The Role of Widefield Optical Coherence Tomography Angiography in the Diagnosis and Management of Acute Vogt-Koyanagi-Harada Disease

PURPOSE

We explore the choroid vasculature changes of acute Vogt-Koyanagi-Harada (VKH) disease using widefield optical coherence tomography angiography (OCTA).

METHODS

In this retrospective, observational, longitudinal study, 16 patients with acute VKH disease (32 eyes, mean age: 42.19 ±13.66 years) were measured using widefield OCTA.

RESULTS

In this study, we first described the multiple dark foci in choriocapillaris and Sattler's layer in the panoramic montage of the five 12x12mm images in 30 eyes (93.8%) of acute VKH disease. OCTA follow-up in these 30 eyes demonstrated the diminished size and number of these dark foci in choriocapillaris and Sattler's layer after the initiation of treatment.

CONCLUSIONS

Widefield OCTA enables noninvasive identification of characteristics of flow void at the level of superficial choroidal vessels in the acute phase and may be a novel valuable tool for diagnosis and monitoring of disease progression in VKH disease in the future.

Efficacy of intravitreal dexamethasone implant in patients with Vogt-Koyanagi-Harada Disease and bilateral panuveitis: Two case reports

INTRODUCTION

Vogt-Koyanagi-Harada (VKH) disease is a multisystemic disorder characterized by intraocular inflammation associated with serous retinal detachment, optic disc edema, uveitis, and vitritis, and is often associated with neurologic and cutaneous manifestations. Diagnosis can be assisted by fluorescein angiography and optical coherence tomography that can help evaluate changes in the retina. Therapy relies mainly on the use of corticosteroids, administrated through oral or intravenous high-dose pulses, and immunosuppressants. The purpose of our study was to assess the outcome of VKH disease with bilateral panuveitis treated with dexamethasone intravitreal implant.

PATIENT CONCERNS

Two patients without underlying disease had severe vision deterioration, eye pain, following flu-like symptoms.

DIAGNOSIS

At initial diagnosis, macular edema and sub-retinal fluid lobulated accumulation were noted under SD-OCT exam. FAG revealed multiple pinpoint leakage around macula and pooling of dye within sub-retinal space.

INTERVENTIONS

All two patients received intravenous pulse methylprednisolone at the diagnosis, followed by oral prednisolone and cyclosporine. One patient received bilateral eye dexamethasone intravitreal implant two weeks after diagnosis, while the other received left eye dexamethasone intravitreal implant at the time of diagnosis.

OUTCOMES

Vision and macular structure recovered more rapidly after receiving dexamethasone implants in the short-term follow-up. All macular structures recovered to normal, and vision recovered to 20/20 in both eyes. One patient, receiving bilateral dexamethasone implant, didn't relapse during the 13-month follow-up; the other, receiving left eye dexamethasone implant, didn't relapse during the 6-month follow-up. None of them required intravenous high-dose steroids again.

CONCLUSION

VKH disease is a multisystemic disorder; intravenous pulse steroid therapy and oral prednisolone can control systemic inflammation. In addition to systemic prednisolone treatment of VKH disease in the acute phase, dexamethasone implants can enhance short-term and long-term control of intraocular anti-inflammation.

[Autofluorescence combined with spectral domain optical coherence tomography for diagnosis and follow-up of acute Vogt-Koyanagi-Harada disease]

OBJECTIVE

To evaluate the value of fundus autofluorescence (FAF) imaging combined with spectral domain optical coherence tomography (SD-OCT) in diagnosis, prognostic assessment and follow-up observation of acute Vogt-KoyanagiHarada (VKH) disease.

METHODS

Clinical data were collected from 12 patients (23 eyes) with acute VKH disease treated in our hospital from May, 2018 to November, 2019, including detailed medical history, best corrected visual acuity (BCVA), and results of slit lamp biomicroscopy, fundus photography, SD-OCT, fundus fluorescein angiography (FFA) and FAF imaging.SDOCT and FAF imaging were repeated after a course of treatment and in follow-up examination, and the results were compared with those at the time of admission.

RESULTS

VKH disease involved both eyes in 11 patients (91.7%).Fundus photography showed optic disc edema in 16 eyes (69.6%), and multiple retinal neuroepithelial detachment was detected by SD-OCT in all the involved eyes (100%).IN all the eyes, FFA revealed small and dense fluorescein leakage in the early stage and fluorescein accumulation in advanced stages of VHK disease to form multiple dye pooling in the areas of serous detachment.Hyperauto fluorescence was a common finding in FAF imaging (100%), and the area involved was consistent with that of fluorescein accumulation shown by FAF imaging.Ten eyes (43.5%) showed patches of relative hypoautofluorescence in the hyperauto fl uorescence areas, and granular hyperauto fl uorescence was found in the lesions in 4 eyes (17.4%).During the remission period of VKH disease, FAF imaging showed normal finding in 8 eyes (34.8%) and reduced areas (by 55.2%) and intensity (by 46.5%) of hyperautofluorescence in 9 eyes (39.1%).In 6 eyes (26.1%), only a few hyperautofluorescent spots scattered in the macula were observed.SD-OCT demonstrated significantly reduced (by 69.5% on average) or even disappearance of subretinal fluid in the eyes.The fluorescence intensity in FAF imaging showed a significant positive correlation with the volume of subretinal fluid detected by SD-OCT (r=0.626, P < 0.05).

CONCLUSIONS

The combination of fluorescein angiography, FAF imaging and SD-OCT can significantly improve the diagnostic accuracy of VKH disease.FAF imaging combined with SD-OCT provides an effective and noninvasive modality for evaluation of remission and monitoring the changes in VKH disease.

Textural Properties of Choriocapillaris on OCTA in Healed Inflammatory Choriocapillaropathies

BACKGROUND AND OBJECTIVE

To evaluate the flow characteristics and textural properties of choriocapillaris (CC) on optical coherence tomography angiography in eyes with resolved inflammatory choriocapillaropathies and Vogt-Koyanagi-Harada (VKH) disease.

PATIENTS AND METHODS

A cohort of eyes with healed acute posterior multifocal placoid pigment epitheliopathy (APMPPE), serpiginous choroiditis (SC), and VKH disease were included. A 3 mm × 3 mm OCT angiogram of CC was acquired and graded for flow characteristics and textural properties.

RESULTS

This study included 16 patients. Texture was heterogeneous in all eyes in the SC and VKH groups, and in four eyes (40%) in the APMPPE group. Most of the eyes with VKH disease had severe low flow, whereas most of the SC and APMPPE eyes demonstrated mild low flow. Heal duration had a strong negative correlation with severity of CC low flow and a weak, statistically nonsignificant correlation with texture heterogeneity.

CONCLUSION

Despite the resolution of active inflammation, partial CC hypoperfusion and texture disruptions persist for longer durations and may resolve in a time dependent manner. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:566-572.].

Positron emission tomography/computed tomography scan of Vogt-Koyanagi-Harada syndrome with associated autoimmune thyroid disease: A case report and literature review

RATIONALE

Vogt-Koyanagi-Harada (VKH) syndrome is a rare disease and could be associated with autoimmune thyroid disease (AITD). This report was aimed to investigate the utility of F-fludeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) for the diagnosis of VKH syndrome with AITD and to perform a literature review on the association between the 2 diseases.

PATIENT CONCERNS

A 55-year-old woman without the history of ocular trauma suffered from chronic headache. She was presented with painful blurred vision of both eyes with headache for 2 weeks. Ophthalmic evaluations revealed panuveitis, exudative retinal detachment, and papilloedema in both eyes. The clinical symptoms and presentations are compatible with the diagnosis of VKH syndrome. Other examinations for intraocular infection, malignancy, and lupus choroidopathy were of negative results. The result of contrast-enhanced computed tomography (CT) of the brain was normal. Due to the history of cancer in the patient's families, a F-FDG PET/CT whole-body scan was performed. The result indicated a focal of 2-fluoro-2-deoxy-D-glucose (FDG) uptake at the right upper lobe of the thyroid. Therefore, the patient's thyroid function was examined and the result indicated euthyroidism with detectable thyroid peroxidase/thyroglobulin antibodies.

DIAGNOSES

VKH syndrome with associated AITD.

INTERVENTIONS

Treatment with intravenous pulse systemic methylprednisolone (1000 mg daily) was prescribed for 3 days and then shifted gradually to tapered oral steroid medication.

OUTCOMES

Symptoms of papillitis and serous retinal detachment of VKH syndrome was relieved after steroid treatment LESSONS:: F-fludeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) can be used for the effective diagnosis of VKH syndrome with AITD.

[Steroid Resistant Vogt-Koyanagi-Harada Disease Treated Effectively with Cyclosporine]

Purpose: To report two cases of Vogt-Koyanagi-Harada disease (VKH) resistant to systemic corticosteroid therapy, effectively treated with systemic cyclosporine. Case 1: A 52-year-old man diagnosed as VKH was administered oral corticosteroids (40 mg/day), following steroid pulse therapy. Since there was no significant improvement, he underwent a second course of steroid pulse therapy and oral corticosteroid administration (40 mg/day). However, there was still no improvement, and a combination therapy of both oral corticosteroids (40 mg/day) and cyclosporine 200 mg (3 mg/kg) was administered. As a result, the inflammation subsided and the dosage of the drugs was tapered successfully. Case 2: A 50-year-old man diagnosed as VKH underwent two courses of steroid pulse therapy, which did not improve significantly. We performed combination therapy of both corticosteroids and cyclosporine, similar to the case described above and obtained good results. Conclusion: Our experience of these two cases indicates that systemic cyclosporine treatment was effective in the management of VKH patients resistant to conventional systemic corticosteroid therapy.

Ocular findings in a patient with virus-associated hemophagocytic syndrome

PURPOSE

To describe a case of virus-associated hemophagocytic syndrome with ocular changes resembling Vogt-Koyanagi-Harada disease prior to the systemic changes.

METHODS

A 51-year-old man presented with a sudden decline in vision. The patient was examined by fluorescein angiography, bone marrow biopsy, abdominal ultrasound, ocular examinations, and laboratory examinations.

RESULTS

Fluorescein angiography revealed uveitis resembling Vogt-Koyanagi-Harada disease. Bone marrow biopsy specimen demonstrated histiocytic hyperplasia and some hemophagocytes. Abdominal ultrasound findings indicated hepato-splenomegaly. And ocular examinations revealed hematocytopenia and hypoproteinemia.

CONCLUSION

The ocular changes resembling Vogt-Koyanagi-Harada disease observed in this study could be a kind of manifestation of virus-associated hemophagocytic syndrome in retina.

Ultrasound biomicroscopic study of ciliary body changes in the post-treatment phase of Vogt-Koyanagi-Harada disease

AIMS

To investigate the usefulness of ultrasound biomicroscopy for evaluating changes in the ciliary body in patients with Vogt-Koyanagi-Harada disease.

METHODS

Ultrasound biomicroscopy was used to evaluate 14 eyes of seven patients diagnosed with Vogt-Koyanagi-Harada disease. Cross sectional images of the ciliary body and thickness of the pars plana 3.0 mm posterior to the scleral spur were examined. Predicted thickness of the pars plana was obtained by multiple linear regression analysis of thickness in the acute phase and in the remission phase.

RESULTS

In the active phase, the cross sectional images showed a shallow anterior chamber in eight of the 14 eyes, ciliochoroidal detachment in five eyes, and a thickened ciliary body in all 14 eyes. Internal reflectivity of the ciliary stroma was low, with ciliary processes being unclear in 13 eyes. One month after steroid treatment, slit lamp examination findings were normal in 14 eyes. 10 eyes of five patients were examined by ultrasound biomicroscopy at this stage. Ciliochoroidal detachment was no longer seen in any eye. Internal reflection of the ciliary stroma became relatively homogeneous, and the ciliary processes were seen, though not clearly. However, the pars plana remained thickened. The actual thickness was greater at 1 month after steroid treatment than the predicted thickness for the remission phase. In the remission phase, the internal reflection was homogeneous and the ciliary processes were delineated clearly in all 14 eyes.

CONCLUSION

Objective, quantitative evaluation of the ciliary body is possible with ultrasound biomicroscopy during the course of Vogt-Koyanagi-Harada disease. Ultrasound biomicroscopy is useful in determining disease activity in the anterior segment and in monitoring the clinical course, and it may improve evaluation of the efficacy of treatment.

Vitreous surgery for bilateral bullous retinal detachment in Vogt-Koyanagi-Harada syndrome

A successful surgical treatment (vitrectomy) for bilateral bullous retinal detachment in a patient with Vogt-Koyanagi-Harada (VKH) disease is reported. A 78-year-old woman had severe reduction of visual acuity in both eyes because of an extremely bullous nonrhegmatogenous retinal detachment accompanied by VKH disease. We performed lens extraction and vitrectomy on both eyes combined with systemic and topical corticosteroid therapy. The retina was reattached immediately after the surgery and her visual acuity promptly improved in both eyes. She had no recurrence of retinal detachment even after tapering the dose of corticosteroid. We suggest that vitrectomy may be an effective therapeutic option in the treatment for severe bullous retinal detachment associated with VKH disease.

Eye disease in a patient with rheumatoid arthritis

We report the case of a 40-year-old woman with diffuse uveitis, sensorineural hearing loss and cerebrospinal fluid pleocytosis as features of Vogt-Koyanagi-Harada syndrome who developed symmetric polyarthritis and stiffness of small and large joints, in addition to rheumatoid arthritis. Although their target tissues are distinct, both diseases have a possible autoimmune origin strongly associated with HLA-DRB4.

Subtraction ICG angiography in Harada's disease

BACKGROUND/AIM

The significance of indocyanine green (ICG) angiography (ICGA) in Harada's disease still awaits clarification in many respects. This study investigates the details of choroidal lesions observed in Harada's disease by the subtraction method.

METHODS

Eight patients with Harada's disease were followed with ICGA. ICG angiograms were obtained with a Topcon high resolution digital fundus camera and processed with a Topcon IMAGEnet computer system. Image subtraction was conducted for analysing serial angiograms taken at about 2 second intervals during the dye transit phase and those taken in the early and middle phases of angiography.

RESULTS

Standard ICG images of acute stage disease showed delayed choroidal filling in the early phase. Mid phase angiograms showed areas with bright fluorescence of variable intensity, indicating intrachoroidal ICG leakage. With image subtraction of angiograms with an interval of seconds the choroidal vessels could be imaged sequentially, with the choroidal arteries visualised first, followed by the definition of the choriocapillaris and then the choroidal veins. The choroidal veins with delayed filling were visualised as positive images in serial subtraction angiograms. Subtraction with an interval of minutes showed uneven background fluorescence and bright fluorescence corresponding to the areas of intrachoroidal ICG leakage. After the disease subsided with steroid therapy, angiography revealed an improvement in delayed choroidal filling. Image subtraction by the second allowed a clear visualisation of improved choroidal venous filling, while subtraction by the minute showed homogeneous background fluorescence, eliminating brighter areas.

CONCLUSION

Subtraction ICGA demonstrated that delayed filling of the choroidal veins of varying severity occurs in association with hyperpermeability of the choroidal vessels in the course of Harada's disease.

Ultrasound Biomicroscopy of shallow anterior chamber in Vogt-Koyanagi-Harada syndrome

PURPOSE

We studied a case of Vogt-Koyanagi-Harada syndrome in a patient with a shallow anterior chamber.

METHODS

High-resolution, anterior segment ultrasound biomicroscopy was performed to analyze the mechanism of a shallow anterior chamber.

RESULTS

Ultrasound biomicroscopy disclosed a slit-like narrow angle and circumferential supraciliary fluid. The ciliary body was rotated anteriorly, and the iris showed anterior bowing consistent with pupillary block. With systemic corticosteroid treatment, the supraciliary fluid disappeared, and the ciliary body reverted to its normal position.

CONCLUSION

Ultrasound biomicroscopy was useful in diagnosis and evaluation of the response to corticosteroid treatment in a patient with Vogt-Koyanagi-Harada syndrome accompanied by shallow anterior chamber.

Ultrasound biomicroscopic analysis of transient shallow anterior chamber in Vogt-Koyanagi-Harada syndrome

PURPOSE

To evaluate the mechanism of formation of the transient shallow anterior chamber in Vogt-Koyanagi-Harada syndrome.

METHODS

Two patients with Vogt-Koyanagi-Harada syndrome with shallow anterior chambers were examined with an ultrasound biomicroscope.

RESULTS

A ciliochoroidal detachment, which was not obvious on ophthalmoscopic examination, was clearly demonstrated in both patients by ultra-sound biomicroscopy. The detachment disappeared after systemic corticosteroid therapy.

CONCLUSION

The shallowing of the anterior chamber in two patients with Vogt-Koyanagi-Harada syndrome was caused by suprachoroidal effusion secondary to inflammation of the uvea.

Echographic features of the Vogt-Koyanagi-Harada syndrome

Vogt-Koyanagi-Harada (VKH) syndrome represents a spectrum of bilateral panuveitis with associated central nervous system and dermatologic manifestations. The diagnosis is based on clinical and angiographic findings, but some of the characteristic features may be either absent or difficult to visualize in the presence of opaque media. With the use of standardized echography (standardized A-scan and contact B-scan echography), we examined nine patients with clear media and clinical evidence of VKH syndrome. Consistent echographic findings included (1) diffuse, low to medium reflective thickening of the choroid posteriorly; (2) serous retinal detachment, located inferiorly or in the posterior pole; (3) mild vitreous opacities with no posterior vitreous detachment; and (4) thickening of the sclera and/or episclera posteriorly. Resolution of these findings occurred with systemic corticosteroid therapy. Standardized echography should be considered an important diagnostic tool in VKH syndrome, especially when visualization of the fundus is poor or when clinical presentation is atypical.