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

Unveiling Key Pathological Indicators for Disease Progression in Vogt Koyanagi Harada Disease and Sympathetic Ophthalmia Through Advanced Choroidal Volume Analysis

PURPOSE

To evaluate the association between quantitative parameters derived from volume analysis of optical coherence tomography (OCT) data and disease worsening in Vogt-Koyanagi-Harada disease (VKHD) and sympathetic ophthalmia (SO).

METHODS

This retrospective study, conducted at Osaka University Hospital, employed swept-source OCT scans from patients diagnosed with VKHD or SO between October 2012 and January 2021. The choroidal vessel structure was segmented and visualized in three dimensions, generating quantitative vessel volume maps. Region-specific choroidal vessel volume (CVV), choroidal volume (CV), and vessel index (VI) were scrutinized for their potential correlation with disease severity.

RESULTS

Thirty-five eyes of 18 VKHD and 2 SO patient (8 females, 10 males) were evaluated. OCT-derived CVV maps revealed regional CV alterations in VKHD and SO patients. Two parameters, i.e. CV at 3- and 6-month follow-ups (p = 0.044, p = 0.040, respectively, with area under the ROC curve of 0.70) and CVV at 6 months (p = 0.046, area under the ROC curve of 0.71), were significantly higher in recurrent VKHD and SO compared to effectively treated cases.

CONCLUSIONS

The volume analysis of OCT images facilitates a three-dimensional visualization of choroidal alterations, which may serve as a reflection of disease severity in VKHD and SO patients. Furthermore, noninvasive initial CVV or CV measurements may serve as potential biomarkers for predicting disease recurrence in VKHD and SO.

Efficacy and Safety of Adalimumab for Exacerbation or Relapse of Ocular Inflammation in Patients with Vogt-Koyanagi-Harada Disease: A Multicenter Study

PURPOSE

We investigated efficacy and safety of adalimumab (ADA) treatment for exacerbation or recurrence of Vogt-Koyanagi-Harada (VKH) patients.

METHODS

Medical records of 70 VKH patients who received ADA treatment for more than 6 months were retrospectively investigated.

RESULTS

The mean age of VKH patients was 54.8 ± 15.1 years, and male/female ratio was 34/36, and sunset glow fundus was observed in 71.4%. Subfoveal choroidal thickness, indocyanine green angiography scores, and corticosteroid and cyclosporine doses were significantly reduced by ADA treatment for 6 months compared to baseline, while LogMAR and flare counts were also improved without being statistically significant. Adverse events were observed in 17.1%, in which tuberculosis was at 7.14% and psoriasis was at 2.86%; however, ADA treatment was continued in 91.4%.

CONCLUSIONS

ADA was shown to be effective to achieve remission of VKH disease refractory to conventional treatments and was generally well tolerated with few serious adverse events.

Blood Whispers: Exploring Hematologic Indicators for Diagnosing and Predicting Severity of Vogt-Koyanagi-Harada Syndrome

PURPOSE

To investigate the association of clinical findings and indocyanine green angiography (ICGA) score with inflammatory markers derived from complete blood count (CBC) parameters in patients with Vogt-Koyanagi-Harada (VKH) to determine the diagnostic and predictive role.

METHODS

Demographic characteristics, presenting complaints, ocular findings, optical coherence tomography findings, ICGA scores and best corrected visual acuity were recorded in treatment-naive VKH patients at presentation. Patients were divided into two groups as acute stage and chronic recurrent stage. CBC parameters were noted in patients at presentation and healthy controls (HC, n = 25). Neutrophil-lymphocyte-platelet-monocyte counts, neutrophil/lymphocyte (NLR), platelet/lymphocyte (PLR), monocyte/lymphocyte and systemic immune-inflammation index (SII) were recorded. The association between these markers and clinical severity were evaluated.

RESULTS

Thirty-two patients with VKH (23 females/9 males) with a mean age of 34.1 ± 14.6 years were included in the study. There was an increase in neutrophil count, NLR and SII in patients with VKH compared to HC (p < 0.001). The cut-off values for these three parameters were 4.37, 2.24 and 562.35, respectively. Twenty-six patients presented in the acute stage and six patients presented in the chronic recurrent stage. Choroidal thickness, early stromal hyperfluorescence and total ICGA scores were higher in patients presenting in the acute stage (p < 0.001, 0.001 and 0.025, respectively). Patients with higher disease severity at presentation were treated earlier. Early stromal vessel hyperfluorescence and choroidal vasculitis scores were correlated with decreased lymphocyte count, increased NLR, PLR and SII (p < 0.05).

CONCLUSION

CBC-derived inflammatory parameters indicate that VKH is a systemic inflammation. These parameters can be used in the diagnosis and determination of disease severity of VKH.

Vogt-Koyanagi-Harada Disease: A Narrative Review

Vogt-Koyanagi-Harada (VKH) disease is an idiopathic immune-related sickness that affects multiple systems and melanocytes in organs such as the uvea, ear, and meninges. The primary cause of activity is cellular immunological responses. Vogt-Koyanagi disease is identified primarily by skin abnormalities and anterior uveitis. Harada's illness is distinguished by neurological symptoms and exudative retinal detachments, which are associated with the HLA-DR4 and HLA-DRw53 genes. Pigmented races, such as Hispanics and Native Americans, are more likely to have VKH disease. Clinical features are blurred vision, floaters, alopecia, vitiligo, diffuse choroidal inflammation with disc edema, and exudative retinal detachment. Differential diagnoses include posterior scleritis, uveal effusion syndrome, central serous chorioretinopathy, and sympathetic ophthalmitis. The investigations used are optical coherence tomography (OCT), fundus fluorescein angiography (FA), and B-scan ultrasonography (USG). Treatment is done by using systemic steroids, cycloplegics, and immunosuppressants.

Diagnosing and Managing Uveitis Associated with Immune Checkpoint Inhibitors: A Review

This review aims to provide an understanding of the diagnostic and therapeutic challenges of uveitis associated with immune checkpoint inhibitors (ICI). In the wake of these molecules being increasingly employed as a treatment against different cancers, cases of uveitis post-ICI therapy have also been increasingly reported in the literature, warranting an extensive exploration of the clinical presentations, risk factors, and pathophysiological mechanisms of ICI-induced uveitis. This review further provides an understanding of the association between ICIs and uveitis, and assesses the efficacy of current diagnostic tools, underscoring the need for advanced techniques to enable early detection and accurate assessment. Further, it investigates the therapeutic strategies for ICI-related uveitis, weighing the benefits and limitations of existing treatment regimens, and discussing current challenges and emerging therapies in the context of their potential efficacy and side effects. Through an overview of the short-term and long-term outcomes, this article suggests recommendations and emphasizes the importance of multidisciplinary collaboration between ophthalmologists and oncologists. Finally, the review highlights promising avenues for future research and development in the field, potentially informing transformative approaches in the ocular assessment of patients under immunotherapy and the management of uveitis following ICI therapy.

Vogt-Koyanagi-Harada Disease: The Clinical Spectrum and Management of Case Series in a Tertiary Eye Centre in Northern Part Of Malaysia

AIMS

We present the clinical spectrum, the initial clinical presentation with management trends in treating 14 Vogt-Koyanagi-Harada (VKH) disease cases in a tertiary center in the Northern part of Malaysia.

CASE SERIES

There were 14 cases of Vogt-Koyanagi-Harada (VKH) disease retrospectively reviewed over five years (from 2015 to 2020). The mean age at presentation was 37.7 years (range 21-64 years), with female predominance (85.7%). All cases presented with acute uveitic stage and bilateral eye involvement. Of them, 11 (78.6%) were probable VKH, and three (21.4%) were incomplete VKH. All patients attended with acute panuveitis at first presentation. The main posterior segment involvement was disc edema in 57.1% (16 out of 28 eyes) and exudative retinal detachment (ERD) in 35.7% (10 out of 28 eyes). Most of them presented with blindness (3/60 and worse) and moderate visual impair- ment (6/18-6/60); 35.71% each, followed by mild visual impairment (6/12-6/18), and severe visual impairment (6/60-3/60); 7.1% each. Ten patients (71.4%) required combination second-line immunomodulatory treatment during subsequent visits, and only four patients (28.6%) responded well to corticosteroid therapy. Most of the cases achieved no visual impairment (64.3%), followed by mild visual impairment (21.4%) and moderate visual impairment (14.3%), and none were severe or blind at the end of follow-up.

CONCLUSION

VKH is a potentially blinding illness if there is inadequate control of the disease in the acute stage. Most of our patients achieved good visual outcomes with early immunomodulatory treatment and systemic corticosteroids.

Regarding Kaya P et al. "Predictive Factors for the Prognosis of Vogt-Koyanagi-Harada Disease"

INTRODUCTION

VKH is a primary stromal choroiditis. Studies with indocyanine green angiography (ICGA) have shown that inflammation begins at the choroid and may persist without clinically apparent inflammation. Thus, systemic therapy must target choroidal inflammation and be maintained until the choroiditis resolves, as proven by ICG and/or EDI-OCT imaging studies.

DISCUSSION

Aggressive therapy with oral corticosteroids, with or without "pulsed" intravenous methylprednisolone, has been the mainstay of VKH therapy in the acute phase for many years. However, there is convincing evidence that corticosteroid monotherapy is insufficient to prevent progression onto the chronic recurrent form of the disease, which is associated with poor visual outcomes.

CONCLUSION

Numerous studies suggest that combined therapy with systemic corticosteroids and immunosuppressants is necessary to prevent the progression toward chronic recurrent disease, avoiding complications, get a better control of inflammation and visual outcomes in VKH patients seen at the uveitic phase of the disease.

Authors Reply to Letter to the Editor - In Response to Comment on Raul E. Ruiz-Lozano et al.'s "Predictive Factors for the Prognosis of Vogt-Koyanagi-Harada Disease"

An aggressive treatment, including immunomodulatory therapy, is very important in preventing the development of the chronic recurrent stage in Vogt-Koyanagı-Harada (VKH) disease. However, the way of treatment is not the only factor determining the prognosis, and there are other factors that affect the outcome.

HIGH LONG-TERM DRUG-FREE REMISSION RATE FOR ACUTE VOGT-KOYANAGI-HARADA DISEASE WITH AN APPROPRIATE IMMUNOSUPPRESSIVE REGIMEN

PURPOSE

To report the clinical profile and outcomes of acute Vogt-Koyanagi-Harada disease with a strict immunosuppression regimen and investigate the risk factors for a prolonged disease course.

METHODS

A total of 101 patients with acute Vogt-Koyanagi-Harada (202 eyes) with more than 24 months of follow-up were recruited from January 2011 to June 2020. They were divided into two groups according to the interval between the onset of Vogt-Koyanagi-Harada and treatment. Oral prednisone was gradually tapered off by a diminished dose according to a relatively strict protocol. Patient responses to the treatment regimen were classified as long-term drug-free remission or chronic recurrent.

RESULTS

Ninety-six patients (95.0%) achieved long-term drug-free remission without recurrence, while 5 (5.0%) had chronic recurrence. Most patients achieved good best-corrected visual acuity (90.6% ≧20/25). A generalized estimation equation model demonstrated that time of visit, ocular complications, and cigarette smoking were independent risk factors for a longer disease course, and smokers required a higher drug dose and longer treatment course than nonsmokers.

CONCLUSION

An immunosuppressive regimen with an appropriate tapering speed can lead to long-term drug-free remission in patients with acute Vogt-Koyanagi-Harada. Cigarette smoking significantly affects ocular inflammation.

Incidence and pre/post-treatment risk factors of glaucoma in Vogt-Koyanagi-Harada disease

PURPOSE

To investigate the incidence and pre/post-treatment risk factors of glaucoma in patients with Vogt-Koyanagi-Harada (VKH) disease.

METHODS

Data regarding secondary glaucoma were collected from the medical records of patients with VKH disease who were followed up at the uveitis service at Hiroshima University for more than 6 months. We examined the incidence of glaucoma and pre/post-treatment risk factors for glaucoma in patients with VKH disease.

RESULTS

Forty-nine patients with VKH disease were included in this study (31 women and 18 men). The mean age at onset was 50.4 ± 15.4 years and the mean length of follow-up was 40.7 ± 25.5 months. The most common initial treatment was pulse intravenous corticosteroid therapy (89.8%). Fifteen patients developed secondary glaucoma during follow-up. The median time of glaucoma onset from VKH development was 4.5 months (range 0-44 months). Disc swelling type as a pre-treatment factor (p = 0.089, hazard ratio = 7.268), worse final best corrected visual acuity (p = 0.099, odds ratio = 1.545), and cataract progression (p = 0.076, odds ratio = 7.886) as post-treatment factors showed trends for glaucoma development. The patients who progressed to the chronic recurrent stage had more complications including glaucoma.

CONCLUSION

Secondary glaucoma occurred in more than 30% of patients with VKH disease. The factors that showed a trend toward glaucoma development may reflect an association with delayed treatment initiation and prolonged ocular inflammation.

A randomized non-inferiority trial of therapeutic strategy with immunosuppressants versus biologics for Vogt-Koyanagi-Harada disease

Biologics are increasingly used to treat Vogt-Koyanagi-Harada disease, but head-to-head comparisons with conventional immunosuppressants are lacking. Here in this randomized trial (Chinese Clinical Trial Registry, ChiCTR2100043061), we assigned 110 patients (27 early-phase and 83 late-phase) to cyclosporine-based immunosuppressant strategy (N = 56) or adalimumab-based biologic strategy (N = 54), each combined with a modified corticosteroid regimen. The primary outcome is change from baseline in best-corrected visual acuity at week 26. The margin of non-inferiority for cyclosporine is -7 letters. The primary outcome is 11.2 letters (95% CI, 7.5 to 14.9) in the cyclosporine group and 6.3 letters (95% CI, 3.1 to 9.6) in the adalimumab group (difference, 4.9; 95% CI, 0.2 to 9.5; P < 0.001 for non-inferiority). The between-group difference is -0.8 letters (95% CI, -6.1 to 4.5) in early-phase disease and 5.7 letters (95% CI, 0.2 to 11.2) in late-phase. Serious adverse events are reported less frequently in the cyclosporine group than in the adalimumab group (0.70 vs. 1.21 events per patient-year). Here, we report that combined with a non-standard corticosteroid regimen, cyclosporine-based immunosuppressant strategy is non-inferior to adalimumab-based biologic strategy by 26 weeks for visual improvement in a cohort of patients with Vogt-Koyanagi-Harada disease, 75% of whom have a late-phase disease.

Acute phase clinical manifestations of patients with Vogt-Koyanagi-Harada disease in Southern China

BACKGROUNDS

To characterize the acute phase clinical manifestations and visual outcomes of the patients with Vogt-Koyanagi Harada (VKH) disease in southern China.

METHODS

In total, 186 patients with acute-onset VKH disease were recruited. The demographic data, clinical signs, ophthalmic examinations, and visual outcomes were analyzed.

RESULTS

Among the 186 VKH patients, 3 were diagnosed as complete VKH, 125 as incomplete VKH, and 58 as probable VKH. All patients visited the hospital within 3 months of onset and complained of decreased vision. For the extraocular manifestations, 121 patients (65%) referred neurological symptoms. Anterior chamber activity was negative in most eyes within an onset of 7 days, which increased slightly with onset beyond 1 week. Exudative retinal detachment (366 eyes, 98%) and optic disc hyperaemia (314 eyes, 84%) were commonly observed at presentation. A typical ancillary examination helped with the diagnosis of VKH. Systemic corticosteroid therapy was prescribed. The logMAR best-corrected visual acuity improved significantly from 0.74 ± 0.54 at baseline to 0.12 ± 0.24 at the 1-year follow-up visit. The recurrence rate was 18% in the follow-up visits. Erythrocyte sedimentation rate and C-reactive protein were significantly correlated to VKH recurrences.

CONCLUSION

Posterior uveitis, followed by mild anterior uveitis, is the typical initial manifestation in the acute phase of Chinese VKH patients. Visual outcome improvement is promising in most patients receiving systemic corticosteroid therapy in the acute phase. Detection of the clinical features at the initial onset of VKH could facilitate early treatment and better vision improvement.

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.

Therapeutic Response After Immunosuppressive Drug Prescription in Non-infectious Uveitis: A Survival Analysis

INTRODUCTION

To identify factors affecting the response rate to immunosuppressive drugs (ISDs) in patients with non-infectious uveitis (NIU).

METHODS

This longitudinal retrospective cohort study included patients from the Hospital Clinico San Carlos Uveitis Clinic diagnosed with NIU from 1992 to 2016. Subjects were followed up from ISD prescription until the achievement of good therapeutic response (GTR), ISD treatment change, or up to 12 months. GTR was defined as the complete resolution of the eye inflammatory manifestations with a corticosteroid dose ≤ 10 or ≤ 5 mg per day of prednisone or equivalent (GTR10 and GTR5, respectively) maintained for at least 28 days. Kaplan-Meier curves were estimated for GTR. Demographic, clinical, and treatment-related factors were analyzed using Cox robust regression.

RESULTS

A total of 73 patients (100 episodes of ISD prescription) were analyzed. In 44 and 41 episodes, GTR10 and GTR5 were achieved, respectively. A lower hazard for both GTRs was associated with uveitic macular edema at prescription and with a higher "highest oral corticosteroid dose prescribed in the year before ISD prescription". GTR10 was higher if cyclosporine was prescribed (compared to other ISDs), and if a higher number of ISDs had been previously prescribed. GTR5 hazard was lower for patients with posterior uveitis or if the ISDs were prescribed before 2008, and higher if periocular corticosteroids had been administered before ISD prescription, or if the duration of the posterior segment activity was shorter.

CONCLUSIONS

Factors associated with GTR to ISDs may help to identify patients with NIUs who could benefit from a thorough follow-up.

Seasonal Patterns of Vogt-Koyanagi-Harada Disease

PURPOSE

To identify the relationship between the incidence of Vogt-Koyanagi-Harada (VKH) disease and seasonality.

METHODS

A retrospective cohort study was performed, including patients with a confirmed diagnosis of VKH whose month of disease onset was available. Information on patients was entered retrospectively into a database and analyzed according to the month and season.

RESULTS

Twenty-four patients who met the inclusion criteria were included in the analysis. There was a statistically significant deviation from expected values in the incidences of VKH per season (P = .043). The most common season for the onset of VKH was fall, with 50% of the patients presenting in this season, while spring was the least common season for VKH presentation, with 12.5% of the patients presenting in this season.

CONCLUSION

Our study suggests that the onset of VKH in Puerto Rico follows a seasonal pattern, with most cases occurring during the fall.

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.

How to place the duality of specific MMP-9 inhibition for treatment of inflammatory bowel diseases into clinical opportunities?

Crohn’s disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBD) with the involvement of immune cells and molecules, including cytokines, chemokines and proteases. A previous extensive review about the molecular biology of matrix metalloproteases (MMPs) and tissue inhibitors of metalloproteases (TIMPs), related to intestinal barrier destruction and restoration functions in IBD, is here complemented with the literature from the last five years. We also compare IBD as a prototypic mucosal inflammation of an epithelial barrier against microorganisms with inflammatory retinopathy as a disease with a barrier dysfunction at the level of blood vessels. Multiple reasons are at the basis of halting clinical trials with monoclonal antibodies against MMP-9 for IBD treatment. These include (i) the absence of a causative role of MMP-9 in the pathology in animal models of IBD, (ii) the fact that endotoxins, crossing the intestinal barrier, induce massive local release of both neutrophil collagenase (MMP-8) and gelatinase B (MMP-9), (iii) insufficient recognition that MMPs modify the activities of cytokines, chemokines and their receptors, (iv) ignorance that MMPs exist as mixtures of proteoforms with different posttranslational modifications and with different specific activities and (v) the fact that MMPs and TIMPs act in an interactive network, possibly having also beneficial effects on IBD evolution. Nevertheless, inhibition of MMPs may be a useful therapeutic approach during specific IBD disease phases or in specific sub-phenotypes. This temporary “window of opportunity” for MMP-9 inhibition may be complemented by a locoregional one, provided that the pharmacological agents are targeted in time to affected tissues, as is achieved in ophthalmological inflammation. Thus, in order to discover spatial and temporal windows of opportunity for MMP inhibition as treatment of IBD, more preclinical work including well controlled animal studies will be further needed. In this respect, MMP-9/NGAL complex analysis in various body compartments is helpful for better stratification of IBD patients who may benefit from anti-MMP-9.

Efficacy of Rituximab Treatment in Vogt-Koyanagi-Harada Disease Poorly Controlled by Traditional Immunosuppressive Treatment

PURPOSE

To evaluate the efficacy of Rituximab (RTX) therapy in patients affected by Vogt-Koyanagi-Harada (VKH) disease poorly controlled by traditional immunosuppressive treatment.

METHODS

Retrospective case series of recurrent VKH uveitis treated with intravenous RTX between January 2019 and November 2020. All patients were treated with intravenous RTX and underwent complete ophthalmic examination, best-corrected visual acuity (BCVA), fundus photography, subfoveal choroidal thickness (SFCT) measurement on enhanced depth imaging optical-coherence tomography (EDI-OCT), fluorescein, and indocyanine green angiography.

RESULTS

Five patients were included. All patients received at least 3 RTX infusions. Mean BCVA improved from 20/32 Snellen equivalent at baseline before RTX treatment to 20/28 Snellen equivalent (p = .008). Mean SFCT on EDI-OCT showed a reduction from 564.4 µm(SD = 176.2) to 280.0 µm(SD = 140.4) (p = .015). Follow-up ranged from 12 to 21 months, with a mean of 18.2 ± 3.7 months.

CONCLUSIONS

In these case series, RTX was effective in VHK disease poorly controlled by traditional immunosuppressive treatment.

Risk factors for secondary Glaucoma in patients with Vogt-Koyanagi-Harada disease

BACKGROUND/PURPOSE

Identify the prevalence and risk factors for secondary glaucoma among Mexican-mestizo patients with Vogt-Koyanagi-Harada Disease (VKH).

METHODS

Retrospective cohort study analyzing the demographic, clinical, and epidemiological variables. Risk estimates were calculated using a Cox proportional hazards regression model.

RESULTS

One hundred eyes of 50 patients, 44 (88%) women and 6 men (12%) with a median age of 35.5 years (IQR 29-46) and a median follow-up time of 72 months (IQR 13.7-126.7) were analyzed. The prevalence of glaucoma was 20%, with angle-closure accounting for 70% of all cases. Significant clinical risk factors for glaucoma development were a chronic recurrent stage at presentation (RR 2.88, 95% CI 1.11-12.63, p = 0.037), ≥ 2 episodes of recurrent anterior uveitis (RR 8.52, 95% CI 2.02-35.92, p < 0.001), angle-closure disease (ACD, RR 7.08, 95% CI 2.44-20.48, p < 0.001), iris bombé (RR 5.0, 95% CI 2.10-11.90, p < 0.001), and peripapillary atrophy (RR 3.56, 95% CI 1.43-8.85, p < 0.001). Exposure to > 24 months of oral (RR 9.33, 95% CI 2.21-39.28, p < 0.001) or > 12 months of topical corticosteroids (RR 3.88, 95% CI 1.31-11.46, p = 0.007) were associated with an increased likelihood for secondary glaucoma development.

CONCLUSION

Glaucoma is a frequent complication of VKH, often attributed to mixed pathogenic mechanisms. Chronic disease at presentation, recurrent inflammation, angle-closure mechanisms, iris bombé, and peripapillary atrophy represent clinically significant risk factors for developing secondary glaucoma. Prompt and aggressive steroid-spearing immunosuppressive therapy for adequate inflammation control may lower the risk of glaucoma in VKH.

High prevalence of angle-closure glaucoma in Vogt-Koyanagi-Harada disease

PURPOSE

To determine the prevalence, clinical characteristics, and mechanisms of secondary glaucoma in Vogt-Koyanagi-Harada (VKH) disease.

METHODS

This retrospective, longitudinal observational study analyzed the demographic data, disease stage, glaucoma development, intraocular pressure, best-corrected visual acuity, lens status, optic nerve, gonioscopy, management, and visual outcomes of VKH disease. Clinical features were used to categorize the stage of VKH disease. VKH eyes were divided into two groups, with or without glaucoma, undergoing further analysis, including statistical analysis.

RESULTS

305 eyes of 155 patients with VKH disease with a median follow-up of 22 months were included. Secondary glaucoma developed in 67 (22%) eyes, most of which (64.2%) had chronic recurrent VKH at presentation. Angle-closure was present in 55 (82.1%) of glaucoma eyes. Peripheral anterior and posterior synechiae were present in 58 (86.6%) and 51 (76.1%) eyes, respectively. Pupillary block and posterior synechiae resulted in iris bombé in 17 (25.4%) eyes with glaucoma. At the last visit, visual acuity was worse in eyes with glaucoma (p < 0.001).

CONCLUSION

We found that angle-closure disease is a significant cause of secondary glaucoma in VKH. Eyes with glaucoma were more likely to present in the chronic recurrent stage of the disease.

Role of Swept source optical coherence tomography in management of acute Vogt-Koyanagi-Harada's disease

Purpose:

To evaluate the role of swept-source optical coherence tomography (SS-OCT) in the management of acute Vogt–Koyanagi–Harada’s (VKH) disease.

Methods:

Retrospective analysis of SS-OCT images of acute VKH patients between January 2015 and February 2020 in a tertiary eye care hospital.

Results:

We studied 34 eyes of 17 patients with acute probable VKH disease. The mean age was 31.6 ± 10.4 years. Twelve patients were women. The mean follow-up was 17.1 ± 9.3 months. The mean visual acuity was 0.86 logMAR (Snellen equivalent: 6/45) at presentation and 0.18 logMAR (Snellen equivalent: 6/9) at the last follow-up. The mean subfoveal choroidal thickness (SFCT) was 784.97 microns at presentation, 431.40 microns at the first month of therapy, 453.94 microns at six months of therapy, and 405.83 microns at the last follow-up. Qualitative features noted on SS-OCT on presentation was subretinal fluid (SRF) in 29 (85%) eyes, subretinal hyperreflective dots in 34 (100%) eyes, subretinal septa in 33 (97%) eyes, RPE undulations in 21 (61.7%) eyes, posterior vitreous cells in 34 (100%) eyes, SRF around disc in 9 (26%) eyes, and disc swelling in 34 (100%) eyes. At the end of 1 year of follow-up, RPE undulations were absent in 30 eyes (88%) and disc swelling was notably absent in all 34 eyes (100%), though SRF around disc was noted in 4 eyes (11.7%) of 2 patients who had recurrences.

Conclusion:

SFCT, SRF around disc, RPE undulation, and disc swelling may be important indicators on SS-OCT to guide therapy and prognosticate recurrences in acute VKH.

Treatment and Prognosis of Vogt-Koyanagi-Harada Disease: Real-Life Experience in Long-Term Follow-Up

Background: Vogt−Koyanagi−Harada (VKH) disease is a form of uveitis that is rare in Western countries. The aim of this study was to report on the long-term real-life treatment and prognosis of VKH in Italy. Methods: The clinical features, complications, and final visual acuity were retrospectively evaluated in 38 patients with VKH (mean follow-up: 120 months) globally, according to oral or intravenous corticosteroid treatment at onset and subsequent immunosuppressive therapy. Results: The mean final visual acuity was 0.13 ± 0.4 logMAR, which was a significant increase from the baseline (p < 0.0001). The patients who received intravenous rather than oral corticosteroids relapsed less (p = 0.026), with fewer relapses/patient/month of follow-up (p < 0.0001), and showed less frequent sunset glow fundus (33.3% versus 55%) and more relapse-free cases after induction therapy (p = 0.007). Delayed immunosuppressive therapy (median: 180 days from the onset of symptoms) reduced the rate of sunset glow fundus. The onset of sunset glow fundus was associated with a worse final visual acuity (p = 0.006). Conclusion: The long-term prognosis of VKH is quite good. Intravenous corticosteroids given at the onset of VKH are more effective than oral corticosteroids. Even if it is not given immediately after symptoms onset, immunosuppressive therapy is able to reduce the incidence of sunset glow fundus and to improve the final visual prognosis.

Vogt-Koyanagi-Harada disease: the step-by-step approach to a better understanding of clinicopathology, immunopathology, diagnosis, and management: a brief review

BACKGROUND

Appraisals of Vogt-Koyanagi-Harada disease (VKH) have become progressively more complete, since its first description in 1906. The availability of new investigational methods has improved our knowledge of the immunopathology, clinicopathology, diagnosis, and management of VKH disease. This review aimed to describe some of the steps that led to better characterization of VKH as a clinical entity.

METHODS

We searched on PubMed for articles that described the history of VKH disease and analyzed the progress in disease appraisal with new investigational and imaging methods. In particular, we searched for articles that investigated the clinicopathology, diagnosis, and management of VKH.

FINDINGS

The following developments were considered essential for improving the appraisal and understanding of VKH: (1) the history of the disease, (2) immunopathological mechanisms, (3) clinicopathology, (4) the importance of distinguishing initial-onset from chronic disease, (5) relevant imaging modalities, among which indocyanine green angiography is crucial, (6) diagnostic criteria that facilitate early diagnosis, and (7) the need for early, prolonged, aggressive treatment that combines steroidal and non-steroidal immunosuppression.

CONCLUSION

Based on these findings, the definition of VKH has improved. VKH disease starts in the choroidal stroma and later involves other structures when it is not diagnosed and treated early. Indocyanine green angiography and enhanced depth imaging optical coherence tomography facilitate early diagnosis and precise monitoring of choroidal inflammation. ICGA is clearly the gold standard for appraisals and follow-ups in VKH disease, however EDI-OCT should be especially considered in those areas where ICGA is not fully available. These modalities have contributed substantially to a "cure" for VKH, when treatment is introduced within the therapeutic window of opportunity.

Mechanisms, Pathophysiology and Current Immunomodulatory/Immunosuppressive Therapy of Non-Infectious and/or Immune-Mediated Choroiditis

Non-infectious choroiditis comprises immune-mediated diseases resulting from diverse pathophysiological mechanisms. These conditions are sub-divided into two main groups, (1) diseases of the choriocapillaris and (2) diseases of the choroidal stroma. The purpose of this study is to expose the pathophysiology of the most common diseases of both these groups and recommend the optimal immunomodulatory/immunosuppressive therapy of each analyzed condition based on literature data and data from our own centers. Material and Methods: Narrative review. In the group of choriocapillaritis entities or primary inflammatory choriocapillaropathies (PICCPs) including multiple evanescent white dot syndrome (MEWDS), acute posterior multifocal placoid pigment epitheliopathy (APMPPE), idiopathic multifocal choroiditis (MFC) and serpiginous choroiditis (SC), as well as secondary choriocapillaritides including acute syphilitic posterior multifocal placoid chorioretinitis (ASPMPC) and tuberculosis-related SC (TB-SC), were analyzed. In the group of stromal choroidites, HLA-A29 birdshot retinochoroiditis (BRC) and Vogt-Koyanagi-Harada (VKH) disease were included. For each entity a literature search, in the PubMed database, on treatment was performed and analyzed and the therapeutic attitudes of our own centers were presented. Management of immune-mediated choroiditis implies vigorous immunosuppressive therapy given in a prompt and prolonged fashion in most of these entities.

Vogt-Koyanagi-Harada Relapse after COVID-19 Vaccination

PURPOSE

To report a relapse of Vogt-Koyanagi-Harada (VKH) disease in a patient after COVID-19 vaccination.

CASE REPORT

A VKH disease patient, well controlled on azathioprine therapy, presented a uveitis relapse eleven days after the first vaccination for COVID-19. She received an induction high-dose intravenous corticosteroid therapy, followed by oral therapy, which led to a complete recovery from the uveitis in two weeks. No relapses occurred in the following five months of follow-up. Despite high-dose corticosteroid therapy and azathioprine, and one dose only of vaccination, the patient resulted positive for anti-RBD spike COV19 antibody.

CONCLUSION

Relapse of VKH disease can occur after COVID-19 vaccination, despite an appropriate immunosuppressive therapy is ongoing. It responds to the classic therapy for VKH, and a serological response to an incomplete COVID-19 vaccination can also be found.

Clinical Characteristics and Efficacy of Adalimumab and Low-Dose Methotrexate Combination Therapy in Patients With Vogt-Koyanagi-Harada Disease

This retrospective study investigated the clinical characteristics and efficacy of adalimumab and low-dose methotrexate combination therapy in patients with Vogt-Koyanagi-Harada disease who were treated at Hiroshima University from February 2012 to May 2021. The patients' demographics, clinical features at administration of immunosuppressive therapy, steroid-sparing immunosuppressive therapy, side effects, and relapses were recorded. The efficacies of steroid-sparing immunosuppressive therapy (methotrexate, cyclosporine A, adalimumab, and adalimumab and methotrexate combination therapy) were analyzed. Among 62 patients, the median age at diagnosis was 47 years and the median duration of uveitis was 51 months. Systemic corticosteroid therapy was administered to 93.5% of patients (n = 58). Thirty-four patients (54.8%) were treated with steroid-sparing immunosuppressive therapy. Methotrexate and cyclosporine A were administered to 12 and 22 patients, respectively; relapse occurred in 50.0% and 22.7% of the patients, respectively. Discontinuation of cyclosporine A was required in 63.6% of patients because of side effects. Adalimumab was administered to 14 patients. Recurrence occurred in 11 patients, requiring methotrexate concomitantly. The mean dose of methotrexate at inflammatory quiescence after side effect-related dose decrease was 8.0 mg/week (0.13 mg/kg). The median duration of combination therapy without recurrence was 20 months. There were no serious adverse events during adalimumab therapy. A high relapse rate was observed in patients receiving methotrexate; a high rate of side effects requiring discontinuation was observed in patients receiving Cyclosporine A. Patients with late-stage Vogt-Koyanagi-Harada disease may achieve better control with adalimumab and methotrexate combination therapy.

Diagnosis of Choroidal Disease With Deep Learning-Based Image Enhancement and Volumetric Quantification of Optical Coherence Tomography

Purpose

The purpose of this study was to quantify choroidal vessels (CVs) in pathological eyes in three dimensions (3D) using optical coherence tomography (OCT) and a deep-learning analysis.

Methods

A single-center retrospective study including 34 eyes of 34 patients (7 women and 27 men) with treatment-naïve central serous chorioretinopathy (CSC) and 33 eyes of 17 patients (7 women and 10 men) with Vogt-Koyanagi-Harada disease (VKH) or sympathetic ophthalmitis (SO) were imaged consecutively between October 2012 and May 2019 with a swept source OCT. Seventy-seven eyes of 39 age-matched volunteers (26 women and 13 men) with no sign of ocular pathology were imaged for comparison. Deep-learning-based image enhancement pipeline enabled CV segmentation and visualization in 3D, after which quantitative vessel volume maps were acquired to compare normal and diseased eyes and to track the clinical course of eyes in the disease group. Region-based vessel volumes and vessel indices were utilized for disease diagnosis.

Results

OCT-based CV volume maps disclose regional CV changes in patients with CSC, VKH, or SO. Three metrics, (i) choroidal volume, (ii) CV volume, and (iii) CV index, exhibit high sensitivity and specificity in discriminating pathological choroids from healthy ones.

Conclusions

The deep-learning analysis of OCT images described here provides a 3D visualization of the choroid, and allows quantification of features in the datasets to identify choroidal disease and distinguish between different diseases.

Translational Relevance

This novel analysis can be applied retrospectively to existing OCT datasets, and it represents a significant advance toward the automated diagnosis of choroidal pathologies based on observations and quantifications of the vasculature.

Precise, simplified diagnostic criteria and optimised management of initial-onset Vogt-Koyanagi-Harada disease: an updated review

Vogt-Koyanagi-Harada (VKH) disease is a primary autoimmune stromal choroiditis. This review aimed to provide a novel perspective of the disease. We took into account recent developments in the understanding of the disease and crucial progress in investigational modalities of the choroid, which has led to new, simpler diagnostic criteria. We analysed recent novel notions in the literature and new diagnostic tools for VKH. We identified the following updates for VKH disease: (1) A crucial differentiation between the acute initial-onset and the chronic forms of the disease; (2) the integration of new, precise imaging methods to assess choroidal inflammation; (3) the promotion of simplified, more reliable diagnostic criteria for acute initial-onset of the disease, based on the sine qua non presence of diffuse choroiditis, detected with indocyanine green angiography (ICGA) and/or Enhanced Depth Imaging OCT (EDI-OCT); and (4) treatment optimisation through early, vigorous, sustained corticosteroid and nonsteroidal immunosuppression, as the first line of treatment for initial-onset VKH disease, and monitoring subclinical choroidal inflammation during follow-ups. Several studies have shown that most patients could discontinue treatment without an inflammation relapse. ICGA and EDI-OCT represented the methods of choice for precisely monitoring disease evolution. Simplified, precise, new diagnostic criteria allow early diagnosis of VKH. In VKH disease, inflammation exclusively originates in the choroidal stroma. Therefore, in many cases, early, sustained treatment, with dual corticosteroid and nonsteroidal immunosuppressive therapy can result in full "healing", which obviates chronic, uncontrolled, subclinical choroidal inflammation.

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.

Vogt-Koyanagi-Harada: treatment of recurrence after administration of 3 intravenous bolus of 1 g of corticosteroids and mycophenolate mofetil

The case is presented on a young Honduran female with no medical history of note, who presented with multiple areas of exudative retinal detachment (RD), and a best-corrected visual acuity of 1.3 logMAR in both eyes. She was diagnosed with incomplete Vogt-Koyanagi-Harada syndrome, and treated early with a combination of intravenous therapy with 1 g of prednisolone per day for 3 days, as recommended by published evidence, as well as mycophenolate mofetil (2 g per day). During the corticosteroids tapering, there was a recurrence of exudative retinal detachments, and megadoses of 1 g of intravenous corticosteroids per day were reintroduced for 6 days until the complete resolution of the fluid of the exudative RD, and cyclosporine (100 mg per day), subtenon triamcinolone (40 mg/mL), and intravitreal ranibizumab once a month in the both eyes were added to the treatment, with a great control of choroidal inflammation that resulted in the remission of symptoms and signs.

Vogt-Koyanagi-Harada disease

PURPOSE OF REVIEW

Here, we provide an overview of Vogt-Koyanagi-Harada disease (VKH), including recent updates in our understanding of disease pathophysiology, classification and therapeutics.

RECENT FINDINGS

Advancements in bioinformatics, metabolomics and genomics investigations continue to illuminate VKH pathogenesis, and may provide insight into future therapeutic options. Multimodal imaging is indispensable in the initial evaluation of VKH, and is becoming increasingly important in understanding disease pathogenesis, as well as monitoring therapeutic response. Enhanced VKH classification criteria, released in 2021, provide standardized guidelines and terminology for clinical and research purposes.

SUMMARY

Modern research and imaging techniques continue to improve our understanding of VKH; more work is needed to further elucidate pathogenic mechanisms and establish optimal therapeutic recommendations.

Initial-onset acute uveitis associated with Vogt-Koyanagi-Harada disease presenting with unilateral exudative retinal detachment despite bilateral choroidal involvement

PURPOSE

To investigate the frequency of initial-onset acute uveitis associated with Vogt-Koyanagi-Harada (VKH) disease presenting with unilateral exudative retinal detachment.

METHODS

A retrospective case series.

RESULTS

During the period between January 1998 and December 2020, we identified 135 patients with initial-onset acute uveitis associated with VKH disease. Among them, 5 (3.7%) patients were referred to have unilateral uveitis due to the presence of exudative retinal detachment in only one eye. Optical coherence tomography confirmed the presence of unilateral exudative retinal detachment, however, indocyanine green angiography (ICGA) revealed characteristic findings of bilateral granulomatous choroidal inflammation typical for initial-onset acute uveitis associated with VKH disease.

CONCLUSIONS

Patients with initial-onset acute uveitis associated with VKH disease can present with unilateral exudative retinal detachment. ICGA assessment of the choroid revealed the presence of subclinical involvement of the fellow eyes.

Vogt-Koyanagi-Harada disease in Spain

PURPOSE

To describe the clinical and epidemiological characteristics of patients with Vogt-Koyanagi-Harada (VKH) disease in Spain.

METHODS

This was a retrospective multicenter analysis of data from VKH patients followed for at least 6 months. The data collected were related to demographics, clinical manifestations, treatments, and complications.

RESULTS

Participants were 112 patients (224 eyes), from 13 tertiary referral centers, of mean age 37.5 ± 14.7 years; 83.9% were women. Ethnicities were 61.6% Caucasian and 30.4% Hispanic. The disease was classified as complete in 16.1%, incomplete in 55.4%, and probable in 28.6%. When seen for the first time, the clinical course was acute in 69.6%, recurrent chronic in 15.2%, and chronic in 14.3%. The most frequent treatment was corticosteroids (acute stage 42.2%, maintenance stage 55.6%). The most common complications were cataract (41.1%) and ocular hypertension (16.1%). In most eyes, visual acuity was improved (96.7%) or remained stable at the end of follow up.

CONCLUSION

VKH in Spain mostly affects women and presents as incomplete acute stage disease. Visual prognosis is good. Cataract and glaucoma are the two most frequent complications.

Reactivation of Vogt-Koyanagi-Harada disease under control for more than 6 years, following anti-SARS-CoV-2 vaccination

BACKGROUND/PURPOSE

Vogt-Koyanagi-Harada (VKH) disease is a primary stromal choroiditis with bilateral granulomatous panuveitis. If initial-onset VKH is treated early and relentlessly the disease can be controlled and even "cured" in a substantial number of cases. We are reporting on a patient treated early and in a sustained fashion who was inflammation free for seven years but who presented a reactivation 6 weeks after the second dose of anti-SARS-CoV-2 vaccination.

CASE REPORT

A 43-year-old woman presented with severe initial-onset VKH disease which was brought under control using steroidal and non-steroidal Immunosuppression (mycophenolic acid and cyclosporine) with additional infliximab infusions because of the persistence of subclinical choroiditis identified on ICGA. Under infliximab alone disease had been inflammation free with no subclinical disease and absence of sunset glow fundus for 6 years. However, following anti-SARS-CoV-2 vaccination, severe resurgence of the disease occurred with exudative retinal detachments. Disease was rapidly brought again under control with oral prednisone (1 mg/kg) therapy and a new loading scheme of infliximab therapy.

CONCLUSION

VKH disease results from an autoimmune process directed against melanocyte associated antigens which can be controlled when early and sustained immunosuppressive treatment is introduced. It seems that anti-SARS-CoV-2 vaccination can be at the origin of reactivation of long-time controlled disease.

Classification of Non-Infectious and/or Immune Mediated Choroiditis: A Brief Overview of the Essentials

The choroid was poorly accessible to imaging investigation until the last decade of the last century. With the availability of more precise imaging methods such as indocyanine green angiography (ICGA) and, later, optical coherence tomography (OCT), enhanced depth OCT (EDI-OCT), and OCT angiography (OCTA), appraisal of choroidal inflammation has substantially gained in accuracy. This allowed to precisely determine which structures were touched in the different non-infectious choroiditis entities and made it possible to classify this group of diseases, ICGA signs, mainly hypofluorescent lesions, were identified and described. Previous publications have divided angiographic findings into two main sets of signs: (1) irregular “geographic” hypofluorescent areas corresponding to choriocapillaris non-perfusion and (2) round more regular, hypofluorescent dark dots more evenly distributed in the fundus corresponding to more deep choroidal stromal foci. These distinct findings allowed to subdivide and classify choroiditis into choriocapillaritis and stromal choroiditis. Additional signs were identified from EDI-OCT and OCTA examination supporting the classification of choroiditis into choriocapillaritis and stromal choroiditis. Results: Diseases involving principally the choriocapillaris included Multiple Evanescent White Dot Syndrome (MEWDS), Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE), Idiopathic Multifocal Choroiditis (MFC), and Serpiginous Choroiditis (SC) as well as mixed forms. Diseases primarily involving the choroidal stroma included HLA-A29 Birdshot Retinochoroiditis (BRC), Vogt-Koyanagi-Harada disease (VKH), Sympathetic Ophthalmia (SO), and Sarcoidosis chorioretinitis (SARC). Thanks to new imaging investigations of the choroid, it is now possible to classify and understand the diverse clinicopathological mechanisms in the group of non-infectious choroiditis entities.

miRNA Landscape in Pathogenesis and Treatment of Vogt-Koyanagi-Harada Disease

miRNAs, one of the members of the noncoding RNA family, are regulators of gene expression in inflammatory and autoimmune diseases. Changes in miRNA pool expression have been associated with differentiation of CD4⁺ T cells toward an inflammatory phenotype and with loss of self-tolerance in autoimmune diseases. Vogt–Koyanagi–Harada (VKH) disease is a chronic multisystemic pathology, affecting the uvea, inner ear, central nervous system, and skin. Several lines of evidence support an autoimmune etiology for VKH, with loss of tolerance against retinal pigmented epithelium-related self-antigens. This deleterious reaction is characterized by exacerbated inflammation, due to an aberrant T_H1 and T_H17 polarization and secretion of their proinflammatory hallmark cytokines interleukin 6 (IL-6), IL-17, interferon γ, and tumor necrosis factor α, and an impaired CD4⁺ CD25^high FoxP3⁺ regulatory T cell function. To restrain inflammation, VKH is pharmacologically treated with corticosteroids and immunosuppressive drugs as first and second line of therapy, respectively. Changes in the expression of miRNAs related to immunoregulatory pathways have been associated with VKH development, whereas some genetic variants of miRNAs have been found to be risk modifiers of VKH. Furthermore, the drugs commonly used in VKH treatment have great influence on miRNA expression, including those miRNAs associated to VKH disease. This relationship between response to therapy and miRNA regulation suggests that these small noncoding molecules might be therapeutic targets for the development of more effective and specific pharmacological therapy for VKH. In this review, we discuss the latest evidence regarding regulation and alteration of miRNA associated with VKH disease and its treatment.

Vogt-Koyanagi-Harada disease in a Native American population in Oklahoma

PURPOSE

To describe the presentation, features, and outcomes of patients with Vogt-Koyanagi-Harada disease (VKH) seen by uveitis specialists in Oklahoma.

METHODS

Clinical data were collected for 26 patients (52 eyes) diagnosed with VKH and seen between 1992 and 2018. Main outcome measures included rates of visual loss, ocular complications, and remission.

RESULTS

There were 11 Native American (NA) patients (11/26, 42.3%) and 15 non-Natives (n-NA). NA VKH patients were significantly more likely to present at a younger age (18.6 years) than n-NA VKH patients (30.1 years) (p = 0.023). NA patients were less likely to have meningismus (0.00 vs. 42.9%; 0.048) or systemic symptoms (50.0% vs. 93.3%; p = 0.023) than n-NA patients, but more likely to develop cataracts (100.0% vs. 66.7%; p = 0.003). There were similar rates of macular edema, epiretinal membrane, subretinal fibrosis, and recurrent uveitis between the two groups. Oral corticosteroid use was similar between both groups (72.7% vs. 86.7%; p = 0.61).

CONCLUSIONS

VKH may manifest with earlier disease course in NA patients than n-NA patients, particularly regarding ocular findings. However, NA patients were less likely to have systemic symptoms than n-NA patients.

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.

Vogt-Koyanagi-Harada Disease Managed With Immunomodulatory Therapy Within 3 Months of Disease Onset

PURPOSE

To study the outcome of high-dose corticosteroids with early addition of immunomodulatory therapy (IMT) in patients with Vogt-Koyanagi-Harada (VKH) disease.

DESIGN

Retrospective, interventional case series.

METHODS

Patients with VKH seen at Singapore National Eye Centre from 2008-2018 were studied. The standardized clinical protocol was intravenous methyl prednisolone followed by/or oral prednisolone 1 mg/kg daily with slow taper plus IMT within 3 months. We collected data on demographics, clinical features, and indocyanine green angiography (ICGA). Uveitis activity was assessed clinically and by ICGA. Results were compared when IMT was given before vs after 6 weeks (late IMT) and with historical data (IMT added when uveitis uncontrolled).

RESULTS

Fifty-eight eyes of 29 patients were studied. Half of the patients were Chinese (15, 51.7%). The mean age ± standard deviation was 42.2 ± 13.3 years. Twenty-five patients required 1 IMT and 4 needed 2 drugs. Sunset glow fundus occurred in 34 of 58 eyes (58.6%). Uveitis resolved in 24 of 58 eyes (41.4%), became chronic in 30 (51.7%), and required chronic recurrent in 4 eyes (6.9%). Eyes with IMT initiated within 6 weeks had better visual outcome that was significant at 4 years (P = .036; Mann-Whitney U test) but had a similar occurrence of sunset glow fundus and uveitis. Compared with historical data, visual outcome was better and was significant at 3 years (P = .04; t test), and significantly fewer patients developed chronic recurrent disease (P < .001; χ² test).

CONCLUSION

High-dose corticosteroids with IMT within 3 months resulted in improved visual outcomes and a reduced risk of developing chronic recurrent uveitis compared with IMT given as clinically indicated.

Internal Limiting Membrane Folds as a Presenting Sign in Acute Initial-Onset Vogt-Koyanagi-Harada Disease: A Case Report

PURPOSE

To report a case of initial-onset acute Vogt-Koyanagi-Harada (VKH) presenting with internal limiting membrane (ILM) folds as the initial clinical sign.

METHODS

This is a retrospective case review.

RESULTS

A 36-year-old woman with a recent history of periorbital injection of cosmetic filler who presented with sudden blurred vision in the right eye of a few hours duration. Initial fundus examination revealed only ILM folds in the right eye. Next day, the patient developed the full ophthalmic clinical picture of initial-onset acute VKH disease. Multimodal imaging showed features of ILM undulations and acute VKH disease. Uveitis was treated successfully with systemic corticosteroids combined with mycophenolate mofetil. The patient had complete resolution of posterior segment inflammation and exudative retinal detachment.

CONCLUSION

ILM folds/undulations can be one of the early signs in acute VKH disease, and may serve as an important early clinical clue for this diagnosis.

Vogt-Koyanagi-Harada: treatment of recurrence after administration of 3 intravenous bolus of 1g of corticosteroids and mycophenolate mofetil

The case is presented on a young Honduran female with no medical history of note, who presented with multiple areas of exudative retinal detachment (RD), and a best-corrected visual acuity of 1.3logMAR in both eyes. She was diagnosed with incomplete Vogt-Koyanagi-Harada syndrome, and treated early with a combination of intravenous therapy with 1g of prednisolone per day for 3 days, as recommended by published evidence, as well as mycophenolate mofetil (2g per day). During the corticosteroids tapering, there was a recurrence of exudative retinal detachments, and megadoses of 1g of intravenous corticosteroids per day were reintroduced for 6 days until the complete resolution of the fluid of the exudative RD, and cyclosporine (100mg per day), subtenon triamcinolone (40mg/mL), and intravitreal ranibizumab once a month in the both eyes were added to the treatment, with a great control of choroidal inflammation that resulted in the remission of symptoms and signs.

Initial-onset acute and chronic recurrent stages are two distinctive courses of Vogt-Koyanagi-Harada disease

PURPOSE

To describe distinctive stages of Vogt-Koyanagi-Harada (VKH) disease: initial-onset acute versus chronic recurrent disease.

METHODS

A comprehensive literature review regarding stages and clinical presentations of VKH disease was conducted.

RESULTS

Despite a list of signs that has been described as characteristic features of early or late phases of VKH disease, the current classification -developed by an international committee and published in 2001- does not consider a distinction regarding the time from onset of disease symptoms, and specific findings observed at certain time point from the symptoms presentation and outcomes related to the stage of VKH disease. In that sense, chronic recurrent VKH disease is more refractory to treatment and is associated with a higher rate of complications. Accordingly, this subset of VKH patients has poorer functional and anatomical outcomes than patients with an initial-onset acute disease.

CONCLUSIONS

An early clear distinction of VKH phenotype [Initial-onset acute versus chronic recurrent disease] should be considered in each clinical scenario, evaluating the delay in diagnosis and the clinical presentation, since it may help clinicians to perform a correct disease prognosis categorization and thus to make treatment decisions in terms of potential refractoriness or expected clinical outcomes.

The current status of biological treatment for uveitis

INTRODUCTION

Noninfectious uveitis represents one of the leading causes of blindness in developed Countries, compromising patients' quality of life and social functioning. The main treatment goals are the control of ocular inflammation, to avert and treat sight-threatening complications, thus preserving and/or restoring visual function.

AREAS COVERED

This manuscript deals with systemic therapy with biologic drugs for noninfectious uveitis. An extensive literature search in the MEDLINE database (via PubMed) has been performed up to June 2020. The major classes of biologic molecules employed in ocular inflammatory diseases have been reviewed, focusing on TNF inhibitors, IL-1, IL-6, IL-17, IL-23 inhibitors, interferons, rituximab, and abatacept efficacy and safety. An overview of most recent developments in the field has been provided as well, with reference to the experience with JAK inhibitors and with biosimilar drugs.

EXPERT OPINION

The development of the concept of targeted therapy and the subsequent introduction of biologic molecules in clinical practice have revolutionized the prognosis of uveitis. The target of a rapid and sustained steroid-free remission of ocular inflammation should be pursued for all patients early in the disease course, in order to have a better chance to improve the final visual outcome.

Mycophenolate sodium in the treatment of corticosteroid-refractory non-infectious inflammatory uveitis (MySTRI study)

OBJECTIVES

To evaluate the therapeutic effect and safety profile of next generation mycophenolate sodium (MPS), which is different from mycophenolate mofetil with an enteric-coated formulation, in corticosteroid-refractory non-infectious inflammatory uveitis (CRU) patients.

METHODS

Prospective, uncontrolled, open-label interventional case series. Forty consecutive patients at a tertiary uveitis referral centre received 6 months of oral MPS as the treatment regimen with follow-up 12 months. The main outcome measures were best-corrected visual acuity (BCVA), inflammatory index, steroid-sparing effect of tapering prednisone to ≤10 mg daily and side effects.

RESULTS

Mean age of enroled patients was 49 (49 ± 13) years and 29 (72.5%) were female. Thirty-six (90.0%) had bilateral disease. There were 0 (0%) anterior uveitis, 2 (5.0%) intermediate uveitis, 22 (55.0%) posterior uveitis, and 16 (40.0%) panuveitis. Vogt-Koyanagi-Harada disease was the most common diagnosis (17/40, 42.5%), followed by idiopathic panuveitis (8/40, 20%) and idiopathic retinal vasculitis (5/40, 12.5%). LogMAR BCVA improved from 0.9 (SD = 0.09) to 0.31 (SD = 0.08) after 6 months of MPS with good steroid-sparing effect (p = 0.012). Further maintenance in LogMAR BCVA was evident after MPS discontinuation from 6th month to 12th month, from 0.31 (SD = 0.08) to 0.33 (SD = 0.07), respectively (p = 0.81). MPS was the only immunosuppressive drug needed to reach quiescent state in 29 patients (72.5%). The drug-related safety profile was satisfactory.

CONCLUSION

MPS is an effective steroid-sparing drug for the treatment of CRU. The effect seen was not only during the 6 months of therapy, but also extended to 12 months to maintain BCVA and inflammation control. The side effects were acceptable.

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.

Remnant Epitopes Generating Autoimmunity: From Model to Useful Paradigm

Autoimmune diseases are defined as pathologies of adaptive immunity by the presence of autoantibodies or MHC-restricted autoantigen-reactive T cells. Because autoreactivity is a normal process based on mechanisms producing repertoires of antibodies and T cell receptors, crucial questions about disease mechanisms and key steps for interference have been outstanding. We defined 25 years ago the 'remnant epitopes generate autoimmunity' (REGA)-model in which extracellular proteases from innate immune cells generate autoantigens. Here, we refine the REGA-model, tested in diseases ranging from organ-specific autoimmune diseases to systemic lupus erythematosus. It now constitutes a paradigm in which remnant epitopes generate, maintain, and regulate autoimmunity; are dependent on genetic and epigenetic influences; are produced in a disease phase-specific manner; and have therapeutic implications when targeted.

Impact of Inflammation and Treatment on Self-reported Quality of Life in Patients with Non-acute Vogt-Koyanagi-Harada Disease (VKHD)

Aims: To evaluate associations between vision-related (VR-) and health-related (HR-) QoL metrics and inflammation and treatment in non-acute VKHD patients.Methods: Cross-sectional study in a tertiary center in Sao Paulo, Brazil with 22 patients with non-acute VKHD followed prospectively for ≥12 months since acute disease onset, with systematic evaluation and predefined treatment protocols. VR- and HR-QoL aspects were assessed by VFQ-25 and SF-36 questionnaires, respectively. Associations between the questionnaire's subscale item scores with inflammation and systemic medical therapies were assessed.Results: After generalized linear model analysis, worse VA, severe fundus changes, fluctuation of VA and fluctuation of anterior chamber cells impacted negatively on VR-QoL items. Higher cumulative total dose of corticosteroids and use of immunosuppressive therapy impacted negatively on both questionnaires.Conclusion: Worse VA, clinical inflammation and systemic treatment have a significant impact on VR- and HR-QoL questionnaires. Subclinical choroidal inflammation did not seem to impact QoL.