Role of intravitreal triamcinolone as an adjuvant in the management of Vogt-Koyanagi-Harada disease.

Dear Editor,

Prolonged administration of systemic corticosteroids is the preferred treatment for Vogt-Koyanagi-Harada disease (VKH).1 Oral corticosteroid is associated with systemic complications although it achieves effective intraocular concentration.2 The long half-life of intravitreal triamcinolone (IVTA) is beneficial for various retinal conditions including uveitis.3 We conducted a study to find out if administration of two IVTA at three-month interval would resolve intraocular inflammation and reduce the duration and dosage of oral corticosteroid. This was an open-label unmasked nonrandomized trial with a historical control.

All eyes included in the study fulfilled the revised diagnostic criteria of probable VKH disease (isolated ocular disease).4

In Group A consisting of eight eyes of four consecutive cases of VKH, 4 mg/0.1 ml of IVTA was given in operating room under strict aseptic conditions on day one. Oral prednisolone was started as a once daily dose of 1 mg/kg body weight, which was tapered fast (i.e., every third day) and given for the first month only. Oral azathioprine (1 to 2 mg/kg/day) was given for the first four months. Intravitreal triamcinolone was repeated at the end of three months. Patients with duration of follow-up more than six months were included for the study. All patients in Group A had duration of symptoms less than 30 days.

Group B consisted of 18 eyes (historical controls) with a duration of symptoms less than 30 days that were treated at the institute just prior to this study using the prior protocol for treatment of VKH. Intravenous methylprednisolone - three pulses of 500 mg-1g over 1 to 2 h on three consecutive days was given, followed by oral prednisolone started as a once daily dose of 1 mg/kg body weight and tapered as suggested by Jabs DA and Rosenbaum.5 Steroid-sparing immunosuppressives (oral azathioprine - Cases 1, 2, 3, 4, 7, 8 and oral cyclophosphamide - Cases 5, 6) were used. These agents were used for a median duration of 14 months. The details of the patients in the two groups are given in Table 1,Table 2. All patients in Group B had completed six months of follow-up.

Table 1

Group A: Eight eyes of four cases of VKH treated with intravitreal triamcinolone + systemic corticosteroids and steroid-sparing immunosuppressives

Table 2

Group B: 18 eyes of nine cases of Vogt-Koyanagi-Harada treated with systemic corticosteroids and steroid-sparing immunosuppressives

Favorable clinical outcome was defined as a visual acuity of greater than 20/80 (measured using Snellen′s chart under standard conditions) and absence of cells in the anterior chamber and vitreous on slit lamp evaluation at the end of six months.

At the end of six months, resolution of inflammation was achieved in all eyes in both groups as assessed on slit-lamp. None of the patients in Group A required use of intravenous methylprednisolone.

Because rise in intraocular pressure is the foremost concern when treating with IVTA we recorded the intraocular pressures of the eyes treated with IVTA in Group A and found that there was no rise of intraocular pressure in our study patients.

All patients in Group B required intravenous methylprednisolone. The mean duration of treatment with systemic corticosteroids in Group B was 14.9 months (SD=13.1) 95%CI [4.8-25]. The sign rank test done to compare the mean duration of treatment with oral corticosteroids in the two groups estimated P < 0.001. Intravitreal triamcinolone providing short-term improvement in visual acuity and resolution of serous detachment in the acute stage of VKH disease has been reported by Andrade et al .6 However, their study did not show if use of IVTA could help avoid prolonged use of systemic corticosteroids. In our study, apart from noting favorable clinical outcome in both the groups, the group which had received two IVTA at three-month interval had a shorter duration of oral corticosteroid administration which was clinically significant and also achieved statistical significance. Thus the longer half-life and slow clearance of triamcinolone from the vitreous could mimic gradual taper of oral corticosteroids.

To conclude, IVTA when used as adjuvant can induce remission in acute stage of VKH and help avoid the long-term use of systemic corticosteroids.