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

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

TOPIC

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

CLINICAL RELEVANCE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Autoimmune Inflammatory Eye Disease: Demystifying Clinical Presentations for the Internist

PURPOSE OF REVIEW

Provide a framework for recognizing key symptoms and clinical findings in patients with autoimmune inflammatory eye disease.

RECENT FINDINGS

The most common manifestations of autoimmune inflammatory eye disease are episcleritis, scleritis, uveitis (anterior, intermediate, posterior, and panuveitis), and keratoconjunctivitis sicca. Etiologies can be idiopathic or in association with a systemic autoimmune condition. Referral of patients who may have scleritis is critical for patients presenting with red eyes. Referral of patients who may have uveitis is critical for patients presenting often with floaters and vision complaints. Attention should also be directed to aspects of the history that might suggest a diagnosis of a systemic autoimmune condition, immunosuppression, drug-induced uveitis, or the possibility of a masquerade condition. Infectious etiologies should be ruled out in all cases. Patients with autoimmune inflammatory eye disease may present with ocular or systemic symptoms alone, or in combination. Collaboration with ophthalmologists and other relevant specialists is vital to optimal long-term medical care.

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.

Bilateral posterior scleritis presenting as acute primary angle closure: A case report

BACKGROUND

Scleritis is a rare disease and the incidence of bilateral posterior scleritis is even rarer. Unfortunately, misdiagnosis of the latter is common due to its insidious onset, atypical symptoms, and varied manifestations. We report here a case of bilateral posterior scleritis that presented with acute eye pain and intraocular hypertension, and was initially misdiagnosed as acute primary angle closure. Expanding the literature on such cases will not only increase physicians' awareness but also help to improve accurate diagnosis.

CASE SUMMARY

A 53-year-old man was referred to our hospital to address a 4-d history of bilateral acute eye pain, headache, and loss of vision, after initial presentation to a local hospital 3 d prior. Our initial examination revealed bilateral cornea edema accompanied by a shallow anterior chamber and visual acuity reduction, with left-eye amblyopia (> 30 years). There was bilateral hypertension (by intraocular pressure: 28 mmHg in right, 34 mmHg in left) and normal fundi. Accordingly, acute primary angle closure was diagnosed. Miotics and ocular hypotensive drugs were prescribed, but the symptoms continued to worsen over the 3-d treatment course. Further imaging examinations (i.e., anterior segment photography and ultrasonography) indicated a diagnosis of bilateral posterior scleritis. Methylprednisolone, topical atropine, and steroid eye drops were prescribed along with intraocular pressure-lowering agents. Subsequent optical coherence tomography (OCT) showed gradual improvements in subretinal fluid under the sensory retina, thickened sclera, and ciliary body detachment.

CONCLUSION

Bilateral posterior scleritis can lead to secondary acute angle closure. Diagnosis requires ophthalmic accessory examinations (i.e., ultrasound biomicroscopy, B-scan, and OCT).