Immunosuppressive therapy for Vogt-Koyanagi-Harada disease: a retrospective study and review of literature

BACKGROUND: Vogt-Koyanagi-Harada (VKH) disease is an idiopathic autoimmune disease which targets melanin-containing tissues such as the uvea, meninges, ear and skin. This typically presents in the eye with acute findings of granulomatous anterior uveitis, diffuse choroidal thickening, multiple focal areas of sub-retinal fluid and, in severe cases, optic nerve involvement with bullous serous retinal detachment can occur. Early initiation of treatment has been advocated to prevent progression to the chronic stage of the disease, which can result to a sunset glow fundus with devastatingly poor visual outcome. Treatment is usually initiated with corticosteroids followed by an early introduction of immunosuppressive treatment (IMT) to achieve immediate response after disease presentation, although the choice of IMT for VKH can vary. MAIN FINDINGS: We conducted a retrospective case-series to investigate the management trend of treating VKH over a 20-year period. Twenty-six patients were included and we found a shift from steroid monotherapy to combined IMT/low-dose steroid for the management of acute initial-onset of VKH in the last 10 years. Our average time from diagnosis to initiation of IMT was 2.1 months. 81% (21 of 26 patients) of our patients treated with combined IMT/steroid were able to achieve disease stability with significant good visual outcome at 24 months (Median VA(pre-IMT) = 0.3 Logmar vs VA(post-IMT) = 0.0 Logmar, p = 0.0001). MMF monotherapy was the most common IMT used and it was well-tolerated by our patients. Even so, 50% of our patients who were treated with MMF did not achieve disease control. We then performed a literature review to identify any IMT which could be superior in the treatment of VKH. We also share our experience (where applicable) on the various treatment options found from the literature review. SHORT CONCLUSION: Our study found that patients with VKH who were treated with combined IMT/low-dose steroids achieved significantly better visual improvement at 24 months compared to steroid monotherapy. We frequently chose MMF and this appears to be well tolerated by our patients. Since its introduction, anti-TNF agents are increasingly becoming a popular choice of treatment for VKH as these have been shown to be safe and effective. However, more data is required to provide evidence that anti-TNF agents can be used as first-line treatment and as monotherapy.