Title

MANAGEMENT OF CHOROIDAL NEOVASCULARIZATION (CNV) IN A PATIENT WITH VOGT-KOYANAGI-HARADA DISEASE (VKHD): A CLINICAL CASE

Summary

A 15-yo female student from São Paulo presented with progressive blurred vision in both eyes (OU) for 30 days associated with tinnitus and headache. Past medical history: hypothyroidism; past ocular history: unremarkable. On initial exam, visual acuity (VA) was hand motions in OU. At slit lamp there were 3+ of anterior chamber cells (ACC), posterior synechiae and 2+ cells in anterior vitreous in OU. Dilated fundus examination revealed optic disc edema and hyperemia and exudative retinal detachment in posterior pole. Fluorescein angiography (AFG): multiple pinpoints and optic disk hyperfluorescence; indocyanine green angiography (ICGA): diffuse hyperfluorescence of the choroid, optic disk hyperfluorescence and dark dots; optic coherence tomography (OCT): serous retinal detachment in macular area and a marked thickened choroid on enhanced depth image. Systemic work-up was unremarkable, except for cerebral spinal fluid pleocytosis. A diagnosis of incomplete VKHD was made and the patient underwent 3-day pulsetherapy with methylprednisolone (1g/day) followed by oral prednisone (1mg/kg/day) with slow tapering. At M18 patient was still under 10mg/day of prednisone due to low grade persistent ACC, VA was 1,0 OU. At M21, ACC increased to 3+ in OU and there was fluctuation of choroidal signs of inflammation (ICGA). Prednisone dose was increased to 30mg/day in addition of azathioprine (AZA) 50mg/day. At M29, while under prednisone dose of 5mg/day and AZA 100mg/day and VA of 1.0 OU, AFG and ICGA revealed a peripapillary CNV in left eye (OS) and OCT showed intraretinal cists associated with this CNV. AZA dose was increased to 150mg/day (2.1mg/kg/day) concomitantly with 3-monthly intravitreal injections of bevacizumab in OS. At M35 VA remained stable (1,0 OU) and there were no signs of activity of CNV. At M71 without systemic medications, VA was 1,0 OU and there were no signs of activity of CNV. This clinical case reminds the inflammatory nature of CNV in VKHD.

Area

CLINICAL CASE

Authors

Fernanda Maria Silveira Souto, Marcelo Mendes Lavezzo, Viviane Mayumi Sakata, Ruy Felippe Brito Gonçalves Missaka, Priscilla Figueiredo Campos Nóbrega, Carlos Eduardo Hirata, Sérgio Luis Gianotti Pimentel, Joyce Hisae Yamamoto