Vogt-Koyanagi-Harada disease

Outcomes in Patients With Vogt-Koyanagi-Harada Disease From the First-Line Antimetabolites for Steroid-Sparing Treatment Uveitis Trial

PURPOSE

To compare the effectiveness of methotrexate (MTX) and mycophenolate mofetil (MMF) in achieving corticosteroid-sparing control of uveitis in patients with Vogt-Koyanagi-Harada (VKH) disease.

METHODS

A subanalysis of patients with VKH from the First-line Antimetabolites as Steroid-sparing Treatment Uveitis Trial, a randomized, observer-masked, comparative effectiveness trial, with comparisons by treatment (MTX vs MMF) and disease stage (acute vs chronic). Individuals with noninfectious uveitis were placed on a standardized corticosteroid taper and block randomized 1:1 to either 25 mg weekly oral MTX or 1.5 g twice daily oral MMF. The primary outcome was treatment success defined by corticosteroid-sparing control of uveitis at 6 months. Additional outcomes included change in best spectacle-corrected visual acuity (BSCVA), retinal central subfield thickness (CST), and resolution of serous retinal detachment (SRD).

RESULTS

Ninety-three out of 216 enrolled patients had VKH; 49 patients were randomized to MTX and 44 to MMF, of which 85 patients (46 on MTX, 39 on MMF) contributed to the primary outcome. There was no significant difference in treatment success by antimetabolite (80.4% for MTX compared to 64.1% for MMF; P = .12) or in BSCVA improvement (P = .78). MTX was superior to MMF in reducing CST (P = .003) and resolving SRD (P = .02). There was no significant difference in treatment success by disease stage (P = .25), but patients with acute VKH had greater improvement in BSCVA (P < .001) and reduction of CST (P = .02) than chronic VKH patients.

CONCLUSIONS

MTX and MMF have comparable outcomes as corticosteroid-sparing immunosuppressive therapies for VKH. Visual acuity improvement was greater in acute vs chronic VKH. NOTE: Publication of this article is sponsored by the American Ophthalmological Society TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00182929.

Choroidal venous overload in Vogt‒Koyanagi‒Harada disease

BACKGROUND/OBJECTIVES

This study aimed to investigate the change of choroidal venous overload in Vogt‒Koyanagi‒Harada (VKH) disease. Clinical records of 52 patients with VKH disease (52 eyes) and 24 control subjects (24 eyes) who underwent multimodal imaging, including fluorescein angiography (FA) and indocyanine green angiography (ICGA), were retrospectively reviewed.

SUBJECTS/METHODS

Imaging data were assessed for signs associated with choroidal venous overload, e.g., choroidal perfusion delay, choroidal vascular hyperpermeability, dilated choroidal veins, and intervortex venous anastomosis (IVA). Dual FA and ICGA scoring for active posterior segment inflammation was performed. Clinical and imaging features associated with choroidal venous overload were compared between early- and late-stage VKH disease.

RESULTS

Choroidal perfusion delay, choroidal vascular hyperpermeability, dilated choroidal veins, and IVA were more prevalent in eyes with VKH disease (69.2%, 67.3%, 61.5%, and 65.4%, respectively) than in control eyes (25.0%, 20.8%, 25.0%, and 37.5%, respectively) (p < 0.05). All eyes with IVA in the early-stage of VKH disease had got other 3 signs. All choroidal venous overload signs were more prevalent in patients with early-stage (20 eyes) than in those with late-stage VKH disease (32 eyes) (p < 0.05). The number of choroidal venous overload signs were inversely related to disease duration (p < 0.001) and proportionally related to the total ICGA score (p < 0.001). IVA was significantly associated with the total ICGA score in logistic regression (p = 0.014).

CONCLUSIONS

Choroidal venous overload occurs early in VKH disease. Angiographic signs of choroidal venous overload may be useful markers to assess the status of VKH disease.

Differential Diagnosis of Suspected Multiple Sclerosis in Pediatric and Late-Onset Populations: A Review

IMPORTANCE

While the typical onset of multiple sclerosis (MS) occurs in early adulthood, 2% to 10% of cases initially present prior to age 18 years, and approximately 5% after age 50 years. Guidance on approaches to differential diagnosis in suspected MS specific to these 2 age groups is needed.

OBSERVATIONS

There are unique biological factors in children younger than 18 years and in adults older than age 50 years compared to typical adult-onset MS. These biological differences, particularly immunological and hormonal, may influence the clinical presentation of MS, resilience to neuronal injury, and differential diagnosis. While mimics of MS at the typical age at onset have been described, a comprehensive approach focused on the younger and older ends of the age spectrum has not been previously published.

CONCLUSIONS AND RELEVANCE

An international committee of MS experts in pediatric and adult MS was formed to provide consensus guidance on diagnostic approaches and key clinical and paraclinical red flags for non-MS diagnosis in children and older adults.

Diagnosis and Treatment of Uveitis in Children: A Summary of the Latest Data from a 5-Year Literature Review (2018-2023)

Pediatric uveitis has a low incidence. It is very diverse in its presentation and is often the first sign of a severe systemic disease. The pediatric population poses a special therapeutic and diagnostic challenge due to the potentially adverse effects of therapeutic agents on the young body and difficult cooperation with the patient during the examination, as well as the increased risk of complications that can lead to severe disability. The most commonly diagnosed type of uveitis is non-infectious, with first-line therapy consisting of systemic corticosteroids followed by disease-modifying drugs (methotrexate (MTX), mycophenolate mofetil (MMF), and cyclosporin A (CsA)). In severe, refractory cases, biologic therapy is used. The authors reviewed the current literature on the etiology, diagnostic tools, and treatment of uveitis in the pediatric population covering the years 2018-2023, presenting current methods of modern diagnosis and treatment. The reason for writing this article was the need to update the knowledge on uveitis, driven by the increasing prevalence of autoimmune uveitis in the pediatric population. This trend presents significant challenges in diagnosing and treating the disease, as well as managing its complications. Correctly identifying the pathogenetic factor of uveitis can facilitate the diagnosis of the systemic disease underlying the ocular infection and enable the timely implementation of systemic treatment. Furthermore, the emergence of new diagnostic methods necessitates a revision and update of ophthalmic knowledge, essential for both ophthalmologists and other specialists involved in the treatment of uveitis.

Vogt-Koyanagi-Harada disease after SARS-CoV-2 infection: Case report and literature review

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for coronavirus disease 2019 (COVID-19), a complex and multifaceted illness. COVID-19 is associated with various ocular manifestations including conjunctivitis, retinal vein occlusion and optic neuritis. However, the case of Vogt-Koyanagi-Harada (VKH) disease associated with SARS-CoV-2 is infrequent, and the specific association is still unclear.

CASE PRESENTATION

In the present study, a 35-year-old female patient without any significant medical history presented with 1 week of bilateral blurred vision, occurring 2 weeks after a clinical course of COVID-19. Upon examination, both eyes exhibited bullous serous retinal detachments. She was diagnosed with incomplete VKH disease. Early diagnosis and treatment of VKH disease are essential for the visual prognosis of this aggressive disease. In this particular patient, ocular inflammatory signs and visual acuity improved via corticosteroid therapy. It is worth noting that the occurrence of VKH disease associated with SARS-CoV-2 is uncommon, and the specific connection between the two remains unknown. We review and summarize the clinical characteristics of VKH disease following SARS-CoV-2 infection, and discuss the potential mechanisms that may explain this phenomenon, based on similar studies previously reported.

CONCLUSION

Despite the unclear causality, it is important for ophthalmologists and physicians to be recognizant of the possible association between VKH disease and COVID-19. SARS-CoV-2 may play a potential immunological triggering role in VKH disease. However, further in-depth research is necessary to investigate the clinical and epidemiological features, as well as the underlying mechanisms of this association.

Ultrasonographic study of the orbit as an early diagnostic tool in Vogt Koyanagi Harada disease (VKH): A case report

In recent years, ultrasound has demonstrated its usefulness in the approach to vascular structures and other tissues such as the orbit, facilitating the early diagnosis of various diseases without having to rely on other more invasive or less available tests. In Vogt Koyanagi Harada syndrome, characterised by bilateral acute uveitis, ocular ultrasound is a clear example of the usefulness of ultrasonography in early diagnosis, facilitating the initiation of specific treatment to change the ominous natural history of this disease. This case shows the usefulness of the echography to make the differential diagnosis with other diseases that clinical onset could be similar than VKH, but with a different diagnostic and therapeutic approach.

Cytokines in Immune-mediated "Non-infectious" Uveitis

Uveitis is a significant cause of ocular morbidity and accounts for approximately 5 - 10% of visual impairments worldwide, particularly among the working-age population. Infections are the cause of ~ 50% cases of uveitis, but it has been suggested that infection might also be implicated in the pathogenesis of immune-mediated "non-infectious" uveitis. There is growing evidence that cytokines (i.e., interleukins, interferons, etc.) are key mediators of immune-mediated "non-infectious" uveitis. For example, activation of the interleukin-23/interleukin-17 signalling pathway is involved in immune-mediated "non-infectious" uveitis. Studies in animal models have been important in investigating the role of cytokines in uveitis. Recent studies of clinical samples from patients with uveitis have allowed the measurement of a considerable array of cytokines even from very small sample volumes (e.g., aqueous and vitreous humour). The identification of complex patterns of cytokines may contribute to a better understanding of their potential pathogenetic role in uveitis as well as to an improved diagnostic and therapeutic approach to treat these potentially blinding pathologies. This review provides further insights into the putative pathobiological role of cytokines in immune-mediated "non-infectious" uveitis.

Primary Sjögren's syndrome-related Choroiditis in a Newly Diagnosed Older Adult

PURPOSE

To report a case of secondary bilateral choroiditis in a patient with primary Sjögren's syndrome(pSS).

STUDY DESIGN

Case report.

RESULTS

A 69-year-old woman visited our hospital for consultation due to decreased visual acuity in both eyes for 1 month. At the first visit, best corrected visual acuity (BCVA) was 0.2 and 0.3 in her right and left eyes, respectively. Intraocular pressure values were 15 mmHg and 16 mmHg in her right and left eyes, respectively. Examination revealed edema of the eyelids and conjunctiva,and corneal fluorescence staining was positive. No inflammation in the anterior chamber or vitreous opacities were observed. Bilateral multiple retinal detachments were observed on the posterior fundus, and optical coherence tomography revealed bilateral multiple areas of retinal neuroepithelial detachment, choroidal thickening, and choroidal folds. No abnormal fluorescence leakage was observed on fundus fluorescein angiography or indocyanine green angiography. In addition, systematic manifestations included recurrent bilateral parotid gland enlargement. Labial gland biopsy revealed dilated glandular ducts, scattered interstitial glands, and lymphocytic foci. Salivary gland scintigraphy revealed severe impairment of glandular excretory function. Moreover, blood tests for anti-Ro/SSA and anti-La/SSBantibodies were positive. The patient was diagnosed with primary Sjögren's syndrome. After 2 months treatment with oral prednisolone acetate combined with hydroxychloroquine, her BCVAimproved to 0.8 and 1.0 in the right and left eyes, respectively. The fundus also recovered to normal, and no recurrence was observed during the 1-year follow-up period.

CONCLUSIONS

The current case highlights that pSS, which usually manifests with dry eye and keratoconjunctivitis, may manifest with chronic choroiditis in both eyes as well. Based on our experience with this case, patients with clinically suspected bilateral choroiditis should be evaluated for pSS.

Vogt-Koyanagi-Harada disease with a unilateral presentation in a patient with marijuana overuse: Role of multimodal imaging in suspected patients

Key Clinical Message

Harada disease could uniquely present with only unilateral symptoms, as was seen in our patient. However, multimodal imaging including ICG angiography could show bilateral involvement. Considering the immunomodulatory effects of Cannabis, the absence of inflammatory findings and the unusual presentation of the disease, in our case, may have been caused by the use of marijuana.

Abstract

To report a patient addicted to marijuana with the diagnosis of Vogt-Koyanagi-Harada (VKH) disease with a unilateral presentation. A 24-year-old man presented to us with painless decreased vision in his right eye (RE) and photophobia 3 days ago. No history of significant family or past medical history was documented. Spectral-domain optical coherence tomography (SD-OCT) of the RE showed multiple areas of subretinal fluid in the macula. Indocyanine green angiography (ICGA) revealed round hypocyanescent dark dots (HDD) of similar size, evenly distributed in both eyes. With the diagnosis of VKH disease, anti-inflammatory treatment was started. To our knowledge, this is the first reported case of suspected VKH in a patient with marijuana overuse. Regarding the complex effects of tetrahydrocannabinol (THC), the active ingredient of marijuana, on the vascular and immune systems, reaching a definite conclusion is not possible. This report shows the value of multimodal imaging in patients with unusual presentations.

Common practice patterns in the diagnosis and management of Vogt-Koyanagi-Harada syndrome: a survey study of uveitis specialists

Introduction

Vogt-Koyanagi-Harada (VKH) syndrome is an inflammatory condition characterized by bilateral, granulomatous panuveitis with or without systemic manifestations, and accounts for up to 18% of referrals for panuveitis at tertiary centers in the United States of America. Despite ongoing research, there is limited evidence and no clear consensus on how to diagnose and treat patients with VKH, leading to variations in practice patterns among uveitis specialists.

Methods

An anonymous, online survey was distributed to uveitis specialists in the American Uveitis Society (AUS). The survey included 21 questions that asked for non-identifiable demographics and covered topics such as preferred imaging modalities, treatment for the first episode of VKH, and perceived efficacy of immunomodulatory therapy (IMT).

Results

A total of 104 surveys were included for analysis, representing a 38.4% response rate from the AUS listserv. A majority of respondents were uveitis fellowship trained and practiced in North America in an academic setting. Fluorescein angiography and enhanced depth imaging with optical coherence tomography were rated as the most consistently useful methods for the diagnosis of VKH. For treatment of acute initial-onset VKH, responses were divided between a preference for high-dose systemic corticosteroids with IMT (61.5%) and without IMT (37.5%). Methotrexate and mycophenolate mofetil were the most common IMTs to be used as first-line therapies, but adalimumab and infliximab were perceived to be the most effective for the treatment for VKH.

Discussion

While there are some common trends in the practice patterns for the diagnosis and treatment of patients with VKH, there was no clear consensus on the topic of IMT. There was a slight preference among uveitis specialists to use both IMT and systemic corticosteroids for the first episode of acute VKH.

Beyond skin white spots: Vitiligo and associated comorbidities

Vitiligo is a common depigmentation disorder of an unknown origin characterized by the selective loss of melanocytes, resulting in typical white macules and patches. However, vitiligo is now recognized as more than just a skin disease, what a dermatologist observes as a white spot of skin is just the "tip of the iceberg" of the condition. We attempt to clarify the classification of comorbidities associated with vitiligo from various reviews and reports, and describe their possible pathogenesis. In conclusion, the literature provides evidence of an association between vitiligo and ocular and auditory abnormalities, autoimmune disorders, other dermatological diseases, metabolic syndrome and related disorders, and psychological diseases. These associations highlight the importance of a multidisciplinary approach in managing vitiligo patients.

Changes of Peripapillary Capillary Density in Patients with Vogt-Koyanagi-Harada Disease Evaluated by Optical Coherence Tomography Angiography

Objective

To analyze the longitudinal changes in peripapillary capillary density in patients with acute VKH with or without optic disc swelling by optical coherence tomography angiography (OCTA).

Methods

Retrospective case series. 44 patients (88 eyes) were enrolled and were divided into two groups according to presence/absence of optic disc swelling before treatment. Peripapillary capillary images were obtained by OCTA before and after 6 months of corticosteroid treatment and used to determine the radial peripapillary capillary (RPC), retinal plexus, and choriocapillaris vessel perfusion densities.

Results

Optic disc swelling was present in 12 patients (24 eyes) and absent in 32 patients (64 eyes). The sex distribution, age, intraocular pressure, and best-corrected visual acuity before and after treatment were not significantly different between the two groups (all P > 0.05). Compared to those in nonoptic disc swelling group, the percentages of decreased vessel perfusion densities after treatment in the supranasal (RPC, 100.00% vs. 75.00%), infranasal (RPC, 100.00% vs. 56.25%), infratemporal (RPC, 66.67% vs. 37.50%), and infranasal quadrants (retinal plexus, 83.33% vs. 56.25%) were significantly more in optic disc swelling group. The choriocapillaris vessel perfusion density increased after treatment in both groups.

Conclusions

Decreases in vessel perfusion densities of the RPC and retinal plexus after treatment in VKH patients with optic disc swelling were more common than in those without optic disc swelling. The choriocapillaris vessel perfusion density increased after treatment, regardless of the presence/absence of optic disc swelling.

Choroidal thickening with serous retinal detachment in BRAF/MEK inhibitor-induced uveitis: A case report

BACKGROUND

Immune checkpoint inhibitors have revolutionized the treatment of patients with unresectable metastatic malignant melanoma. In addition to systemic side effects, several usually mild ocular adverse effects have been reported. We report a case of rarely reported vision-threatening bilateral panuveitis with serous retinal detachment, thickened choroid, and chorioretinal folds associated with dabrafenib and trametinib targeted therapy for B-Raf proto-oncogene serine/threonine kinase (BRAF) mutant metastatic cutaneous melanoma.

CASE SUMMARY

A 59-year-old female patient with metastatic melanoma treated with dabrafenib and trametinib presented with blurry vision and central scotoma lasting for 3 d in both eyes. Clinical examination and multimodal imaging revealed inflammatory cells in the anterior chamber, mild vitritis, bullous multiple serous retinal detachments, and chorioretinal folds in both eyes. Treatment with dabrafenib and trametinib was suspended, and the patient was treated with topical and intravenous corticosteroids followed by oral corticosteroid treatment with a tapering schedule. One and a half months after the disease onset, ocular morphological and functional improvement was noted. Due to the metastatic melanoma dissemination, BRAF/mitogen-activated protein kinase inhibitors were reintroduced and some mild ocular adverse effects reappeared, which later subsided after receiving oral corticosteroids.

CONCLUSION

Patients on combination therapy with dabrafenib and trametinib may rarely develop severe bilateral panuveitis with a good prognosis. Further studies have to establish potential usefulness of ophthalmological examination for asymptomatic patients. Furthermore, appropriate guidelines for managing panuveitis associated with dabrafenib and trametinib should be established.

Retinal Proteomic Analysis in a Mouse Model of Endotoxin-Induced Uveitis Using Data-Independent Acquisition-Based Mass Spectrometry

Uveitis is a group of sight-threatening ocular inflammatory diseases, potentially leading to permanent vision loss in patients. However, it remains largely unknown how uveitis causes retinal malfunction and vision loss. Endotoxin-induced uveitis (EIU) in rodents is a good animal model to study uveitis and associated acute retinal inflammation. To understand the pathogenic mechanism of uveitis and screen potential targets for treatment, we analyzed the retinal proteomic profile of the EIU mouse model using a data-independent acquisition-based mass spectrometry (SWATH-MS). After systemic LPS administration, we observed activation of microglial cells accompanied with the elevation of pro-inflammatory mediators and visual function declines. In total, we observed 79 upregulated and 90 downregulated differentially expressed proteins (DEPs). Among the DEPs, we found that histone family members (histone H1, H2A, H2B) and blood proteins including haptoglobin (HP), hemopexin (HPX), and fibrinogen gamma chain (FGG) were dramatically increased in EIU groups relative to those in control groups. We identified phototransduction and synaptic vesicle cycle as the top two significant KEGG pathways. Moreover, canonical pathway analysis on DEPs using Ingenuity Pathway Analysis revealed top three most significant enriched pathways related to acute phase response signaling, synaptogenesis signaling, and eif2 signaling. We further confirmed upregulation of several DEPs associated with the acute phase response signaling including HP, HPX, and FGG in LPS-treated retinas by qPCR and Western blot. In summary, this study serves as the first report to detect retinal proteome changes in the EIU model. The study provides several potential candidates for exploring the mechanism and novel therapeutic targets for uveitis and other retinal inflammatory diseases.

The Role of Optical Coherence Tomography and Optical Coherence Tomography Angiography in the Differential Diagnosis of Posterior Uveitis

PURPOSE

Modalities such as optical coherence tomography (OCT) and OCT angiography (OCTA) have improved the diagnostic utility of fundus imaging in management of uveitis. The purpose of this study is to review role of OCT and OCTA in differential diagnosis of certain posterior uveitic entities.

METHODS

Narrative review.

RESULTS

In this review, we have comprehensively summarized the utility of OCT and OCTA in helping the clinician diagnose common but challenging inflammatory conditions including ocular toxoplasmosis, viral retinitis, and vitreoretinal lymphoma, among others. OCT and OCTA can also be used to assess the choriocapillaris involvement in conditions such as multiple evanescent white dot syndrome, and choroidal granulomas in tubercular and sarcoid uveitis.

CONCLUSIONS

Fundus imaging with OCT and OCTA has assumed a significant role in establishing the diagnosis in uveitis apart from microbiological and other laboratory analysis. Advantages such as rapidity and non-invasiveness make these imaging modalities very useful and convenient.