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Indocyanine green angiography-guided management of Vogt–Koyanagi–Harada disease: differentiation between choroidal scars and active lesions

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Abstract

When following Vogt–Koyanagi–Harada disease (VKH), indocyanine green angiography (ICGA) is crucial in the subacute and convalescent stages of the disease in order to detect subclinical choroiditis and prevent the development of ‘sunset glow’ fundus. Hypofluorescent dark dots (HDDs) indicate persisting granulomas in the choroid. However, probably as a result of the healing process of choroidal granulomas, stromal choroidal fibrosis can also be shown by HDDs. We present two cases where intravenous corticosteroid administration because of persistent HDDs led to resolution of lesions in one case while they persisted in the other case. We reviewed the medical history of two VKH patients. Complete routine work-up for patients with posterior uveitis was performed. The charts were screened for the presence of HDDs by ICGA in the subacute and convalescent stages of the disease before and after administration of body weight-adapted pulse intravenous methylprednisolone (PIM). The evolution of HDDs was studied and compared in both patients. A female patient presented with a persistent bilateral granulomatous panuveitis compatible with VKH. Cerebrospinal fluid analysis had shown lymphocytic pleocytosis. At presentation, therapy consisted of oral prednisone 80 mg/day. Prednisone was tapered down to 22 mg/day over 3 months, when a recurrence occurred with the presence of disseminated HDDs. PIM was administered, followed by oral corticosteroids. After 8 days of therapy, ICGA showed an almost complete disappearance of HDDs. A girl presented with bilateral panuveitis and widespread depigmented areas of her fundus. Cerebrospinal fluid analysis showed monocytic pleocytosis. Because of relative resistance to oral inflammation suppressive therapy (IST), PIM was administered for 3 days. Nevertheless, ICGA showed persistence of HDDs. Therapy was continued, and 3 months later, a follow-up ICGA still depicted numerous HDDs. Another PIM course was given, which had no effect on ICGA signs. HDDs in this case were interpreted as stromal choroidal scars. ICGA-guided therapy (mainly HDD evolution monitoring) helps to eradicate occult stromal disease in VKH and avoids ‘sunset glow’ fundus, by allowing precise adjustment of therapy. In some cases, HDDs do not represent active lesions but presumed intrastromal scars which need to be identified. A limited course of maximal IST including PIM can unmask such cases and avoid overtreatment of these patients.

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References

  1. Wang C, Tian Y, Lei B et al (2012) Decreased IL-27 expression in association with an increased Th17 response in Vogt–Koyanagi–Harada disease. Invest Ophthalmol Vis Sci 53:4668–4675

    Article  PubMed  CAS  Google Scholar 

  2. Yang Y, Xiao X, Li F et al (2012) Increased IL-7 expression in Vogt–Koyanagi–Harada disease. Invest Ophthalmol Vis Sci 53:1012–1017

    Article  PubMed  CAS  Google Scholar 

  3. Yamaki K, Gocho K, Hayakawa K, Kondo I, Sakuragi S (2000) Tyrosinase family proteins are antigens specific to Vogt–Koyanagi–Harada disease. J Immunol 165:7323–7329

    PubMed  CAS  Google Scholar 

  4. Nussenblatt R, Whitcup S (2010) Uveitis, 4th edn. Mosby Elsevier, Philadelphia

    Google Scholar 

  5. Yanoff M, Duker JS (2009) Ophthalmology, 3rd edn. Mosby Elsevier, Philadelphia

    Google Scholar 

  6. Bouchenaki N, Herbort CP (2011) Indocyanine green angiography guided management of Vogt–Koyanagi–Harada disease. J Ophthalmic Vis Res 6:241–248

    PubMed  CAS  Google Scholar 

  7. Herbort CP, Mantovani A, Bouchenaki N (2007) Indocyanine green angiography in Vogt–Koyanagi–Harada disease: angiographic signs and utility in patient follow-up. Int Ophthalmol 27:173–182

    Article  PubMed  Google Scholar 

  8. Inomata H, Sakamoto T (1990) Immunohistochemical studies of Vogt–Koyanagi–Harada disease with sunset sky fundus. Curr Eye Res 9(Suppl):35–40

    Article  PubMed  Google Scholar 

  9. Miyanaga M, Kawaguchi T, Miyata K et al (2010) Indocyanine green angiography findings in initial acute pretreatment Vogt–Koyanagi–Harada disease in Japanese patients. Jpn J Ophthalmol 54:377–382

    Article  PubMed  Google Scholar 

  10. Okada AA, Mizusawa T, Sakai J, Usui M (1998) Videofunduscopy and videoangiography using the scanning laser ophthalmoscope in Vogt–Koyanagi–Harada syndrome. Br J Ophthalmol 82:1175–1181

    Article  PubMed  CAS  Google Scholar 

  11. Yuzawa M, Kawamura A, Matsui M (1993) Indocyanine green video-angiographic findings in Harada’s disease. Jpn J Ophthalmol 37:456–466

    PubMed  CAS  Google Scholar 

  12. Nakao K, Abematsu N, Mizushima Y, Sakamoto T (2012) Optic disc swelling in Vogt–Koyanagi–Harada disease. Invest Ophthalmol Vis Sci 53:1917–1922

    Article  PubMed  Google Scholar 

  13. Suzuki S (1999) Quantitative evaluation of “sunset glow” fundus in Vogt–Koyanagi–Harada disease. Jpn J Ophthalmol 43:327–333

    Article  PubMed  CAS  Google Scholar 

  14. Hogan MJ, Kimura SJ, Thygeson P (1959) Signs and symptoms of uveitis I. Anterior uveitis. Am J Ophthalmol 47:155–170

    PubMed  CAS  Google Scholar 

  15. Herbort CP, Guex-Crosier Y, de Ancos E, Pittet N (1997) Use of laser flare photometry to assess and monitor inflammation in uveitis. Ophthalmology 104:64–71; discussion 71–62

    Article  PubMed  CAS  Google Scholar 

  16. Abu El-Asrar AM, Hemachandran S, Al-Mezaine HS, Kangave D, Al-Muammar AM (2012) The outcomes of mycophenolate mofetil therapy combined with systemic corticosteroids in acute uveitis associated with Vogt–Koyanagi–Harada disease. Acta Ophthalmol 90(8):e603–e608

    Article  PubMed  CAS  Google Scholar 

  17. Read RW, Yu F, Accorinti M et al (2006) Evaluation of the effect on outcomes of the route of administration of corticosteroids in acute Vogt–Koyanagi–Harada disease. Am J Ophthalmol 142:119–124

    Article  PubMed  CAS  Google Scholar 

  18. Kawaguchi T, Horie S, Bouchenaki N et al (2010) Suboptimal therapy controls clinically apparent disease but not subclinical progression of Vogt–Koyanagi–Harada disease. Int Ophthalmol 30:41–50

    Article  PubMed  Google Scholar 

  19. Bouchenaki N, Herbort CP (2001) The contribution of indocyanine green angiography to the appraisal and management of Vogt–Koyanagi–Harada disease. Ophthalmology 108:54–64

    Article  PubMed  CAS  Google Scholar 

  20. Gupta SR, Suhler EB, Rosenbaum JT (2010) Intravenous methylprednisolone can cause an acute, vision-threatening rise in intraocular pressure. J Clin Rheumatol 16:397–398

    PubMed  Google Scholar 

  21. Badsha H, Edwards CJ (2003) Intravenous pulses of methylprednisolone for systemic lupus erythematosus. Semin Arthritis Rheum 32:370–377

    Article  PubMed  CAS  Google Scholar 

  22. Haugeberg G, Griffiths B, Sokoll KB, Emery P (2004) Bone loss in patients treated with pulses of methylprednisolone is not negligible: a short term prospective observational study. Ann Rheum Dis 63:940–944

    Article  PubMed  CAS  Google Scholar 

  23. Erstad BL (1989) Severe cardiovascular adverse effects in association with acute, high-dose corticosteroid administration. DICP 23:1019–1023

    PubMed  CAS  Google Scholar 

  24. Markomichelakis NN, Halkiadakis I, Papaeythymiou-Orchan S et al (2006) Intravenous pulse methylprednisolone therapy for acute treatment of serpiginous choroiditis. Ocul Immunol Inflamm 14:29–33

    Article  PubMed  CAS  Google Scholar 

  25. Bartalena L, Krassas GE, Wiersinga W et al (2012) Efficacy and safety of three different cumulative doses of intravenous methylprednisolone for moderate to severe and active graves’ orbitopathy. J Clin Endocrinol Metab 97(12):4454–4463

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

This work has been supported by the "Grieshaber Consulting" grant as well as the "Herta Messerli" trust.

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Authors and Affiliations

  1. Retinal and Inflammatory Eye Diseases, Centre for Ophthalmic Specialized Care (COS), Clinic Montchoisi, Rue de la Grotte 6, 1003, Lausanne, Switzerland

    Pascal B. Knecht & Carl P. Herbort

  2. Department of Ophthalmology, University Hospital Zurich, Zurich, Switzerland

    Pascal B. Knecht

  3. Eye Clinic, Department of Ophthalmology, Hospital Valduce, Como, Italy

    Alessandro Mantovani

  4. University of Lausanne, Lausanne, Switzerland

    Carl P. Herbort

Authors
  1. Pascal B. Knecht
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  2. Alessandro Mantovani
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  3. Carl P. Herbort
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Correspondence to Carl P. Herbort.

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Knecht, P.B., Mantovani, A. & Herbort, C.P. Indocyanine green angiography-guided management of Vogt–Koyanagi–Harada disease: differentiation between choroidal scars and active lesions. Int Ophthalmol 33, 571–577 (2013). https://doi.org/10.1007/s10792-012-9692-4

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  • DOI: https://doi.org/10.1007/s10792-012-9692-4

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