1. Atypical case of Vogt- Koyanagi-Harada disease
Rim Kahloun
Nesrine Abroug
Moncef Khairallah
Department of ophthalmology
Fattouma Bourguiba University Hospital
Faculty of Medicine,University of Monastir
Monastir, Tunisia

2. History
53-year-old woman
History of systemic hypertension
Progressive decrease in visual acuity in the left eye (OS)

3. First Presentation Visual acuity: 20/32 OD; 20/100 OS
No cells or flare in anterior chamber OD
0.5+ anterior chamber cells OS
Intraocular pressure: 19 mmHg OD, 25 mmHg OS
No cells or flare in vitreous OU
Anterior segment photograph was normal OD, and shows a sunset glow ‘pupil’ appearance and posterior synechiae OS.

4. Fundus examination shows optic disc edema and multifocal serous retinal detachment OD, and a sunset glow fundus OS.

5. Fluorescein angiographyB C
Early (A) and mid-phase (B) fluorescein angiogram OD show areas of delayed choriocapillaris filling. (C) Late-phase fluorescein angiogram shows multiple pinpoints and optic disc staining.

6. Fluorescein angiographyB
Early-phase (A) and late-phase (B) fluorescein angiogram OS show areas of retinal pigment epithelial changes predominating around optic disc

7. Optical coherence tomography
OD: OCT shows ERD with multifocal folds of the retinal pigment epithelium and Bruch’s membrane
OS: normal

8. Ultrasonography A B
OD (A): 20-MHz ultrasonography shows diffuse low- to medium-reflective choroidal thickening most marked in the posterior fundus
OS (B): choroidal atrophy

9. Initial differential diagnosis
Atypical Vogt-Koyanagi-Harada disease
Sympathetic Ophthalmia
Posterior scleritis

10. Work-up Internal Medicine examination: normal
Syphilis serology: negative

11. Atypical Vogt Koyanagi Harada (VKH) disease
Final diagnosis
Atypical Vogt Koyanagi Harada (VKH) disease

12. Treatment
Systemic prednisone 1 mg/Kg/day

13. Follow-up Three months after Visual acuity: 20/25 OD; 20/32 OS
Sunset glow fundus
Normal fundus appearance

14. Conclusion
Atypical case of VKH disease with features of acute phase in one eye and chronic convalescent phase in the fellow eye
It may be related to an asymmetric T cell-mediated autoimmune reaction against one or more antigens found on or associated with melanocytes
Awareness of asymmetric or “apparently” unilateral acute VKH disease is of utmost importance for early initiation of corticosteroid therapy to prevent chronic disease, recurrences, complications, and subsequent visual loss