Outcomes of early treatment in acute Vogt-Koyanagi-Harada disease: a 24-month retrospective analysis

Background To evaluate structural and functional outcomes in patients with acute Vogt-Koyanagi-Harada (VKH) disease, based on the timing of systemic corticosteroid (CS) initiation and the early introduction of noncorticosteroid immunomodulatory therapy (IMT). Methods This retrospective single-centre study included 35 consecutive patients (70 eyes) diagnosed with acute Vogt-Koyanagi-Harada disease at a tertiary center in São Paulo, Brazil. Patients received methylprednisolone pulse therapy (1,000 mg/day, 3 days) followed by gradually tapered oral prednisone (1 mg/kg/day). Patients were classified by the timing of CS initiation. The early treatment group (ETG, n = 24) initiated CS within 30 days of onset and comprised two subgroups: CS monotherapy (Group 1, n = 9) and CS plus IMT within 3 months (Group 2, n = 15). Those treated after 30 days because of late presentation formed the late treatment group (LTG, Group 3, n = 11). Follow-up was 24 months with multimodal imaging and full-field electroretinography. Results At 24 months, 98.6% of the eyes achieved BCVA ≤ 0.3 logMAR (Snellen 20/40), with no significant differences among the groups. Compared with Groups 1 and 3, Group 2 achieved a prednisone dose of ≤ 10 mg sooner (7.3 ± 1.8 months; p = 0.043) and had a significantly lower cumulative dose (8,719 ± 3,067 mg; p = 0.02). BCVA worsening episodes occurred less frequently in Group 2 than in Group 3 (6.7% vs. 59.1%; p < 0.001). Compared with the ETG, the LTG presented higher rates of BCVA worsening episodes (59.1% vs. 16.7%; p = 0.004), anterior uveitis recurrences (45.5% vs. 8.3%; p = 0.02), subretinal fibrosis (45.5% vs. 8.3%; p = 0.02), and peripapillary atrophy (72.7% vs. 22.9%; p = 0.003). Adverse events occurred in 7 patients (20%): 6 related to azathioprine and 1 related to CS therapy. Conclusions Early initiation of high-dose CS in VKH disease patients was associated with fewer relapses and structural complications. Early IMT introduction provided a CS-sparing effect, although it did not significantly improve visual or structural outcomes. Prompt CS initiation remains critical; further studies should identify patients who may benefit most from early IMT.