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LETTER TO EDITOR
Year : 2014  |  Volume : 2  |  Issue : 1  |  Page : 69-70

Vogt-Koyanagi-Harada disease with delayed fellow eye involvement


1 Uveitis and Ocular Immunology, Narayana Nethralaya, Bengaluru, Karnataka; Uvea Clinic, Aravind Eye Hospital, Tirunelveli, Tamil Nadu (previous affiliation where the study has been done), India
2 General Ophthalmology Department, Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India

Date of Web Publication3-Dec-2013

Correspondence Address:
Ankush A Kawali
Narayana Nethralaya, Chord Road, Bengaluru - 560 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3897.122662

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How to cite this article:
Kawali AA, Harshey KB. Vogt-Koyanagi-Harada disease with delayed fellow eye involvement. J Clin Ophthalmol Res 2014;2:69-70

How to cite this URL:
Kawali AA, Harshey KB. Vogt-Koyanagi-Harada disease with delayed fellow eye involvement. J Clin Ophthalmol Res [serial online] 2014 [cited 2022 Jun 26];2:69-70. Available from: https://www.jcor.in/text.asp?2014/2/1/69/122662

Dear Editor,

Vogt-Koyanagi-Harada (VKH) disease classically presents as bilateral posterior or pan uveitis. Bilaterality is one of the necessary criteria to classify VKH disease into complete, incomplete and probable. [1] We report an interesting case of VKH whose presentation was unilateral. A 65-year-old male patient, presented to us with a history of pain and defective vision in the right eye since 1 week. Best corrected visual acuity was 6/24 in the right eye and 6/18 in the left eye. Anterior segment examination revealed circumcorneal congestion, diffuse keratic precipitates, 2 + cells, Koeppe nodules and immature cataract in the right eye. Anterior vitreous face showed 1 + cells and the fundus showed hyperemic, edematous disc and multifocal peripapillary choroiditis. Left eye showed immature cataract, asteroid hyalosis in the vitreous and medullated nerve fibers superiorly and temporal to the macula. Hearing deficit was also noted during the preliminary examination. Investigations were negative except for slightly raised erythrocyte sedimentation rate (22 mm/h). Fluorescein angiography (FA) and B-scan was not done due to patient's financial constraints. He was started on oral and topical steroids, but he discontinued on his own after a week and lost to follow-up. He reported 1 month later with a huge inferior exudative retinal detachment (RD) in addition to his previous findings. Patient had no fresh complaints for his left eye and the eye was quiet on examination. B-scan confirmed exudative RD and revealed increased choroidal thickness in the right eye while choroidal thickness was normal in the left eye. There was no evidence of posterior sub-tenon's fluid. Patient was restarted on systemic steroids and a sub-tenon's depot injection of steroid was given to the right eye. Patient again had to discontinue systemic steroids due to a viral fever. After a week, he came back with redness and pain for the 1 st time in his left eye. On examination, right eye was quiet with an early sunset glow appearance of the fundus [Figure 1]a while the left eye showed granulomatous panuveitis with choroiditis [Figure 1]b. Systemic and topical steroids were restarted for his left eye. This time the patient agreed for FA which revealed starry sky appearance in the left eye and disc leak in both the eyes suggestive of VKH disease [Figure 2]a and b. Oral methotrexate 15 mg/week was added along with folic acid.

VKH disease classically presents as multiple pockets of serous RD in both eyes. Forster et al. have reported that even if one eye is involved at the beginning, fellow eye involvement can occur approximately after a month or more. [2] In our case fellow eye involvement occurred after 4 months. Several cases of unilateral VKH disease have been reported. Roe et al. reported three cases of VKH disease with significant delay of the fellow eye involvement ranging from 11 months to 6 years. [3] There are similar reports by Usui et al. [4] It is possible that in reported cases of unilateral VKH fellow eye remained quiet for a longer period due to timely commencement of systemic medications. In our case when systemic steroids were discontinued due to patient's febrile illness VKH showed its manifestations in the fellow eye. Bilateral involvement is an absolute requirement of revised international diagnostic criteria to classify a uveitis entity into complete, incomplete or probable VKH disease. [1] In fact, complete categorization of VKH disease reveals a delayed diagnosis and furthermore, indocyanine green angiography data and those of optical coherence tomography were not considered by these revised criteria. [5] Unilateral VKH cases will remain excluded from clinical studies when international diagnostic criteria is applied. Hence we emphasize on re-revision of the "revised international diagnostic criteria of VKH" to consider cases of VKH with delayed fellow eye involvement.
Figure 1:

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Figure 2:

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  References Top

1.Read RW, Holland GN, Rao NA, Tabbara KF, Ohno S, Arellanes-Garcia L, et al. Revised diagnostic criteria for Vogt-Koyanagi-Harada disease: Report of an international committee on nomenclature. Am J Ophthalmol 2001;131:647-52.  Back to cited text no. 1
[PUBMED]    
2.Forster DJ, Green RL, Rao NA. Unilateral manifestation of the Vogt-Koyanagi-Harada syndrome in a 7-year-old child. Am J Ophthalmol 1991;111:380-2.  Back to cited text no. 2
[PUBMED]    
3.Roe RH, Rathinam SR, Wong RW, McDonald HR, Jumper JM, Cunningham ET Jr. Delayed fellow eye involvement in patients with Vogt-Koyanagi-Harada disease. Br J Ophthalmol 2009;93:701-2.  Back to cited text no. 3
[PUBMED]    
4.Usui Y, Goto H, Sakai J, Takeuchi M, Usui M, Rao NA. Presumed Vogt-Koyanagi-Harada disease with unilateral ocular involvement: Report of three cases. Graefes Arch Clin Exp Ophthalmol 2009;247:1127-32.  Back to cited text no. 4
[PUBMED]    
5.Attia S, Khochtali S, Kahloun R, Zaouali S, Khairallah M. Vogt-Koyanagi-Harada disease. Expert Rev Ophthalmol 2012;7:565-85.  Back to cited text no. 5
    


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