Indocyanine green angiography guided management of Vogt-Koyanagi-Harada disease

To report the management of Vogt-Koyanagi-Harada [VKH] disease based on indocyanine green angiography [ICGA]. VKH patients with acute episodes of inflammation [inaugural or recurrent] who had received standard ICGA-guided care were studied retrospectively. Standard of care included high dose systemic corticosteroids at presentation and close ICGA follow-up with addition of immunosuppressive agents and/or intensification of ongoing therapy when recurrent choroidal lesions were detected by ICGA. Visual acuity, number of subclinical recurrences, type and duration of therapy, proportion of quiescent patients after therapy, and ICGA findings were recorded. Nine patients including 8 female and one male subject were studied. Five patients had inaugural disease and 4 presented with recurrent acute episodes. Visual acuity increased from 0.86 +/- 0.36 to 1.14 +/- 0.34 in the right eyes, and from 0.77 +/- 0.34 to 1.05 +/- 0.33 in the left eyes. The number of ICGA-detected occult choroidal recurrences amounted to 13. Mean duration of treatment was 30.1 +/- 34.6 months leading to recurrence-free status after discontinuation of therapy in 6 cases with mean duration of 29.5 months. Continuous monitoring and aggressive therapy guided by ICGA in VKH disease prolongs treatment as compared to textbook guidelines but offers the prospect of reaching inflammation-free status after discontinuation of therapy. Zero tolerance to subclinical choroidal inflammation avoids irremediable evolution towards sunset glow fundus in patients treated early after the initial acute inflammatory attack

Fuchs' Uveitis: Failure to associate vitritis and disc hyperfluorescence with the disease is the major factor for misdiagnosis and diagnostic delay

Fuchs' uveitis is often diagnosed with substantial delay at the origin of deleterious consequences such as unnecessary treatment. The aim of the study was to analyze the type and frequency of posterior inflammatory and fluorescein angiographic signs in Fuchs' uveitis in conjunction with the other clinical signs and evaluate their respective importane in the diagnosis of the disease. In particular, diagnostic delay and erroneous diagnosis were investigated. Patients seen in our centers between 1995 and 2008 with the diagnosis of Fuchs' uveitis were analyzed. The data collected included age, initial and final visual acuities; clinical findings at presentation, mean diagnostic delay, erroneous diagnosis, laser flare photometry values, fundus and fluorescein angiography manifestations and ocular complications. One hundred and five patients were included. The mean age at diagnosis was 34 years. Twelve patients [11.4%] had bilateral involvement. The mean diagnostic delay was 3.04 +/- 4.30 years. The most frequent clinical signs were vitreous infiltration [97.40%], typical Fuchs' keratic precipitates [94.90%], crystalline lens opacities or cataract [47%], heterochromia [42.60%], ocular hypertension or glaucoma [12.80%]. The mean laser flare photometry value at presentation was 9.85 +/- 6.28 ph/ms. Thirty-nine patients [37.14%] had undergone fluorescein angiography showing disc hyperfluorescence in 97.7% and peripheral retinal vascular leakage in 13.6%. Fuchs' uveitis is significantly underdiagnosed likely because vitreous involvement was previously described but not commonly recognized as an association with Fuchs' uveitis in the clinician's mind and therefore has often been given a different diagnostic label, Moreover, the very frequent inflammatory signs on fluorescein angiography such as disc hyperfluorescence and more rarely peripheral retinal vascular leakage, which has not been typically associated with Fuchs' uveitis, appear to represent an additional factors leading to misdiagnosis. Such clinical findings need to be publicized in order to reduce misdiagnosis, and diagnostic delay