Retromode imaging in Vogt-Koyanagi-Harada disease

Vogt-Koyanagi-Harada (VKH) disease is an idiopathic inflammatory disease characterized by bilateral, chronic, and diffuse granulomatous panuveitis frequently associated with neurological, auditory, and integumentary findings.[1,2] Retroillumination mode (Retromode) fundus imaging with Mirante is a simple, rapid, and noninvasive technique capable of creating “pseudo-three-dimensional” (pseudo-3D) images of the retina.[3] The current report highlights features of retromode imaging in the diagnosis of VKH disease. Case Description A 25-year-old female presented with a history of headache and decreased vision in both eyes since 1 week. Her best corrected visual acuity was 20/200 in the right eye and 20/70 in the left eye. Intraocular pressures were normal in both eyes. Slit-lamp examination showed mild circumciliary congestion with cells in the anterior chamber of both eyes. Fundus examination showed pockets of subretinal fluid in both eyes [Fig. 1a and b]. Spectral-domain optical coherence tomography (SD-OCT) showed septated subretinal fluid in both eyes [Fig. 1c and d]. Fundus fluorescein angiography (FFA) revealed multiple pinpoint leaking spots with pooling of dye in the neurosensory detachment and disc leak [Fig. 2a and b]. Retromode fundus imaging on the Mirante scanning laser ophthalmoscopy (SLO) imaging platform (Nidek Co. Ltd.) showed hyporeflective dark dots throughout the posterior pole corresponding to hyperfluorescent leaks on FFA [Fig. 2c and d]. A diagnosis of VKH disease was made, and she was treated with high-dose systemic, topical steroids, and mydriatics. On 1 month follow-up, there was resolution of subretinal fluid in both eyes [Fig. 3a and b]. There was persistence of hyporeflective dark dots throughout the posterior pole on retromode imaging [Fig. 3c and d].Figure 1: Fundus examination of the right eye (a) and left eye (b) showing pockets of subretinal fluid (arrow). SD-OCT of the right eye (c) and left eye (d) showing septated subretinal fluid (star)Figure 2: FFA of right (a) and left eye (b) showing multiple pinpoint leaking spots (arrow) with pooling of dye in the neurosensory detachment and disc leak. Retromode imaging of right (c) and left eye (d) showing hyporeflective dark dots (arrow) throughout the posterior pole corresponding to hyperfluorescent leaks on FFAFigure 3: Fundus examination of right (a) and left eye (b) showing resolution of subretinal fluid on follow-up (arrow). Retromode imaging of right (c) and left eye (d) showing hyporeflective dark dots (arrow) throughout the posterior poleDiscussion VKH is an autoimmune disease that affects tissues containing melanin. The most common symptoms include vitiligo, headaches, hair loss (alopecia), and hearing loss. Early and aggressive systemic corticosteroids are the primary initial therapy for VKH.[4] Multimodal retinal imaging such as the Mirante is becoming increasingly popular for assessing vitreoretinal pathology. Retromode imaging is performed by SLO working at infrared wavelength (790 nm) that uses a laterally deviated confocal aperture with a central stop that creates a shadow and allows deeper retinal and retinal pigment epithelium changes to be visualized.[5,6] Hyporeflective dark dots (HDDs) were clearly visible on retromode imaging in our case. Kinoshita et al.[7] have reported the utility of retromode imaging in detecting and monitoring choroidal folds in VKH disease. Retromode imaging is a noninvasive technique that can reveal HDD as seen on Indocyanine green angiography (ICGA) and may add to the armamentarium of retinal imaging in uveitic eyes. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.