Vogt–Koyanagi–Harada syndrome: the useful role of punch grafting

Abstract

A 19-year-old woman presented with photophobia, pain in the eyes and diminishing vision for 12 years, intermittent fever associated with headache, giddiness, and nausea for 8 years, and depigmented macular lesions bilaterally around the eyes for 8 years. Examination revealed mild exophthalmos, poliosis of the eyelashes, depigmented macules over the bilateral upper and lower eyelids ( Fig. 1), and loss of hair over the scalp. An ophthalmologic evaluation revealed circumcorneal congestion in the eyes with fine pigmented keratotic precipitates and irregular pupils, suggesting iridocyclitis. The right eye showed vitreous opacities. Vision was 6/36 on either side and the intraocular pressure was 10 mmHg and 12 mmHg on the left and right eyes, respectively. Examinations of other areas of the body and other systems, including the nervous system, were within normal limits. Figure 1 Periorbital. depigmentation, exophthalmos, and circumcorneal congestion Download figure to PowerPoint Investigations, such as complete blood picture, liver and renal function tests, human immunodeficiency virus (HIV) testing, and audiometry were within normal limits. The eye complaints were controlled with prednisolone at a dose of 10–40 mg. The depigmented macules were unaffected by several medications, including topical corticosteroids and PUVASOL therapy (oral 8-methoxypsoralen followed by exposure to sunlight for 5–10 min for 3 days in a week). Because of cosmetic disfigurement, we performed autologous punch grafting on the depigmented macules. The donor area (retroauricular sulcus) and the recipient area (eyelid skin) were surgically prepared and anesthetized with 1% lignocaine containing epinephrine (1 : 100,000). The donor grafts were taken from the left retroauricular sulcus using a 2.25-mm punch, nontraumatizing forceps and iris scissors. The grafts were stored in normal saline. Similarly, grafts of 2 mm in size were taken from the recipient areas to form circular chambers or beds 5 mm apart. The stored grafts were then transferred to the recipient chambers by nontraumatizing forceps. After achieving hemostasis, the grafted area was covered with a double layer of framycetin tulle dressing. The dressing was removed on the fifth day and PUVASOL therapy was resumed 2 weeks after the procedure. The lesions pigmented completely ( Figs 2 and 3) in about 1 year. Figure 2 Depigmented. lesions immediately after punch grafting Download figure to PowerPoint Figure 3 The. lesions 6 months after punch grafting Download figure to PowerPoint