koyanagi-Harada (VKH) disease over a 12-year period.

METHODS

A retrospective chart review was used to identify VKH patients, from January 1999 to December 2011.

RESULTS

In total, 154 patients (308 eyes) were diagnosed with VKH. The mean age at diagnosis was 33.8 ± 13 years. Mean baseline best-corrected visual acuity (BCVA) was 20/125; (0.8 ± 0.6 logMAR). Recurrent episodes occurred in 107 (54%) patients. Oral prednisone was administered in all patients. At the last visit, the mean BCVA was 20/50 (0.4 ± 0.7 logMAR). The most common complications post-treatment were: glaucoma [104 (33.8%) eyes] and cataract [84 (27.2%) eyes].

CONCLUSIONS

In Saudi Arabia, VKH-related uveitis is predominant in young females. Bilateral panuveitis is the most common ocular manifestation and near 50% of eyes present with exudative retinal detachment. Oral prednisone was the primary treatment and the majority of eyes maintained 20/50 or better vision.

Rituximab for sight-threatening refractory pediatric Vogt-Koyanagi-Harada disease

Rituximab was trialed in a refractory Vogt-Koyanagi-Harada disease (VKH). A 10-year-old girl with panuveitis recalcitrant to treatment, including corticosteroids, was diagnosed with VKH 20 months later. Following rituximab at 0, 1, 6, and 18 months, response was favorable after the second dose, usual life activity resumed after the third dose (uveitis was inactivated and vision improved), and eyes stabilized 9 months after the fourth dose. Rituximab is effective in the treatment and long-term control of advanced, pediatric VKH.

High rate of clinical recurrence in patients with Vogt-Koyanagi-Harada disease treated with early high-dose corticosteroids

PURPOSE

To analyse the rate of clinical recurrences in Brazilian patients with Vogt-Koyanagi-Harada (VKH) disease after early high-dose corticosteroid treatment.

METHODS

Retrospective study including patients treated with early high-dose corticosteroids (prednisone, 1-1.5 mg/kg/day, or 3-day 1 g methylprednisolone pulsetherapy) within 1 month from disease onset followed by slow taper (at least 6 months). Patients with a minimum 12-month follow-up were subdivided based on the presence of disease recurrence or persistence after 6 months from initial presentation into: acute-resolved (AR, no recurrences), chronic-recurrent (CR), and chronic-recurrent with subretinal fibrosis (SRF). Recurrences were defined as the presence of clinical and/or fluorescein angiography findings.

RESULTS

Twenty-nine patients (58 eyes) with a median follow-up of 65 months were included. Six (21 %), 11 (38 %) and 12 (41 %) patients were allocated to AR, CR, and SRF groups respectively. Though having received treatment within 1 month of onset, median time to initial treatment differed among groups (11, 15, and 25 days, in AR, CR, and SRF groups respectively). Intensity of immunosuppression, cataract development, and longer time to achieve logMAR visual acuity ≤0.8 differed significantly among the groups, being more severe in SRF group. HLA-DRB1*0405 allele followed the same trend, though not reaching significance (0.5 in AR group, 0.6 in CR, and 0.8 in SRF).

CONCLUSION

VKH disease in Brazilian patients evolved to chronic-recurrent disease in 79 % of cases; 38 % developed subretinal fibrosis, in spite of similar initial treatment regimens. Time to initiate treatment influenced outcomes.

High rate of clinical recurrence in patients with Vogt-Koyanagi-Harada disease treated with early high-dose corticosteroids

PURPOSE

To analyse the rate of clinical recurrences in Brazilian patients with Vogt-Koyanagi-Harada (VKH) disease after early high-dose corticosteroid treatment.

METHODS

Retrospective study including patients treated with early high-dose corticosteroids (prednisone, 1-1.5 mg/kg/day, or 3-day 1 g methylprednisolone pulsetherapy) within 1 month from disease onset followed by slow taper (at least 6 months). Patients with a minimum 12-month follow-up were subdivided based on the presence of disease recurrence or persistence after 6 months from initial presentation into: acute-resolved (AR, no recurrences), chronic-recurrent (CR), and chronic-recurrent with subretinal fibrosis (SRF). Recurrences were defined as the presence of clinical and/or fluorescein angiography findings.

RESULTS

Twenty-nine patients (58 eyes) with a median follow-up of 65 months were included. Six (21 %), 11 (38 %) and 12 (41 %) patients were allocated to AR, CR, and SRF groups respectively. Though having received treatment within 1 month of onset, median time to initial treatment differed among groups (11, 15, and 25 days, in AR, CR, and SRF groups respectively). Intensity of immunosuppression, cataract development, and longer time to achieve logMAR visual acuity ≤0.8 differed significantly among the groups, being more severe in SRF group. HLA-DRB1*0405 allele followed the same trend, though not reaching significance (0.5 in AR group, 0.6 in CR, and 0.8 in SRF).

CONCLUSION

VKH disease in Brazilian patients evolved to chronic-recurrent disease in 79 % of cases; 38 % developed subretinal fibrosis, in spite of similar initial treatment regimens. Time to initiate treatment influenced outcomes.

Gender differences in vogt-koyanagi-harada disease and sympathetic ophthalmia

Vogt-Koyanagi-Harada disease (VKH) and sympathetic ophthalmia (SO) are types of T-cell mediated autoimmune granulomatous uveitis. Although the two diseases share common clinical features, they have certain differences in gender predilections. VKH classically has been reported as more prevalent in females than males, yet some studies in Japan and China have not found differences in gender prevalence. Male patients have a higher risk of chorioretinal degeneration, vitiligo, and worse prognosis. Conversely, the changing levels of estrogen/progesterone during pregnancy and the menstrual cycle as well as higher levels of TGF-β show a protective role in females. Potential causes of female predilection for VKH are associated with HLA-DR and HLA-DQ alleles. SO, a bilateral granulomatous uveitis, occurs in the context of one eye after a penetrating injury due to trauma or surgery. In contrast to the female dominance in VKH, males are more frequently affected by SO due to a higher incidence of ocular injury, especially during wartime. However, no gender predilection of SO has been reported in postsurgical cases. No clinically different manifestations are revealed between males and females in SO secondary to either ocular trauma or surgery. The potential causes of the gender difference may provide hints on future treatment and disease evaluation.

Diagnosis and classification of Vogt-Koyanagi-Harada disease

Vogt-Koyanagi-Harada (VKH) disease is a systemic autoimmune disorder that affects pigmented tissues of the body, with its most dire manifestations affecting the eyes. This review focuses on the diagnostic criteria of VKH disease, including some information on history, epidemiology, appropriate clinical and classification criteria, etiopathogenesis, treatment and outcomes. Expert review of most relevant literature from the disease's first description to 2013 and correlation with the experience in the care of VKH disease patients at a tertiary Uveitis Service in Brazil gathered over the past 40 years. The clinical manifestations and ancillary assessment of VKH disease have been summarized in the Revised Diagnostic Criteria proposed in 2001 in a manner that allows systematic diagnosis of both acute and chronic patients. It includes the early acute uveitic manifestations (bilateral diffuse choroiditis with bullous serous retinal detachment and optic disk hyperemia), the late ocular manifestations (diffuse fundus depigmentation, nummular depigmented scars, retinal pigment epithelium clumping and/or migration, recurrent or chronic anterior uveitis), besides the extraocular manifestations (neurological/auditory and integumentary). There are two exclusion criteria, i.e. absence of previous ocular penetrating trauma or surgery and any other ocular disease that could be confounded with VKH disease. HLA-DRB1*0405 plays an important role in pathogenesis, rendering carriers more susceptible to disease. The primary ocular pathological feature is a diffuse thickening of the uveal tract in the acute phase. Later on, there may be a compromise of choriocapillaris, retinal pigment epithelium and outer retina, mostly due to an "upstream" effect, with clinical correlates as fundus derangements. Functional tests (electroretinogram and visual field testing) as well as imaging modalities (retinography, fluorescein/indocyanine green angiography, optical coherence tomography and ultrasound) play an important role in diagnosis, severity grading as well as disease monitorization. Though high-dose systemic corticosteroids remain gold-standard therapy, refractory cases may need other agents (cyclosporine A, anti-metabolites and biological agents). In spite of good visual outcomes in the majority of patients, knowledge about disease progression even after the acute phase and its impact on visual function warrant further investigation.

Vogt-Koyanagi-Harada disease: clinical and demographic characteristics of patients in a specialized eye hospital in Turkey

PURPOSE

To evaluate clinical and demographic features of Vogt-Kayanagi-Harada disease (VKH) disease in Turkish patients and compare them with previously published data.

METHODS

Demographic and clinical features of 32 patients diagnosed as VKH in a tertiary referral center were retrospectively reviewed.

RESULTS

The mean age at presentation was 33.6 ± 10.4 years. Seventy-five percent of the patients were female and 62.5% of the patients presented during the last 2 years. The disease was complete in 31.2%, incomplete in 50%, and probable in 18.8% of the patients. The clinical course was acute in 50%, chronic recurrent in 34.4%, and chronic in 15.6%. The most common findings were bilateral serous retinal detachment ± papillitis in acute cases and retinal pigment epithelial changes of the macula in chronic cases.

CONCLUSIONS

Although rare in Turkey, VKH disease seems to have increased during the last few years. The disease is incomplete and acute in half of the patients and has a quite good visual prognosis.

Headache as an initial manifestation of Vogt-Koyanagi-Harada disease

A 29 year-old healthy Saudi female presented with a 1 week history of headache followed by decreased vision in both eyes. Biomicroscopy revealed anterior uveitis without hypopyon, posterior synechia or keratic precipitate. Fundus examinations were remarkable for serous retinal detachment and hyperemic discs. Fundus fluorescein angiogram showed a hot disc with multiple pinpoint leakage in both eyes. CT scan and MRI were normal, all uveitis workups were negative. Five months later, the patient presented with complete criteria of Vogt-Koyanagi-Harada disease including a 2 weeks history of tinnitus, alopecia, poliosis and vitiligo. Headache alone followed by decreased vision before the onset of neurological and auditory symptoms can be an initial presentation of VKH disease. VKH should be considered in the differential diagnosis of atypical presentation of symptoms.

Spectral domain optical coherence tomography of Vogt-Koyanagi-Harada disease: novel findings and new insights into the pathogenesis

OBJECTIVE

To provide novel spectral domain optical coherence tomography (SD OCT) findings of Vogt-Koyanagi-Harada (VKH) disease as well as new insights into the pathogenesis of this disease.

METHODS

Detailed SD OCT and fluorescein angiography (FA) findings of 18 consecutive VKH patients (11 women and 7 men) from December 2007 to April 2009 who were in acute uveitic stage at presentation were reviewed. All the patients had been followed up for at least 6 months with reevaluation(s) of SD OCT performed in 10 patients.

RESULTS

Intraretinal cysts were found to be located in various layers of the outer retina. In addition to the photoreceptor layer, they could also be found between the outer plexiform layer and the outer nuclear layer, or spanning the external limiting membrane. On FA, intraretinal cysts could be hypofluorescent, normofluorescent, or hyperfluorescent. Some intraretinal cysts had a characteristic FA pattern, in which a small round hypofluorescent area was surrounded by a ring of hyperfluorescence (donut-shaped dye pooling). Subretinal fibrinoid deposit appeared in acute uveitic stage in two severe VKH patients and seemed to develop from subretinal exudates and evolved into typical subretinal fibrosis. Gradual transfiguration/migration and progressive proliferation/pigmentation of the subretinal fibrinoid deposit/subretinal fibrosis was observed in one patient.

CONCLUSIONS

Intraretinal cysts could form in various layers of the outer retina and may result from extension of choroidal inflammation. Subretinal fibrosis may develop from subretinal exudates in VKH patients and may cause substantial visual impairment.

Vogt-Koyanagi-Harada syndrome in a 6-year-old Hispanic boy

A 6-year-old Hispanic boy presented to the ophthalmology department with complaints of pain, photophobia, and blurry vision of both eyes. He was found to have bilateral granulomatous panuveitis, cataracts, and high intraocular pressures. He later developed multiple asymptomatic, ovoid, hypopigmented patches over the mid-lumbosacral back. Biopsy of lesional skin was significant for low melanocyte counts and a mild lymphocytic infiltrate. The patient was diagnosed with Vogt-Koyanagi-Harada syndrome (VKH). This article reviews the literature regarding the cutaneous presentation of VKH.

Vogt-koyanagi-harada syndrome

PURPOSE

Vogt-Koyanagi-Harada syndrome is a bilateral, chronic, diffuse granulomatous panuveitis frequently associated with neurological, auditory, and integumentary manifestations. It is also one of the most common forms of uveitis among pigmented races including Chinese patients.

METHODS

This article reviews the current developments of Vogt-Koyanagi-Harada syndrome, including epidemiology, etiology, clinical features, observational techniques, genetics, treatment, and prognosis.

RESULTS

Increasing reports have been published to describe the clinical features of Vogt-Koyanagi-Harada syndrome in various ethnic populations from different parts of the world. In spite of tremendous progress in laboratory and clinical research, the etiology of Vogt-Koyanagi-Harada syndrome is still not completely known. Numerous studies indicate an autoimmune nature for this disease. A recent study has shown that Th17, a new subset of T cell, plays an important role in the initiation and maintenance of this disease. Early and aggressive systemic corticosteroids are still the mainstay of initial therapy for Vogt-Koyanagi-Harada syndrome. However, nonsteroid immunomodulatory therapy, including cyclosporine, chlorambucil, cyclophosphamide, and azathioprine have brought out encouraging results. Improved visual outcomes in patients with Vogt-Koyanagi-Harada syndrome in recent years have been reported when compared with decades ago, presumably due to the more aggressive use of immunosuppressive agents.

CONCLUSION

Although the prognosis for VKH syndrome was greatly improved, future prospective, controlled, multi-center studies are needed to determine the optimal treatment regime for this disease. The IL17/23 pathway may provide a novel therapeutic target to control inflammation in VKH syndrome.

Effects of the duration of initial oral corticosteroid treatment on the recurrence of inflammation in Vogt-Koyanagi-Harada disease

PURPOSE

To evaluate the effects of the duration of oral corticosteroid treatment on the recurrence of inflammation in Vogt-Koyanagi-Harada (VKH) disease.

METHODS

Retrospective analysis of 35 VKH patients who received oral corticosteroid during the first attack of VKH with a minimum follow-up of 6 months. Patients were divided into two groups on the basis of the oral corticosteroid treatment duration of less than 6 months or 6 months or more. Kaplan-Meier survival and Cox-regression analyses were carried out to compare the recurrence rates of inflammation in the two groups.

RESULTS

The mean age of onset was 42.5 years and the mean follow-up duration was 3.6 years. During the follow-up period, 10 (58.8%) of the 17 patients who received oral corticosteroid for less than 6 months compared with 2 (11.1%) of the 18 patients who had treatment for 6 months or more developed recurrence of inflammation (P=0.003). Cox-regression analysis showed that the duration of oral corticosteroid treatment for less than 6 months was the only significant risk factor for recurrence of VKH after adjustment for age, gender, and the initial dosage of oral corticosteroid treatment (adjusted odds ratio=8.8, P=0.008). Patients who received oral corticosteroid treatment for less than 6 months were also more likely to have one eye with visual acuity of 20/200 or worse (P=0.016).

CONCLUSIONS

Early withdrawal of oral corticosteroid is associated with increased risk of recurrence of VKH and worse visual prognosis. Oral corticosteroid should be tapered off slowly and maintained for at least 6 months for the treatment of acute VKH.

Indocyanine green angiography in Vogt-Koyanagi-Harada disease: angiographic signs and utility in patient follow-up

PURPOSE

Firstly, to give a review of characteristic indocyanine green angiographic (ICGA) signs in Vogt-Koyanagi-Harada (VKH) disease and, secondly, to determine the utility of ICG angiography in the assessment and follow-up of choroidal inflammatory activity during initial high-dose inflammation suppressive therapy and during the tapering of therapy.

METHODS

We have first reviewed characteristic ICGA signs in VKH. This is followed by a study of four patients with an acute initial VKH uveitis episode who received regular initial and follow-up angiographic examinations for at least 9 months. Classical ICGA signs were recorded at onset and followed for at least 9 months and were correlated with treatment levels. The treatment consisted of high-dose oral corticosteroids (0.8-1.5 mg/kg) preceded by pulse intravenous methylprednisolone (500-1000 mg) for 3 days in hyperacute cases and followed by very slow tapering with the addition of an immunosuppressive agent in cases of insufficient response.

RESULTS

The major ICGA signs that were both consistently present and easy to record in the four VKH patients having an acute initial uveitis episode with a pre-treatment angiography and an angiographic follow-up for a minimum of 9 months include (1) early choroidal stromal vessel hyperfluorescence and leakage, (2) hypofluorescent dark dots, (3) fuzzy vascular pattern of large stromal vessels and (4) disc hyperfluorescence. All patients were treated with high-dose inflammation suppressive therapy: in two patients, within 14 and 21 days after initial symptoms, respectively, and in the other two patients, within 6 weeks. Hypofluorescent dark dots, the most constant and easily recordable sign, was very prominent in all cases at presentation. A 90% to complete resolution of dark dots was noted in all four patients after 4 months of therapy. The other three major angiographic signs, early choroidal stromal vessel hyperfluorescence and leakage, indistinct fuzzy vessels at the intermediate angiographic phase and disc hyperfluorescence resolved in all cases within 8 weeks or less of high-dose inflammation suppressive therapy. In three of the four patients, dark dots reappeared after a mean of 7.8 +/- 2.8 months after onset of therapy when the patients were under a mean corticosteroid dose of 13.2 +/- 6.3 mg per day without any significant clinical or fluorescein angiographic signs, indicating subclinical recurrence. An increase in the inflammation suppressive therapy again brought about angiographic resolution of choroidal subclinical disease in all cases.

CONCLUSION

Choroidal inflammation shown by ICG angiography can be suppressed completely by initial high-dose inflammation suppressive therapy. However, recurrent subclinical choroidal inflammation is detected at the end of the tapering period in a high proportion of cases. This indicates that, in the absence of an ICGA follow-up, undetected smoldering subclinical disease may persist, thereby explaining the frequently reported evolution towards sunset glow fundus despite an apparently controlled disease. This is a clear indication that VKH disease should be followed by ICG angiography and, in the case of choroidal subclinical reactivation, a reversal of therapy tapering and an extension of therapy duration should be considered.