Analysis of 87 cases with Vogt-Koyanagi-Harada disease

Correlation between Subfoveal Choroidal Thickness and Anterior Segment Inflammation in Patients with Chronic Stage of Vogt-Koyanagi-Harada Disease

PURPOSE

To correlate changes in subfoveal choroidal thickness (SCT) with the degree of anterior inflammatory activity in chronic Vogt-Koyanagi-Harada (VKH) disease.

METHODS

Anterior segment inflammation was assessed using SUN anterior chamber cell grading criteria, and SCT was measured using EDI-OCT in patients with VKH at multiple visits. ANOVA was used to compare the mean SCT for each anterior chamber cell grade. Regression analysis was used to correlate the anterior segment cell grade and the SCT.

RESULTS

14 patients were included in the study. A total of 432 data points consisting of SCT and anterior segment cell values were analyzed. ANOVA demonstrated significant difference between the mean SCT for different anterior chamber cell grades (p < .0001). Regression analysis demonstrated significant correlation between SCT and grade of anterior chamber cells (R2 = 0.37, p < .001).

CONCLUSIONS

Chronic VKH is characterized by a dynamic change in SCT that correlates with anterior segment inflammatory activity.

Vogt-Koyanagi-Harada Syndrome - A Neurologist's Perspective

Vogt-Koyanagi-Harada (VKH) syndrome is an immune-mediated granulomatous disease which affects melanin-rich organs like eyes, skin, nervous system, and ears. Neurological and auditory manifestations usually precede the involvement of other sites. Patients may manifest with “complete” or “incomplete” syndrome. We report two patients who presented with acute headache and impaired vision. Fundus examination revealed optic disc hyperemia and exudative retinal detachment which provided a clue for the diagnosis at the bedside. Fundus fluorescein angiogram (FFA) revealed abnormal dye leakage, whereas B scan showed choroid thickening. Cerebrospinal fluid (CSF) pleocytosis contrasted with unremarkable brain magnetic resonance imaging and lack of meningeal signs. Melanophagocytosis was evidenced by melanin-laden macrophages in CSF and skin biopsy. This finding is specific for VKH syndrome and helps to clinch the diagnosis even when the complete syndrome is not present cross-sectionally. VKH syndrome should be suspected in patients with aseptic meningitis if tests for common infectious and immune-mediated diseases are negative.

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.

Vogt-Koyanagi-Harada Syndrome in a Canadian First Nations Population

Purpose: To characterize presentations, characteristics and outcomes of uveitis in Vogt-Koyanagi-Harada (VKH) syndrome in a North American First Nations (FN) population.Methods: Charts of 27 Canadian FN patients with VKH uveitis were retrospectively reviewed to characterize demographics, disease characteristics, management, complications and visual outcomes.Results: Average age at uveitis onset was 30.9 ± 13.8 years. Twenty-six patients 10 (96.3%) were female. Nine patients (33.3%) demonstrated complete VKH, 8 (29.6%) incomplete, and 10 (37%) probable VKH. Systemic associations included integumentary (19 patients, 70%), neurologic (17 patients, 63%), and auditory (13 patients, 48%) findings. Initial rates of mild, moderate and severe vision loss were 19 eyes (35.2%), 12 eyes (22.2%), and 23 eyes (42.6%), respectively, compared with final rates of 19 eyes (35.2%), 14 eyes (25.6%) and 21 eyes (38.9%), respectively. Average change in visual acuity was 15 0.1 ± 6.3 Snellen lines. Rates of immunomodulatory therapy (IMT) use (10 patients, 37%) fell short of targets.Conclusions: VKH may cause potentially severe uveitis in this population. Comorbidities including tuberculosis and diabetes, in addition to unique cultural, linguistic and geographic factors, may necessitate complex, individualized management strategies.

Longitudinal observation of subretinal fibrosis in Vogt-Koyanagi-Harada disease

Background

Subretinal fibrosis (SRF) is a vision-threatening complication of Vogt-Koyanagi-Harada disease (VKH). It has long been recognized as a sequela of chronic inflammation. The developmental process of SRF, however, has not been described. The purpose of this study is to provide longitudinal observations of SRF in VKH.

Methods

Retrospective chart review of 10 VKH patients referred to our group between January 2008 and September 2015 at acute uveitic stage with SRF at presentation or who developed SRF during follow up.

Results

Ten patients (6 males and 4 females) with a median age of 39.0 (range, 23 to 58) years old were included. The median disease duration at presentation and median duration of follow up were 25.5 (range 5 to 60) days and 32.5 (range 13 to 61) months respectively. At presentation, all patients except one had been inappropriately treated with glucocorticosteroid (insufficiently dosed or tapered too fast) for longer than 2 weeks. Despite large dose oral glucocorticosteroid (1 mg/kg/d prednisone or equivalent) with slow tapering in combination with at least one immunomodulatory agent (cyclosporin A, cyclophosphamide or azathioprine) after presentation, all patients developed bilateral SRF within the first 4 months of disease course and 7 patients within the first 2 months. In 8 patients, shape-change/migration and progressive proliferation/pigmentation of SRF was observed over a period of several months after its formation, and then became quiescent but may further underwent depigmentation or pigmentation. SRF involved macula in 12 eyes (7 patients) and caused treatment resistant macular detachment and severe visual impairment in 6 eyes (4 patients). At the last visit, eyes with macular involvement were more common to had worse final best corrected visual acuity (≤20/50) than those without (9/12 vs. 0/8, p = 0.001).

Conclusions

SRF usually develop early in the disease course in VKH patients who are not adequately controlled; it usually undergoes a highly dynamic process within the subretinal space and may involve the macula and resulted in poor final visual outcome.

Surgical Treatment of Subretinal Fibrosis Caused Macular Detachment in Vogt-Koyanagi-Harada Disease: A Pioneer Study

PURPOSE

To describe surgical outcomes of macular detachment caused by subretinal fibrosis (SRF) in Vogt-Koyanagi-Harada disease (VKH).

METHODS

Retrospective review of VKH patients who underwent SRF removal surgery.

RESULTS

Seven eyes of six VKH patients with preoperative BCVA ranging from light perception to 20/250 were included. Six eyes underwent uncomplicated SRF removal with C3F8 or silicone oil (SO) tamponade and the following optional primary or subsequent procedures: intravitreal injection of triamcinolone acetonide, SO removal, lensectomy, or phacoemulsification with intraocular lens (IOL) implantation. All six eyes had attached macula and improved BCVA at the last visit (ranging from 20/2000 to 20/67) compared to baseline; the other eye, however, showed no light perception after surgery due to optic nerve injury.

CONCLUSIONS

In VKH patients, macular detachment caused by SRF can be treated with surgery with generally favorable outcomes. Extreme caution should be taken to avoid optic nerve injury.

Vogt-Koyanagi-Harada disease: Novel insights into pathophysiology, diagnosis and treatment

Vogt-Koyanagi-Harada (VKH) disease is one of the major vision-threatening diseases in certain populations, such as Asians, native Americans, Hispanics and Middle Easterners. It is characterized by bilateral uveitis that is frequently associated with neurological (meningeal), auditory, and integumentary manifestations. Although the etiology and pathogenesis of VKH disease need to be further elucidated, it is widely accepted that the clinical manifestations are caused by an autoimmune response directed against melanin associated antigens in the target organs, i.e. the eye, inner ear, meninges and skin. In the past decades, accumulating evidence has shown that genetic factors, including VKH disease specific risk factors (HLA-DR4) and general risk factors for immune mediated diseases (IL-23R), dysfunction of immune responses, including the innate and adaptive immune system and environmental triggering factors are all involved in the development of VKH disease. Clinically, the criteria of diagnosis for VKH disease have been further improved by the employment of novel imaging techniques for the eye. For the treatment, early and adequate corticosteroids are still the mainstream regime for the disease. However, immunosuppressive and biological agents have shown benefit for the treatment of VKH disease, especially for those patients not responding to corticosteroids. This review is focused on our current knowledge of VKH disease, especially for the diagnosis, pathogenesis (genetic factors and immune mechanisms), ancillary tests and treatment. A better understanding of the role of microbiome composition, genetic basis and ongoing immune processes along with the development of novel biomarkers and objective quantitative assays to monitor intraocular inflammation are needed to improve current management of VKH patients.

Pigmentary disorders of the eyes and skin

Oculocutaneous albinism, Menkes syndrome, tuberous sclerosis, neurofibromatosis type 1, dyskeratosis congenita, lentiginosis profusa syndrome, incontinentia pigmenti, and Waardenburg syndrome all are genodermatoses that have well established gene mutations affecting multiple biological pathways, including melanin synthesis, copper transport, cellular proliferation, telomerase function, apoptosis, and melanocyte biology. Onchocerciasis results from a systemic inflammatory response to a nematode infection. Hypomelanosis of Ito is caused by chromosomal mosaicism, which underlies its phenotypic heterogeneity. Incomplete migration of melanocytes to the epidermis and other organs is the underlying feature of nevus of Ota. Vogt-Koyangi-Harada and vitiligo have an autoimmune etiology; the former is associated with considerable multiorgan involvement, while the latter is predominantly skin-limited.

Unusual Case of Vogt-Koyanagi-Harada Syndrome Presenting as Non-specific Headache

Vogt-Koyanagi-Harada syndrome (VKH) is a bilateral intraocular granulomatous panuveitis which is frequently associated with systemic manifestations such as meningismus, tinnitus, poliosis and vitiligo of autoimmune aetiology. Headache by itself, does not fulfill the diagnostic criteria and is insufficient for the diagnosis. A 22-year-old male presented with a 10 day history of headache, followed by decreased vision in both eyes. Slit lamp biomicroscopy revealed sluggishly reactive pupils with anterior uveitis, mild vitritis and hyperaemic discs with bilateral exudative retinal detachments. All uveitis workups were negative. Follow up of three years revealed no neurological or auditory symptoms. Headache alone, followed by decreased vision, before the onset of neurological and auditory symptoms, can be an initial presentation of Vogt-Koyanagi-Harada (VKH) syndrome. VKH should be considered in the differential diagnosis of atypical presentations of headache.

Vogt-Koyanagi-Harada disease: clinical and demographic characteristics of patients in a specialized eye hospital in Turkey

PURPOSE

To evaluate clinical and demographic features of Vogt-Kayanagi-Harada disease (VKH) disease in Turkish patients and compare them with previously published data.

METHODS

Demographic and clinical features of 32 patients diagnosed as VKH in a tertiary referral center were retrospectively reviewed.

RESULTS

The mean age at presentation was 33.6 ± 10.4 years. Seventy-five percent of the patients were female and 62.5% of the patients presented during the last 2 years. The disease was complete in 31.2%, incomplete in 50%, and probable in 18.8% of the patients. The clinical course was acute in 50%, chronic recurrent in 34.4%, and chronic in 15.6%. The most common findings were bilateral serous retinal detachment ± papillitis in acute cases and retinal pigment epithelial changes of the macula in chronic cases.

CONCLUSIONS

Although rare in Turkey, VKH disease seems to have increased during the last few years. The disease is incomplete and acute in half of the patients and has a quite good visual prognosis.

Reversible alopecia in Vogt-Koyanagi-Harada disease and sympathetic ophthalmia

Background

Vogt-Koyanagi-Harada (VKH) disease and sympathetic ophthalmia (SO) are both autoimmune disorders targeting melanin-bearing cells, even though their etiologies are different. Both shared many ocular and systemic manifestations, including integumentary findings. Most of the literature focused on the ocular manifestations and related treatment. Alopecia was seldom mentioned.

Findings

We report one case of VKH disease and one case of SO. Both developed severe alopecia and early sunset glow fundus, which are probably due to incomplete treatment. Fortunately, the alopecia improved soon after systemic steroid treatment.

Conclusions

Early and complete treatments are important in the management of VKH or SO and prevent integumentary manifestation. Alopecia can be reversible after steroid treatment in time.

Vogt-Koyanagi-Harada syndrome in a 6-year-old Hispanic boy

A 6-year-old Hispanic boy presented to the ophthalmology department with complaints of pain, photophobia, and blurry vision of both eyes. He was found to have bilateral granulomatous panuveitis, cataracts, and high intraocular pressures. He later developed multiple asymptomatic, ovoid, hypopigmented patches over the mid-lumbosacral back. Biopsy of lesional skin was significant for low melanocyte counts and a mild lymphocytic infiltrate. The patient was diagnosed with Vogt-Koyanagi-Harada syndrome (VKH). This article reviews the literature regarding the cutaneous presentation of VKH.

Prevalence, clinical characteristics, and causes of vision loss in children with Vogt-Koyanagi-Harada disease in South India

PURPOSE

The purpose of this study was to describe the prevalence, clinical characteristics, and causes of vision loss in children with Vogt-Koyanagi-Harada disease seen at a uveitis referral center in South India.

METHODS

Charts of patients with Vogt-Koyanagi-Harada disease examined in the uveitis referral clinic of Aravind Eye Hospital between January 1998 and December 2007 were reviewed. A subset of patients <or=16 years of age was identified, and the clinical characteristics and causes of vision loss were evaluated.

RESULTS

Vogt-Koyanagi-Harada disease was diagnosed in 267 of 22,959 patients (1.2%) during the study period. Twenty-two children (8.2%) were identified, including 13 girls (59.1%) and 9 boys (40.9%). Age at presentation ranged from 8 years to 16 years, with a mean and a median of 12.6 and 13.5 years, respectively. The most common complaints were blurred vision (39 eyes, 88.6%) and eye redness (36 eyes, 81.8%). Fifteen (68.5%) children had headaches, 6 (27.3%) developed meningismus and alopecia, 4 (18.2%) developed poliosis and vitiligo, and 3 (13.6%) had tinnitus or dysacusis. Initially, all were treated with oral prednisone, but 12 (54.6%) required methotrexate, 5 (22.7%) required azathioprine, and 2 (9.1%) required cyclophosphamide. Seventy-five percent of eyes had a final visual acuity of >or=20/40, whereas 13.6% had a final visual acuity of <or=20/200.

CONCLUSION

Vogt-Koyanagi-Harada disease is an uncommon cause of uveitis in children. The clinical characteristics of pediatric Vogt-Koyanagi-Harada disease in South India resembled those described in cohorts from other regions. Although children in our cohort tended to do well with prompt diagnosis and treatment, long-term vision loss can occur.

Vogt-koyanagi-harada syndrome

PURPOSE

Vogt-Koyanagi-Harada syndrome is a bilateral, chronic, diffuse granulomatous panuveitis frequently associated with neurological, auditory, and integumentary manifestations. It is also one of the most common forms of uveitis among pigmented races including Chinese patients.

METHODS

This article reviews the current developments of Vogt-Koyanagi-Harada syndrome, including epidemiology, etiology, clinical features, observational techniques, genetics, treatment, and prognosis.

RESULTS

Increasing reports have been published to describe the clinical features of Vogt-Koyanagi-Harada syndrome in various ethnic populations from different parts of the world. In spite of tremendous progress in laboratory and clinical research, the etiology of Vogt-Koyanagi-Harada syndrome is still not completely known. Numerous studies indicate an autoimmune nature for this disease. A recent study has shown that Th17, a new subset of T cell, plays an important role in the initiation and maintenance of this disease. Early and aggressive systemic corticosteroids are still the mainstay of initial therapy for Vogt-Koyanagi-Harada syndrome. However, nonsteroid immunomodulatory therapy, including cyclosporine, chlorambucil, cyclophosphamide, and azathioprine have brought out encouraging results. Improved visual outcomes in patients with Vogt-Koyanagi-Harada syndrome in recent years have been reported when compared with decades ago, presumably due to the more aggressive use of immunosuppressive agents.

CONCLUSION

Although the prognosis for VKH syndrome was greatly improved, future prospective, controlled, multi-center studies are needed to determine the optimal treatment regime for this disease. The IL17/23 pathway may provide a novel therapeutic target to control inflammation in VKH syndrome.

Influence of early cerebrospinal fluid-guided diagnosis and early high-dose corticosteroid therapy on ocular outcomes of Vogt-Koyanagi-Harada disease

PURPOSE

To evaluate the importance of early cerebrospinal fluid (CSF)-guided diagnosis and early high-dose corticosteroid therapy on the complications and visual prognosis of Vogt-Koyanagi-Harada (VKH) disease.

PATIENTS AND METHODS

Charts from patients with VKH disease who had been seen at Tokyo Medical and Dental University Hospital and Miyata Eye Hospital between 1994 and 2002 were retrospectively reviewed. The patients were classified into two groups. The first group (group A) consisted of patients who had received a full work-up including CSF examination and corticosteroid pulse therapy at the acute ophthalmic stage of disease. The second group (group B) consisted of patients who were referred to us by local ophthalmologists long after the disease onset, had not had a CSF examination and had been treated with low-dose systemic corticosteroids or topical corticosteroid therapy. The ocular complications, systemic complications and visual prognosis were compared between the two groups.

RESULTS

Twenty-two patients were included in group A and ten patients in group B. The initial diagnosis at the acute ophthalmic stage had been VKH disease in all patients of group A, while, in group B, the diagnosis was idiopathic uveitis in six patients (60%) initially. Frequency of recurrent uveitis and integumentary symptoms were significantly lower in group A. Intensity of sunset glow fundus was significantly more severe in group B. All eyes in group A obtained a final visual acuity of 0.8 or better, whereas 11 eyes (55%) in group B were below this level.

CONCLUSIONS

The results indicate that early diagnosis, helped by CSF examination and early high-dose corticosteroid therapy, decreased the complication rate and improved the visual prognosis.

Clinical Characteristics of Vogt–Koyanagi–Harada Syndrome in Chinese Patients

PURPOSE

To characterize the clinical features of Vogt-Koyanagi-Harada syndrome (VKH) in Chinese patients.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

A total of 410 consecutive VKH patients examined from August 1995 to April 2005.

METHODS

Charts of these patients were reviewed according to international VKH criteria. Patients who consulted us within 2 weeks after a uveitis attack were classified into group 1; between 2 weeks and 2 months into group 2; and after 2 months into group 3. The history and clinical findings of all of the patients were reviewed. Laser flare-cell photometry, fundus fluorescein angiography, indocyanine green angiography, optical coherence tomography, B-scan ultrasonography, and ultrasound biomicroscopy were performed in certain cases. Corticosteroids were mainly used to treat patients in groups 1 and 2, whereas cyclosporine or chlorambucil in combination with corticosteroids were prescribed for patients in group 3.

MAIN OUTCOME MEASURES

Demographics, clinical presentation, and ancillary examinations of the patients in all 3 groups.

RESULTS

The patients were diagnosed as having either complete (n = 273), incomplete (n = 76), or probable (n = 61) VKH syndrome. Exudative retinal detachment and either choroiditis or chorioretinitis were the main findings in group 1. Posterior uveitis with mild to moderate anterior uveitis simulating a nongranulomatous inflammation as evidenced by dust keratic precipitates, anterior chamber cells, and flare was noted in group 2. Recurrent granulomatous anterior uveitis with a "sunset glow" fundus was observed in group 3. Complicated cataract was the most common complication in the patients in group 3. At the final visit, the uveitis was completely controlled in all patients and a best-corrected visual acuity of <20/200 was 1.9%/eye-year, 1.2%/eye-year, and 6%/eye-year in groups 1, 2, and 3, respectively.

CONCLUSION

Vogt-Koyanagi-Harada syndrome in Chinese patients is characterized by early posterior uveitis, and if the syndrome is not controlled, subsequent recurrent granulomatous anterior uveitis. Good visual prognosis is possible if the patients are managed according to a tailored immunosuppressive treatment protocol.

The spectrum of Vogt-Koyanagi-Harada disease in South India

PURPOSE

To report the clinical spectrum of Vogt-Koyanagi-Harada (VKH) disease in a tertiary care center in South India.

METHODS

Medical records of patients diagnosed with VKH disease who presented between January 1995 and December 2003, with a minimum follow-up of one year were reviewed.

RESULTS

Of the 45 patients, 38 (84.44%) were female. The median age was 37 years (SD +/- 14.23) and median duration of symptoms was 30 days (range 1 day to 1 year). 75.5% (34/45) presented with bilateral anterior uveitis. Posterior segment presentation included disc edema (31/45), bilateral serous retinal detachments (26/45), vitritis (17/45) and sunset glow (8/45). Extra ocular manifestations were seen in only 4/45 (tinnitus: 2, meningismus: 1, poliosis: 1). 97.7% (44/45) received oral Prednisolone (1 mg/kg body weight) for a median duration of 14 months. 69% (31/45) received additional three pulses of intravenous methylprednisolone and 22% (10/45) received a single infusion of intravenous Cyclophosphamide. One patient received intravitreal triamcinolone injection 53.33% (24/45) were treated with additional immunosuppressants. At the first visit, best corrected visual acuity (BCVA) was > or =20/40 in 23 eyes (25.55%) and < or =20/400 in 37 eyes (41.11%). At one year, 61 eyes (67.77%) achieved BCVA of > or =20/40 while 12 eyes (13.33%) had BCVA < or =20/400. Complicated cataract, glaucoma and macular scar were the major complications encountered.

CONCLUSIONS

Majority of patients with ocular VKH presented with anterior uveitis and serous retinal detachments and disc edema. Extra-ocular signs are rare in our patients. Visual prognosis is good with treatment with adequate long-term corticosteroids and immunosuppressive agents.

The spectrum of Vogt-Koyanagi-Harada disease in Tunisia, North Africa

OBJECTIVE

To analyze the clinical profile of Vogt-Koyanagi-Harada (VKH) disease in Tunisia, North Africa.

METHODS

We retrospectively reviewed the clinical records of 49 patients diagnosed with VKH disease at the Department of Ophthalmology of Fattouma Bourguiba University Hospital, Monastir, Tunisia, between January 1994 and September 2005.

RESULTS

Of all the uveitis cases diagnosed during the study period, VKH disease was the fourth most commonly occurring type (7.4%). Thirty-two patients (65.3%) were female, and 17 patients (34.7%) were male. The mean age at disease onset was 35 years (range: 16-54 years). The majority of patients (51%) had probable VKH disease, followed by incomplete type (47%); only 2% had the complete type. At presentation, 47 patients (96%) had bilateral ocular involvement. Clinical presentation was a panuveitis in 25 patients (51%) and a posterior uveitis in 24 patients (49%). Visual acuity (VA) at presentation ranged from less than 20/200 (40.8%) to more than 20/40 (28.5%). All patients were treated with systemic corticosteroids for 2-19 months (mean: 10.5 months). Four patients (8%) were treated with cyclosporin because of serious systemic side effects of corticosteroids. Complications included cataract in 18 eyes (33.9%), glaucoma in nine eyes (16.96%) and choroidal neovascularization in one eye (1%). Fifty-eight eyes (59%) had a final VA of 20/40 or better. Factors associated with a poor VA at the final follow-up were the presence of a poor VA at presentation (P = 0.02), the occurrence of complications (P = 0.001) and/or recurrences (P = 0.02).

CONCLUSION

In Tunisia, VKH disease is a common cause of uveitis that predominantly affects young women. The overwhelming majority (98%) have probable or incomplete VKH disease, presenting as panuveitis or posterior uveitis. More than 50% of patients undergoing treatment with corticosteroids will maintain a VA of 20/40 or better.

[Vogt-Koyanagi-Harada disease. Characteristics of a series of Andalusian patients]

BACKGROUND

To describe the characteristics of a series of patients diagnosed of Vogt-Koyanagi-Harada disease (VKHD) and controlled by an Uveitis Unit (composed of ophthalmologists and internists) in our population.

PATIENTS AND METHOD

Retrospective descriptive study of 11 patients with VKHD (5 males and 6 women; median age at diagnosis 32.6 years old) followed-up between 1980 and 2003.

RESULTS

All patients suffered panuveitis and/or exudative retinal detachment. Extraocular signs were present in all cases: neurological in 63.7% (aseptic meningitis and/or focal symptoms), cutaneous in 81.8% (vitiligo, whiteness, poliosis, alopecia), neurosensorial hypoacusis (50% of patients with audiometry), and general symptoms in 25%. They all received systemic corticosteroids. Cyclosporine was added in 5 patients (45.4%) with posterior uveitis, and azathioprine in 2 of them for iridocyclitis. The final visual acuity was 0.5 or better in 81.8% of cases, but 2 patients had an unfavourable evolution (one, who had cataract and band keratopathy in the left eye and severe visual worsening, needed right vitrectomy, and the other suffered severe ocular hypotension). Complications developed in 2 other patients: cataract and glaucoma in one, and synechiae without glaucoma in the other.

CONCLUSIONS

We found less frequency of exudative retinal detachment and greater frequency of cutaneous signs than the communicated. A significant percentage of cases needed immunosuppressive agents. Final visual acuity was good in the majority of patients.

The spectrum of Vogt-Koyanagi-Harada disease in Turkey

AIM

The aim of this report was to provide a detailed description of the clinical features of Vogt-Koyanagi-Harada (VKH) disease in Turkish patients.

METHODS

We retrospectively analyzed 45 patients diagnosed with VKH disease at seven referral centers in Turkey. A standard data acquisition form was used for the analysis of demographic and clinical features.

RESULTS

The study cohort consisted of 45 patients (32 female, 13 male) who had a mean age at presentation of 31 years. Seven patients (15%) were aged 16 years or younger. Nineteen (42%) patients presented in the acute or subacute stage and 26 (58%) in the chronic stage. According to the revised diagnostic criteria, nine (20%) patients had the complete form of the disease, 23 (51%) had the incomplete form, and 13 (29%) had probable VKH disease. All patients had bilateral ocular involvement. Sunset-glow fundus was observed in 89% of the patients, pigment clumping in 73%, nummular depigmented scars in 71%, cataract in 53%, optic atrophy in 31%, glaucoma in 29%, subretinal fibrosis in 22%, choroidal neovascular membranes in 7%, and phthisis in 4%. All patients who presented at the acute uveitic stage received systemic corticosteroid therapy. Immunosuppressive treatment was employed in 30 (66%) patients, which was initiated at the acute uveitic stage in ten (22%) patients. Final visual acuity was better than 0.5 in 59% of the patients' eyes, between 0.1 and 0.5 in 21%, and less than 0.1 in 20%.

CONCLUSIONS

VKH disease is rare in Turkey. We conclude that the majority of patients with VKH in Turkey do not have the complete form of the disease. Based on our results, most patients with VKH seem to be late referrals. Ocular complications were common among these patients.

[Vogt-Koyanagi-Harada syndrome]

INTRODUCTION

Vogt-Koyanagi-Harada syndrome is a rare, inflammatory disease with manifestations affecting the ocular, central nervous, audito-vestibular, and integumentary systems. Vogt-Koyanagi-Harada syndrome is more frequent in Asia but is also described in Europe. We report three new non asiatic cases of this syndrome.

OBSERVATIONS

The three patients had bilateral panuveitis and hypoacusia. Two of them had peripheral facial palsy, two of them had vestibular syndrome and one of them lymphocytic meningitis. In each case we found characteristic HLA II typing and in one case we discovered the simultaneous presence of three auto-antibodies: anti-retina (anti-Arrestin type), anti-choroid and anti-cochlea. These patients were treated by corticosteroids but required an additional treatment by cyclophosphamide (0.8g/m2). The clinical course was favorable with visual sequelae for two and auditory one for one.

DISCUSSION

These biological and therapeutic elements and a review of the recent literature are in favor of an autoimmune origin of this syndrome.

Update on uveomeningoencephalitides

PURPOSE OF REVIEW

Uveomeningoencephalitides, commonly known as Vogt-Koyanagi-Harada (VKH) disease, are characterized by chronic bilateral granulomatous panuveitis involving the central nervous, auditory and integumentary systems. Visual prognosis is generally favourable, but outcomes in patients with VKH disease may vary. Also, the treatment of choice differs in different parts of the world. This review addresses the literature on the possible pathogenesis, diagnosis and treatment of this disorder.

RECENT FINDINGS

Atypical presentations of VKH disease, as well as those associated with interferon-alpha therapy, have been reported. Most reports suggest an association with autoimmunity. The diagnostic criteria were revised by the International Workshop on VKH in 1999, allowing for the presence of different ocular findings in the early and late stages of the disease. New techniques have also been developed to aid in the rapid diagnosis of VKH disease and evaluation of treatment. Different routes of administration of corticosteroid and adjuvant therapy were tried, with positive results.

SUMMARY

Although the pathogenesis of VKH disease is uncertain and antigen-specific treatment strategies have not yet been developed, reports increasingly suggest an autoimmune nature for uveomeningoencephalitides. Currently, systemic corticosteroid therapy remains the standard initial treatment. Different routes of administration are used to reduce the frequency of side effects of systemic corticosteroids, and there are various adjuvant therapies. With the aid of modern equipment, early diagnosis and prompt and appropriate treatment, resulting in better visual outcomes, can be anticipated. A large-scale, multinational, prospective study is warranted to determine the optimal initial therapy.

Comparative study of two sets of criteria for the diagnosis of Vogt-Koyanagi-Harada's disease

PURPOSE

The Vogt-Koyanagi-Harada's (VKH) Disease Committee established the "Revised diagnostic criteria for VKH disease" in 2001. The purpose of the present study was to assess the concordance between these criteria and the traditional Sugiura's diagnosis system.

DESIGN

Observational case series.

METHODS

The medical records of patients previously diagnosed with VKH disease based upon Sugiura's criteria at the Uveitis Survey Clinic of the Hokkaido University Hospital between 1991 and 2003 were retrospectively reevaluated using the VKH Committee's revised diagnostic criteria for VKH disease.

RESULTS

Sugiura's criteria were used to identify 169 patients with VKH disease. All patients were Japanese, and 95 cases (56%) were women. Mean age at the time of their first visit to our clinic was 44.7 +/- 13.9 years (range, 9 to 74 years). Using the VKH Committee's new criteria, 91.7% of the previously diagnosed VKH patients were classified as having the disease. Of this group, 11.8% were classified as complete, 71% incomplete, and 8.9% as probable VKH disease.

CONCLUSIONS

The VKH Committee's revised diagnostic criteria proved useful for VKH disease diagnosis, as the concordance rate for the two criteria was more than 90%. However, patients who had prior cataract surgery or who lacked signs of serous retinal detachment were not classified as having VKH disease because of exclusion by the VKH Committee's new criteria.

Le syndrome de Vogt-Koyanagi-Harada : aspects cliniques, traitement et suivi à long terme dans une population caucasienne et africaine

PURPOSE

Seventeen consecutive cases of Vogt-Koyanagi-Harada (VKH) disease were studied to determine their clinical profile.

METHODS

This was a retrospective study of 17 cases, in a white and African population.

RESULTS

The sex ratio (female/male) was 1.6. Mean age was 37.65 +/- 10.2 years. Eight patients were Caucasian (47%), and seven were from North Africa (41%), and two were black Africans (12%). Eleven patients were referred during the acute stage, and six patients secondarily. All patients had bilateral ocular involvement. Panuveitis with retinal serous detachment was the most frequent presentation (88%). Extraocular signs were found in 87% of the cases. Initial visual acuity was 0.29 +/- 0.36, and final visual acuity was 0.78 +/- 0.3. Patients seen during the acute stage were treated with general corticotherapy. Immunosuppressive agents were given in 56% of the cases.

CONCLUSIONS

Vogt-Koyanagi-Harada disease, in a Caucasian and African population, has a presentation close to that of the Japanese population. However, cutaneous signs are much rarer. Visual prognosis was generally favorable.

Fever, headache, and visual blurring in a 17-year-old woman

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Significant Prognostic Factors for Vogt-Koyanagi-Harada Disease in the Early Stage

This study identified possible prognostic signs in the acute stage of Vogt-Koyanagi-Harada (VKH) disease in a retrospective chart review of all patients diagnosed with VKH disease between 1991 and 2001. Those who were diagnosed more than 1 month after the onset of ocular symptoms were excluded. Data recorded included age, sex, clinical features, systemic manifestations, recurrence, treatment, complications, and final visual acuity. Exudative retinal detachment was ranked into 3 grades (grade 1: within peripapillary 3 disc diameters and arcade; grade 2: larger than grade 1 but no inferior retinal detachment; grade 3: inferior or total retinal detachment). Of the 31 patients, 19 were males and 12 were females. Mean age at presentation was 38.55 +/- 10.63 years. The mean follow-up period was 33.09 months. Extraocular manifestations were present in 17 cases. Four patients had at least one complication, including cataract in seven eyes and glaucoma in one eye. Forty-nine eyes (79%) had a final visual acuity of 6/12 or better. Final visual acuity was significantly better in younger patients (p = 0.023) and those who had less extensive retinal detachment (p = 0.006), no pigmentary change (p = 0.008) and no complications (p = 0.030). The visual prognosis of VKH disease is variable, though generally favorable. In the acute stage, the extent of retinal detachment may be an important risk factor for visual outcome. Further study of this factor as an indicator for treatment is necessary.