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

Vogt-Koyanagi-Harada Disease Presenting as Papillitis vs. Classic Serous Retinal Detachment: A Comparative Analysis of Outcomes

BACKGROUND

To compare the treatment outcome and visual prognosis of Vogt-Koyanagi-Harada (VKH) disease presenting as papillitis vs. serous retinal detachment (SRD).

METHODS

Retrospective comparative cohort study of 35 patients with previously unknown VKH diagnosis, followed-up for ≥6 months. Outcomes measured: (1) time to achieve inflammatory control; (2) VKH relapse; (3) ocular complications (glaucoma, sunset glow fundus, cataract, and vision loss ≥2 Snellen lines); and (4) chances for developing a chronic-recurrent disease.

RESULTS

Females predominated in both groups: 12/16 (75%) papillitis and 18/19 (94.7%) SRD. The mean age at presentation was 29 ± 12 years in the papillitis and 36 ± 14 years in the SRD group (p = 0.119), with an overall median follow-up of 26 months (6-180 months). The papillitis-onset VKH group's mean time elapsed between symptoms onset and initial treatment was shorter (2.9 ± 1.0 vs. 4.6 ± 2.8 weeks, p = 0.024). Anterior segment inflammation was lower (56% vs. 79%, p = 0.018), requiring a shorter corticosteroids treatment duration (12.8 ± 16.1 vs. 32.7 ± 34.1 months, p = 0.040), achieving an earlier inflammatory control (1.9 ± 0.6 vs. 4.1 ± 3.2 months, p <0.001) with fewer ocular complications (13% vs. 74%, p <0.001), including sunset glow fundus (SGF) (0% vs. 63%, p <0.001). Conversely, SRD-onset VKH was a risk factor for developing disease relapse (HR: 4.53; 95% CI: 1.31-15.69, p = 0.017), ocular complications (OR: 19.60, 95% CI: 3.24-118.50, p = 0.001), and chronic-recurrent disease (OR: 20.63; 95% CI: 2.24-189.84, p = 0.008).

CONCLUSION

Mexican-mestizo VKH patients with papillitis-onset VKH disease showed earlier inflammatory control, fewer recurrences, and better visual and ocular complication outcomes.

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 patients with Vogt-Koyanagi-Harada (VKH) syndrome compared with nonglaucoma 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 patients with VKH.

METHODS

The review protocol was preregistered on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (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 National Institutes of Health 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% confidence interval [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 with nonglaucoma 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.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Neovascular Glaucoma: A Rare Presenting Feature of Vogt-Koyanagi-Harada Syndrome

Vogt-Koyanagi-Harada syndrome (VKH) is an uncommon multi-system autoimmune inflammatory disorder characterized by bilateral granulomatous panuveitis with serous retinal detachment accompanied by neurological, auditory, and cutaneous manifestations like headache, hearing loss, vitiligo, and poliosis. It has a female preponderance, usually in middle age. We report the case of a 20-year-old male who presented to us with rapidly progressive visual loss accompanying granular panuveitis, complicated cataract, and a mixed mechanism neovascular glaucoma with acute angle closure. He was treated for IOP control and underwent aggressive immunosuppression and, later, bilateral laser iridotomies. It wasn't until one month after the initial presentation that he presented with vitiligo and poliosis of the eyebrows and eyelashes, clinching the diagnosis of VKH syndrome. This case highlights the diagnostic challenge faced due to acute neovascular glaucoma being the initial presenting feature of VKH; hitherto not documented before, although acute angle closure glaucoma or crisis has occasionally been reported at presentation; the classical VKH presentation being an acute posterior segment uveitis or less commonly, a chronic, recurrent panuveitis presenting with/ without complications. This case underlines the importance of considering VKH syndrome in a patient with bilateral granulomatous panuveitis, as dermatological involvement can emerge later in the disease course, by which time vision might have already been compromised significantly.

Update on Diagnosis and Treatment of Uveitic Glaucoma

Glaucoma is a common and potentially blinding complication of uveitis. Many mechanisms are involved alone or in combination in the pathogenesis of uveitic glaucoma (UG). In terms of diagnostic evaluation, the effects of inflammatory activity in the retinal nerve fiber layer may be a source of bias in the interpretation of optical coherence tomography measurements. For the successful treatment of UG, the control of intraocular inflammation specific to the cause or anti-inflammatory treatment, combined with IOP management, is mandatory. The early institution of specific treatment improves the prognosis of UG associated with CMV. The young age of UG patients along with increased failure rates of glaucoma surgery in this group of patients warrants a stepwise approach. Conservative and conjunctival sparing surgical approaches should be adopted. Minimally invasive surgical approaches were proved to be effective and are increasingly being used in the management of UG along with the traditionally used techniques of trabeculectomy or tubes. This review aims to summarize the progress that recently occurred in the diagnosis and treatment of UG.

Incidence and Risk Factors of Recurrent Anterior Uveitis in Initial Acute-Onset Vogt-Koyanagi-Harada Disease

PURPOSE

We report the estimated incidence of, and risk factors for, recurrent anterior uveitis in patients with initial acute-onset Vogt-Koyanagi-Harada (VKH) disease using survival analyses.

METHODS

Patients who were diagnosed with initial acute-onset VKH disease during 2003-2022 at two university hospitals were included. Recurrent anterior uveitis was defined as the first occurrence of the granulomatous anterior uveitis with anterior chamber cells and flare of 2+ or more by the Standardization of Uveitis Nomenclature (SUN) Working Group grading scheme, after the disappearance of conspicuous uveitis and serous retinal detachment for at least 3 months, regardless of systemic or local treatment. The univariate log-rank test and multivariate Cox regression analyses were performed, including patients' demographic characteristics, underlying diseases, presence of prodromal symptoms, duration of visual symptoms, visual acuity, slit-lamp and fundus findings, and height of serous retinal detachment. The treatment method and response to treatment were also included.

RESULTS

The estimated incidence was 39.3% at 10 years. Fifteen of 55 patients (27.3%) had recurrent anterior uveitis during the mean follow-up of 4.5 years. The presence of focal posterior synechiae at the diagnosis increased the risk of recurrent anterior uveitis 6.97-fold compared to the absence of synechiae (95% confidence interval [CI], 2.20-22.11; p < 0.001). Use of systemic high-dose steroid therapy more than 7 days after the development of visual symptoms resulted in a hazard ratio of 4.55 (95% CI, 1.27-16.40; p = 0.020).

CONCLUSIONS

This study reports the estimated incidence and risk factors of recurrent anterior uveitis in VKH disease from survival analyses. However, because of the retrospective nature of this study, it is hard to confirm the consistency of the medical records regarding risk factors, thus, the presence of focal posterior synechiae can be inconclusive as a risk factor. Further studies are warranted.