The use of intravitreal ranibizumab for choroidal neovascularization associated with vogt-koyanagi-harada syndrome

Abstract

Purpose. To describe the use of intravitreal ranibizumab for choroidal neovascular membrane (CNVM) secondary to Vogt-Koyanagi-Harada (VKH) syndrome. Methods. Interventional case report. Results. A 50-year-old woman presented with conjunctival injection and bilateral eye pain. Vision was 20/400 and 20/80 in the right and left eyes, respectively. Bilateral iritis, vitritis, and choroidal thickening were evident. Exudative retinal detachment was present in the left eye. Corticosteroid treatment improved vision to 20/40 bilaterally. Methotrexate (MTX) was initiated and vision remained stable for 3 months. After a 5-month loss to follow-up, vision in the left eye decreased to finger counting (CF) and a parafoveal CNVM was identified. After 3 intravitreal ranibizumab injections, vision improved to 20/40. Twelve months later, despite inflammation control, vision decrease to CF due to recurrent CNVM. A fourth ranibizumab injection was given. Twenty months later, best-corrected vision was 20/400, and an inactive CNVM was present in the left eye. Conclusion. After initial CNVM regression and visual acuity improvement due to ranibizumab, the CNVM recurred and became refractory to treatment. Despite control of inflammation and neovascularization, VKH chronicity lead to permanent vision loss in our patient. A combinational treatment approach may be required in such patients.

Figures

Figure 1

Images of the left eye at presentation. (a) Fluorescein angiography shows multiple, punctate, hyperfluorescent RPE changes and optic nerve hyperfluorescence. (b) Optical coherence tomography shows subretinal fluid in the macula.

Figure 2

Images of the left eye after a 5-month loss to follow-up (the visual acuity was finger counting). (a) Fluorescein angiography shows an active CNVM. (b) Optical coherence tomography shows a parafoveal CNVM and mild intraretinal fluid.

Figure 3

Images of the left eye 12 months after the third ranibizumab injection. (a) Color fundus photo shows retinal hemorrhage surrounding a CNVM, hyperpigmented macular RPE, and peripheral RPE hypopigmentation. (b) Fluorescein angiography shows a CNVM and hyperfluorescent, peripheral RPE changes. (c) Optical coherence tomography shows a parafoveal CNVM with a significantly increased amount of intraretinal fluid (compare with Figure 2(b)).