Combination Intravitreal Therapy With Ranibizumab and Triamcinolone for Refractory Serous Macular Detachment in Vogt Koyanagi Harada Disease

Abstract

Purpose: : To describe the management of a case of refractory and recurrent Vogt Koyanagi Harara Disease

Methods: : We report the case of a 42-year-old woman from Argentina who attended our Ocular Emergency Department complaining for periocular pain and bilateral visual impairment for the last two weeks. She also referred tinnitus and hair whitening. Her BCVA was 20/100 OD and light perception OS. Our ophthalmological examination revealed a 2+ panuveitis with papillary edema and multifocal retinal serous detachment OU. The OCT exam showed a macular thickness of 659 microns OD and 1329 microns OS. We performed a fluorescein angiography showing a typical mottling pattern in both macular areas. The diagnosis was Vogt-Koyanagi-Harada disease. The patient followed ambulatory treatment with oral corticosteroids megadoses (Methylprednisolone, 1 gram every day) associated with topical Dexamethasone (1 drop every 2 hours). Five days later the BCVA was 20/30 OD and 20/40 OS and macular thickness was 280 OD and 326 OS. The patient followed oral corticosteroid treatment with Prednisone (1 mg/kg every day) and topical Dexamethasone (1 drop every 4 hours) but one week later she showed reactivation of the disease and therefore we added to the treatment Cyclosporine A (150 mg every 12 hours) and Adalimumab (40 mg every 15 days). Despite this therapeutic strengthen, the inflammation was still severe and we decided to associate oral Methotrexate (15 mg every week) and intravitreal Dexamethasone (0,4 mg) OU. However, macular thickness remained high and BCVA was 20/200 OD and 20/400 OS. By then we administered intravitreal association of Bevacizumab (0,05 ml) and Triamcinolone (0,1 ml) OU.

Results: : The results were excellent and 1 month later BCVA was 20/60 OU with no signs of intraocular inflammation and macular thickess of 270 microns OD and 281 microns OS.

Conclusions: : Intravitreal treatment with corticosteroids and/or VEGF inhibitors may be useful in order to manage uveitic macular edema refracrory to systemic immunomodulation

Keywords: uvea • vascular endothelial growth factor • retinochoroiditis