Design: Single-centre retrospective case series
Population: 18 patients (36 eyes) among 768 with VKH who presented with angle closure
Primary outcome: Presentation, diagnostic delay and final visual acuity
Effect: Diagnostic delay 1 month to 7 years; presenting BCVA independently predicted final BCVA (p = 0.039)

This retrospective study from an Indian tertiary eye hospital reviewed 768 patients with Vogt-Koyanagi-Harada disease seen between 2013 and 2020. Eighteen patients, 36 eyes or 3.9%, first presented with angle closure: half primary angle closure and half secondary angle closure glaucoma. Mean age was 44, and 89% were women.

The fundus was often not examined at first because of media opacity, and the diagnosis of VKH was delayed by between one month and seven years. Imaging, where done, showed choroidal thickening and ciliochoroidal effusion. With treatment, mean pressure fell from 26.3 to 14 mmHg. Poor presenting vision and delay of more than a month were associated with worse final vision on univariate analysis; presenting vision remained the independent predictor.

The lesson is a familiar one for any secondary angle closure: bilateral shallowing, especially with inflammation or in a younger patient, should prompt a look behind the lens. Ultrasound biomicroscopy, B-scan and OCT can show choroidal thickening or effusion even when the media are hazy, and recognising VKH changes treatment from laser and surgery to immunosuppression.

Consider secondary causes when angle closure is bilateral, especially with inflammation.
Use B-scan, ultrasound biomicroscopy or OCT to look for choroidal thickening when the fundus is hidden.
Ask about headache, tinnitus, hearing change and skin or hair changes that suggest VKH.
Refer promptly to uveitis services when VKH is suspected, since delay was linked to worse vision.
Do not rely on peripheral iridotomy alone until the cause of angle closure is clear.

Why it matters

Treating VKH as primary angle closure delays the immunosuppression that protects vision.

The statistics, in plain English

The association between delay and worse vision came from univariate analysis and did not hold on multivariate analysis, so it may partly reflect that patients diagnosed late also presented with worse vision. The series is small, 18 patients, and descriptive.