The clinical spectrum of Vogt-Koyanagi-Harada syndrome: A single-center experience from South India

Abstract

Aim
To report the clinical features, investigations, management, and outcome in typical cases of Vogt-Koyanagi-Harada Syndrome (VKH) in a tertiary eye care center in South India.

Materials and methods
Retrospective interventional case series of VKH patients.

Results
Seventy-one eyes of 36 patients (age range 12-68 years) were included. Anatomical diagnoses were posterior uveitis (15 eyes) and pan uveitis (56 eyes). The classification of the cases with regard to VKH disease was as follows: six eyes were classified as complete, 41 eyes as incomplete, and 24 eyes as probable VKH disease. Commonest extraocular manifestation noted in 25 cases was headache. The more common ocular presentations were disc hyperemia (40 eyes) and exudative retinal detachment in the posterior pole (46 eyes) and in the retinal periphery (24 eyes). All patients were managed on systemic steroids. Systemic immunosuppressive therapy was given in 21 cases. Majority of the participants had good visual outcome.

Conclusion
Early recognition and aggressive treatment of VKH disease result in good visual outcome in typical VKH cases.

Full text

Internet Journal of Rheumatology and Clinical Immunology Page 1 of 8
IJRCI. 2013;1(S1):SO2
ORIGINAL ARTICLES
The clinical spectrum of Vogt-Koyanagi-Harada syndrome: A single-center
experience from South India
Padmamalini Mahendradas1*, Ankush Kawali2, Neha Bharti3, Dhawal Haria4, Poornachandra Gowda3, Naren Shetty4,
Rohit Shetty5, Bhujang K Shetty6
1Head of Department of Uveitis and Ocular Immunology, Narayana Nethralaya and Postgraduate Institute of Ophthalmology, 21/C, Chord road,
Rajajinagar, Bangalore
2 Consultant, Department of Uveitis and Ocular Immunology, Narayana Nethralaya and Postgraduate Institute of Ophthalmology
3 Fellow, Vitreo-Retina Services, Narayana Nethralaya and Postgraduate Institute of Ophthalmology
4 Postgraduate, Narayana Nethralaya and Postgraduate Institute of Ophthalmology
5 Vice Chairman, Narayana Nethralaya and Postgraduate Institute of Ophthalmology
Abstract
Aim
To report the clinical features, invesgaons, management, and outcome in typical cases of Vogt-Koyanagi-Harada
Syndrome (VKH) in a terary eye care center in South India.
Materials and methods
Retrospecve intervenonal case series of VKH paents.
Results
Seventy-one eyes of 36 paents (age range 12-68 years) were included. Anatomical diagnoses were posterior uveis
(15 eyes) and pan uveis (56 eyes). The classicaon of the cases with regard to VKH disease was as follows: six eyes
were classied as complete, 41 eyes as incomplete, and 24 eyes as probable VKH disease. Commonest extraocular
manifestaon noted in 25 cases was headache. The more common ocular presentaons were disc hyperemia (40 eyes)
and exudave renal detachment in the posterior pole (46 eyes) and in the renal periphery (24 eyes). All paents were
managed on systemic steroids. Systemic immunosuppressive therapy was given in 21 cases. Majority of the parcipants
had good visual outcome.
Conclusion
Early recognion and aggressive treatment of VKH disease result in good visual outcome in typical VKH cases.
Introduction
Vogt-Koyanagi-Harada syndrome (VKH) is an oculo-
cutaneo-meningeal syndrome characterized by
granulomatous panuveitis associated with neurological,
auditory, and cutaneous manifestations. It is an autoimmune
disorder directed against melanocytes in the uveal tract,
meninges, inner ear, and skin. The disease is commonly
seen in pigmented races. Asians, Native Americans,
Hispanics, Asian Indians and those with Middle Eastern
heritage are most frequently affected, but interestingly the
disease is rare among Sub-Saharan Africans, indicating
that the amount of skin pigmentation alone is not the sole
etiologic factor in the pathogenesis of VKH syndrome.1
Identication of association with major histocompatibility
complex class II antigens, strongly supports an underlying
genetic predisposition in the pathogenesis of the disorder.
In Japan, VKH disease accounts for more than 8% of
uveitis, 2.9% in the Middle East, 1.2% in Europe and 1%
to 4% in the United States.2, 3 In a study done at one of the
referral eye care centers in South India, the prevalence of
VKH in uveitis cohorts was found to be 1.4% to 3.5%.4

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Though ocular manifestations are common, VKH patients
frequently land up in general physician’s clinic or they are
referred to neurologist for their extra-ocular features like
meningism and undergo unnecessary investigations and
imaging, which may further delay the treatment. The disease
has very good prognosis when managed in time by an
ophthalmologist.
The aim of this study is to analyze demographics, clinical
characteristics, treatment response, and complications in
VKH patients referred to a tertiary eye care center in South India.
Materials and methods
This is a retrospective, non-randomized, non-
comparative interventional case series. Patients
diagnosed as typical VKH disease presenting to the
department of uveitis and ocular immunology between
January 2005 and December 2012 in a tertiary eye care
center in Bangalore, India were included in the study.
Institutional ethical committee approval was obtained for
the retrospective chart review for this study. The clinical
records of 35 patients diagnosed with VKH were reviewed
for patient demographics, clinical signs, investigations,
treatment received, complications, and visual outcome. All
patients underwent a complete ophthalmic examination,
including measurement of best corrected visual acuity
(VA), slit-lamp examination, applanation tonometry,
dilated fundus examination with scleral indentation, colour
fundus photography, and ocular ultrasonography (if the
view of the fundus was not clear). External examination
evaluated the presence of poliosis and vitiligo.
The diagnosis of VKH disease was made according to
the clinical presentations and it was conrmed by fundus
uorescein angiography (FFA) in all cases. Additional
investigations such as B-scan ultrasonography, spectral
domain optical coherence tomography (Spectralis,
Hiedelberg engineering) and indocyanine green angiography
(ICG) was done in selected cases. A history of trauma was
ruled out in all cases. Investigations were done to rule out
tuberculosis (Mantoux skin hypersensitivity test, PA view of
chest X-ray), syphilis (Treponema pallidum hemaglutination)
and sarcoidosis (serum angiotensin converting enzyme).
We used revised diagnostic criteria for Vogt-Koyanagi-
Harada disease by Read et al. for classifying the study
participants into complete, incomplete, and probable VKH.5
All patients with associated diseases such as tuberculosis,
sarcoidosis, syphilis or trauma were excluded. All
the patients were treated with systemic corticosteroid
therapy. Topical corticosteroids and immunosuppressive
therapy were used in selected cases. Statistical
analysis was done using the SPSS version 12 software.
Results
Thirty-ve patients were included in the study. Age group
of the subjects ranged between 12-68 years (mean 34.1
years). Eleven patients were male and 24 patients were
female. Thirty-four patients had bilateral presentation
and 1 patient had unilateral VKH. The clinical type of
VKH disease was classied as complete in 3 patients,
incomplete in 20 patients, and probable in 12 patients.
Clinical presentation was posterior uveitis in 15 eyes
and panuveitis in 55 eyes. Thirty eyes (42.8%) had acute
VKH disease, 28 eyes (40%) had chronic presentation,
and 12 eyes (17.1%) had recurrent uveitis. (Table 1)
Meningism and headache were the commonest acute
presentations followed by poliosis and vitiligo in chronic
cases. Sensorineural hearing loss was present in 2 cases
(Table 2). Eighteen eyes presented with best corrected
visual acuity of 20/200 or worse at presentation (Fig 5).
The ocular ndings of slit-lamp examination were
circumciliary congestion in 38 eyes (54.2%), keratic
precipitates in 34 eyes (49.2%) and iris nodules in 12
eyes (17.1%) with the presence of anterior chamber
are and cells (Table 3). Fundus examination revealed
vitritis in 70 eyes (100%), optic disc involvement in 40
eyes (57.1%), exudative retinal detachment in 45 eyes
(64.2%), choroidal detachment in 5 eyes (7.1%), sunset
glow fundus in 39 eyes (55.7%), and Dalen-Fuchs
nodules in 20 eyes (28.5%) (Table 3). FFA was done
in all patients, which revealed multiple hyperuorescent
dots at the level of retinal pigment epithelium in 30 eyes,
optic disc leakage in 55 eyes, and late accumulation of
uorescein in the subretinal space in 31 eyes. The ICG
showed early hypouorescent spots, diffuse choroidal
hyperuorescence, and choroidal perivascular leakage
in 16 cases. Follow-up ICG conducted after 6-8 weeks
revealed multiple hypouorescent lesions, even when the
fundoscopic examination and FFA were unremarkable in
13 cases. Low- to medium- reective diffuse thickening of
the choroid was demonstrated by 20 MHz ultrasonography
and was most marked in the juxtapapillary region. This
was associated with retinal detachments in 45 eyes
and choroidal detachments in ve acute cases. Optical
coherence tomography (OCT) ndings in VKH in active
state were multi-lobular serous retinal detachments,

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intra-retinal edema, subretinal septae, and dot
reex in subretinal space. Dalen-Fuchs nodules and
retinal pigment epithelium (RPE) and choriocapillary
hypertrophy were noted in chronic VKH cases.
Treatment duration ranged from 6 to 36 months (mean18
months). Patients with anterior segment inammation
were treated with topical corticosteroids and cycloplegic
agents, in addition to systemic immunosuppressive
therapy. Two patients who could not tolerate the systemic
immunosuppressive therapy due to transient increase
in liver enzymes were treated with bilateral periocular
posterior subtenon’s triamcinolone acetonide injection
and subsequently with systemic immunosuppressive
therapy. Intravenous methyl prednisolone 1gm once
daily for three days was given to 17 patients (48.5%)
who had serous retinal detachment. Oral prednisolone
acetate was given to all the patients (Table 4). The
median duration of oral prednisolone was 7 months
(range 6-12 months). Two patients who developed
diabetes mellitus during the course of the disease
switched over to deozacort along with azathioprine.
Oral immunosuppressives were used for a median
duration of 14 months (range 6-30 months) in 22 patients
(62.81%). Drugs such as methotrexate (14 patients),
azathioprine (11 patients), mycophenolate mofetil (2
patients) and cyclosporine (1 patient) were used (Table
4). Six patients received two immunosuppressive drugs
and triple immunosuppressive therapy comprising of
mycophenolate mofetil and cyclosporine along with
tapering dose of oral steroids by one patient. Once the
ocular inammation and retinal detachments had resolved,
the fundus changes showed near normal fundus in 5
patients and pigmentary changes with sunset glow fundus
in 15 patients of acute uveitis and all patients of chronic
and recurrent uveitis. Recurrences were seen in 12 eyes
(panuveitis in 8 eyes and posterior uveitis in 4 eyes).
Table 1: Demographic and clinical characteristics of VKH patients
Demographic variables No. (%)
Mean Age (yrs) 34.1 (11- 68)
Gender
Male
Female
11(31.4%)
24 (68.5%)
Laterality
Bilateral 35 (100%)
Anatomical classication
Panuveitis
Posterior
55 eyes (78.9%)
15 eyes (21.1%)
Clinical types
Probable
Incomplete
Complete
24 eyes / 12 patients (34.2%)
40 eyes / 20 patients (57.1%)
6 eyes / 3 patients (8.5)
Course
Acute
Chronic
Recurrent
30 eyes (42.8%)
28 eyes (40%)
12 eyes (17.1%)
Table 2: Incidence of diverse systemic manifestations
Systemic manifestations No. (%)
Meningismus
Headache
Poliosis
Vitiligo
Hearing loss
Tinnitus
20 (57.1)
20 (57.1)
8 (11.4)
12 (34.2)
2 (5.7)
14 (40)

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Anterior segment manifestations No. (%)
Circumciliary congestion 38 eyes (54.2)
Keratic precipitates (KP)
Fine KPs
Mutton fat KPs
34 eyes (49.2)
24 eyes (34.2)
10 eyes (14.2)
Iris nodules 12 eyes (17.1)
Flare
1+
2+
3+
45 eyes (64.2)
23 eyes (32.8)
19 eyes (27.1)
3 eyes (4.2 )
Cells
1+
2+
3+
52 eyes (74.2)
24 eyes (34.2)
25 eyes (35.7)
3 eyes (4.2)
Posterior segment manifestations No. (%)
Vitritis
1+
2+
3+
70 eyes (100)
52 eyes (74.2)
16 eyes (22.8)
2 eyes (2.8)
Disc hyperemia 40 eyes (57.1)
Disc edema 40 eyes (57.1)
Retinal detachment
Posterior pole
Periphery
45 eyes (64.2)
45 eyes
24 eyes
Sunset glow fundus 39 eyes (55.7)
Dalen-Fuchs nodules 20 eyes (28.5)
Choroidal detachment 5 eyes (7.1)
Table 3: Clinical ndings on anterior and posterior segment manifestations
Drugs used No. (%)
Topical corticosteroids 61 eyes (87.1)
Oral steroids 35 patients (100)
Periocular steroids 2 patients (5.7)
Intravenous methyl prednisolone 17 patients (48.5)
Immunosuppressive 22 patients (62.8)
Methotrexate 14 patients (40)
Azathioprine 11 patients (31.4)
Cyclosporine 1 patient (2.8)
Mycophenolate mofetil 2 patients (5.7)
Patients on more than one immunosuppressives 6/22 patients (17.1)
Patients on more than two immunosuppressives 1/22 patient (2.8)
Table 4: Medical management of VKH syndrome

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Figures 1- 4 indicate illustrative clinical ndings observed in VKH patients
Figures 1A - 1C : Extraocular manifestations in chronic VKH syndrome
Figures 2A, 2B: Montage colour fundus photograph of the right eye (Figure 2A) and left eye (Figure 2B) showing the hyperemic disc, multiple serous
retinal detachments in the posterior pole with inferior exudative retinal detachments. Patient was treated with IVMP followed by oral steroids and
systemic methotrexate therapy. The patient further presented with recurrence of inammation after stopping the systemic immunosuppressive therapy
on her own. Subsequently, she was treated with systemic steroids and methotrexate therapy. Follow-up picture 2C and 2D reveals sunset glow fundus
with subretinal brosis.
Figure 3: Chronic VKH-fundus photograph showing sunset glow fundus with Dalen-Fuchs nodules in the left eye. FFA & ICG: Montage image showing
normal uorescein angiogram with hypouorescent dark spots in the indocyanine angiography suggestive of active lesions in the choroid.

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Figure 4: A 21-year- old male diagnosed to have bilateral exudative retinal detachment (Figure 4A, 4B) with multiple pinpoint hyperuorescence
with pooling of the dye (Figure 4C, 4D) treated with triple immunosuppressive therapy, showing complete resolution of the inammation in both eyes
(Figure 4E, 4F).
Visual outcome
In our series of patients, a better than or equal to
20/40 VA was maintained in 54 eyes, while 5 eyes had
poor visual outcome due to cataract formation (Fig 5).
Complications
Complicated cataract, seen in 20 eyes, was the commonest
ocular complication. Increased intraocular pressure in 8
eyes and hypotony and subretinal brosis in 2 eyes (Table
6) were also noted. Extraocular manifestations were seen
in chronic and recurrent cases. Two patient developed
urinary tract infection due to E. Coli infection and one patient
developed pneumonia. All the three patients were managed
with appropriate systemic antibiotic therapy. Transient
increase in liver enzymes was observed in 2 patients.
Fig 5: Visual acuity at presentation and at nal follow-up

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Discussion
Vogt-Koyanagi-Harada disease (VKH), a multisystem
autoimmune disorder targeting predominantly
melanocytes, affects organs such as eye, skin, inner ear
and meninges. In the eye, the disease affects the uveal
tract, manifesting as granulomatous panuveitis. Acute
presentation is characterized by the presence of exudative
retinal detachment with preservation of the choriocapillaris.
In the chronic stage, the disease is characterized by the
presence of Dalen-Fuchs nodules and focal chorioretinal
atrophy with loss of retinal pigment epithelium.6 In chronic
stage, patients develop extraocular manifestations. The
ndings from our study as well as from the earlier reports
show that women are more likely to develop VKH disease
than men, whereas Soon-Phaik Chee et al. have reported
equal distribution in both sexes.7-10, 11 The observations in
elderly patients were similar to the study by Kiyomoto et al.12
The present study ndings are similar to that of Ilknur
Tugal-Tutkun et al. With regard to clinical types of the
disease, incomplete VKH (57.7%) was identied as the
commonest followed by probable (33.8%) and complete
forms (8.4%) as published by Ilknur Tugal-Tutkun et al.13
Extra-ocular manifestations were seen in chronic cases
and the results were similar to hispanic population.14
Whereas these manifestations are more common in
studies involving Japanese patients.12 The early and
aggressive use of corticosteroids in acute VKH disease
prevented the appearance of the complete spectrum of
the disease in the current study, as shown by Rajendram
et al.15 Systemic steroid therapy was given for longer
periods of time along with immunosuppressive therapy.
The diagnosis of VKH disease is based on history and
clinical ndings with supportive evidence from ancillary
tests, including fundus uorescein angiography, which
showed classical presentation such as multiple pin-point
hyperuorescence in the early phase at the level of the
RPE, with classical pooling of the dye in the late phase
in all acute presentations. ICG angiography showed
more extensive areas of involvement characterized
by staining and leakage of the larger choroidal
vessels with multiple hypouorescent dark spots.16, 17
In chronic cases, even in the absence of inammatory activity
on fundus examination and uorescein angiography, ICGA
showed the presence of multiple hypouorescent dots
suggestive of active inammation in the choroid, which
helped us to continue the systemic immunosuppressive
therapy. OCT was used when the media was clear to
document the changes and B scan was used in all acute
cases and also in cases of hazy media, where we could not
visualize the fundus to monitor the response to treatment.
All our patients were treated with systemic steroid
therapy. Periocular steroid injections were given in 2
eyes when the systemic immunsupppressive therapy
was contraindicated due to systemic infection. Systemic
immunosuppressive therapy was given to patients who
needed prolonged high-dose corticosteroids and also in
chronic recurrent disease. Systemic immunosuppressive
therapy was administered to 61.1% of the patients.
Double immunosuppressive therapy was given in 27.3%
cases. Triple immunosuppressive therapy (4.5%) with
mycophoelate mofetil, cyclosporine and systemic steroids
were given to one patient and it resulted in good control of
inammation with good visual recovery. Further prospective
evaluation of the role of immunomodulatory agents in the
treatment of VKH disease is recommended due to small
cohort size and retrospective nature of the present study.
CSF analysis was not done in majority of the cases
and hence the probability of CNS being not involved
is primarily due to the absence of clinical signs and
symptoms. Other limitations of the present study were
non-inclusion of atypical presentations and small study
cohort size. We found that the most frequent ocular
complication of VKH disease was cataract (20 eyes,
28.1%), which is similar to other earlier studies. 5, 18, 19
Further multicentric prospective studies to
explore role of immunomodulatory agents in the
treatment of VKH disease are recommended.
In summary, the clinical features of VKH in South India
are similar to the earlier reports, except for the increased
presentations of posterior segment inammations than the
anterior segment reactions during the recurrences.8 Extra
ocular manifestations were not noticed in acute cases
with aggressive management with systemic steroids and
immunosuppressive therapy. Chronic and recurrent cases
had extraocular manifestations at the time of presentation
in majority of the cases. Early and aggressive therapy
resulted in good visual outcome in majority of our patients.
Acknowledgement
We acknowledge the contribution of the treating physicians (Dr. Keerthy
Shetty and Dr. Shylaja Shyamsundar) and the immunologists (Dr.
Chandrasekara, Dr. Dharmanand, Dr. Mahendranath, Dr. Ramesh Jois
and Dr. Sathish Kalange) for helping us with the systemic management.

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Competing interests
The authors declare that they have no competing interests.
Citation
Mahendradas P, Kawali A, Bharti N, Haria D, Gowda P, Shetty N, Shetty
R, Shetty BK. The clinical spectrum of Vogt-Koyanagi-Harada syndrome:
A single-center experience from South India. IJRCI. 2013;1(S1):SO2.
Received: 1 August 2013, Accepted: 18 December 2013, Published:
26 December 2013
*Correspondence: Dr Padmamalini Mahendradas,
Head of Department of Uveitis and Ocular Immunology,
Narayana Nethralaya,121/C, Chord road, Rajajinagar, Bangalore
m.padmamalini@gmail.com
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