Vogt–Koyanagi–Harada disease misdiagnosed as angle closure: Demographic characteristics, clinical presentation, and visual outcomes

PURPOSE: To describe the clinical presentation, diagnostic delay, management, and visual outcomes of Vogt-Koyanagi-Harada (VKH) disease presenting initially as angle closure. METHODS: This retrospective study reviewed the medical records of patients diagnosed with VKH who initially presented with angle closure between January 2013 and December 2020. Clinical features, intraocular pressure (IOP), imaging, treatment modalities, and final visual outcomes were analyzed. Univariate and multivariate analyses were performed to identify factors influencing final BCVA (best corrected visual acuity). RESULTS: Among 768 VKH patients, 18 patients (36 eyes; 3.94%) presented with angle closure with a mean age of 44.4 years and a female preponderance (89%). Eighteen eyes had primary angle closure (PAC), and 18 eyes had secondary angle closure glaucoma (SACG) at presentation. The mean IOP at final follow-up decreased from 26.3 to 14 mmHg. Fundus evaluation was deferred in many due to media opacities, leading to delayed VKH diagnosis (median delay: 1 month to 7 years). Ancillary imaging revealed choroidal thickening and ciliochoroidal effusion in four eyes. Poorer presenting BCVA and delayed diagnosis (>1 month) were associated with worse final BCVA ( P = 0.011 and P = 0.0066, respectively) in univariate analysis, while presenting BCVA remained a statistically significant independent predictor of final visual outcome (p 0.039) in multivariate analysis. CONCLUSION: VKH can uncommonly present as angle closure, often mimicking PAC or SACG. Early clinical suspicion, use of posterior segment imaging (optical coherence tomography, B-scan, ultrasound biomicroscopy), and prompt immunosuppressive therapy are essential for optimal management.