Research report: Short-term outcomes associated with oral prednisolone versus posterior sub-Tenon triamcinolone acetonide in acute ocular Vogt-Koyanagi-Harada disease

A retrospective study of 30 patients with acute ocular Vogt–Koyanagi–Harada (VKH) disease has found no statistically significant differences between oral prednisolone and posterior sub-Tenon triamcinolone acetonide injections (PST/STA) in the short-term clinical and anatomical outcomes assessed. The research, conducted at Benha University Hospital in Egypt and published in BMC Ophthalmology, compared the two corticosteroid-based strategies as initial treatment in treatment-naïve patients seen between January 2021 and December 2025. But the authors themselves caution that the design of the study, the small sample size, and a shortened systemic steroid regimen mean the results describe a real-world experience rather than evidence that the two treatments are equally effective.

VKH disease is a rare, multisystem, T cell–mediated autoimmune disorder that targets melanocyte-containing tissues, predominantly affecting the uveal tract, meninges, inner ear, and skin. In its acute ocular form it typically presents as bilateral granulomatous panuveitis, with diffuse choroidal inflammation, serous retinal detachments, and optic nerve swelling. Systemic manifestations such as meningismus, tinnitus, and skin changes may appear later. If inflammation is left untreated or inadequately controlled, the disease can progress to a chronic recurrent phase marked by the depigmented “sunset-glow” fundus and long-term complications including cataract, glaucoma, and significant visual impairment. Early and aggressive suppression of ocular inflammation is therefore considered critical to limiting both immediate tissue damage and long-term sequelae.

The standard of care has long been high-dose systemic corticosteroids, given orally at 1 to 1.5 mg/kg/day or intravenously as pulse therapy, followed by a gradual taper over at least six months. Prompt initiation and slow tapering are associated with lower recurrence risk and better visual outcomes. However, systemic corticosteroids carry well-documented adverse effects, including hyperglycemia, hypertension, immunosuppression, cataract, and steroid-induced glaucoma. Local strategies such as periocular triamcinolone injections have been explored as primary or adjunctive alternatives because they deliver the drug directly to the eye and may reduce systemic exposure. An earlier observational study by Hosoda and colleagues reported complete resolution without recurrence in 21 of 27 eyes (78%) treated with primary PST/STA in acute VKH, but high-level comparative evidence has remained limited, with most prior work retrospective, small, and heterogeneous in protocol.

In the new study, researchers reviewed medical records of all patients diagnosed with acute-onset ocular VKH during the five-year period, identifying 36 patients. Six were excluded—three for prior systemic corticosteroid treatment, two for not meeting the study’s diagnostic designation, and one for incomplete records—leaving 30 treatment-naïve patients, all with bilateral disease, for analysis. Fifteen received oral prednisolone at 1.0 mg/kg/day, tapered over three to six weeks, and fifteen received posterior sub-Tenon triamcinolone acetonide injections of 40 mg, with a repeat injection after four to six weeks if inflammation persisted. Treatment assignment was not randomized: patients with predominantly ocular disease and minimal systemic involvement were preferentially given PST/STA, while those with significant neurologic, auditory, or other systemic manifestations, severe panuveitis, or contraindications to systemic steroids were preferentially given oral prednisolone.

The primary outcome was complete clinical and anatomical ocular control at three months, a composite endpoint requiring absence of clinically active intraocular inflammation, resolution of subretinal fluid on optical coherence tomography (OCT), and stable or improved best-corrected visual acuity (BCVA), each assessed bilaterally. At three months, 12 of 15 patients (80.0%) in the prednisolone group and 11 of 15 (73.3%) in the PST/STA group achieved this composite outcome, with no significant difference (p = 1.00, Fisher’s exact test). Resolution of subretinal fluid occurred in 86.7% and 80.0% of patients respectively, also without significant difference. Rescue therapy, required by three prednisolone-treated and four PST/STA-treated patients within three months, was treated as initial-treatment failure in the analysis.

Visual acuity improved significantly in both groups over six months of follow-up, with no significant between-group differences at any time point. Both groups also showed anatomical improvement on OCT, including reduction or resolution of subretinal fluid and improvement in central macular thickness. Recurrence, defined as reappearance of active inflammation and/or new subretinal fluid after documented quiescence, occurred in three of 15 patients (20.0%) in the prednisolone group and four of 15 (26.7%) in the PST/STA group, with no significant difference in recurrence-free survival (log-rank p = 0.68). Median recurrence-free survival was not reached in either group, and no patient was lost to follow-up.

Safety findings differed in pattern, though interpretation is constrained by missing baseline data. Systemic corticosteroid–related metabolic complications, including hyperglycemia and hypertension, were observed only in the prednisolone group, while PST/STA was associated with transient local injection discomfort and mild intraocular pressure elevation. No serious ocular complications such as endophthalmitis or retinal detachment occurred. The authors note that baseline diabetes status, glucose control, hypertension, and concurrent medications were not systematically extracted, and because contraindications to systemic steroids influenced treatment allocation, the metabolic events cannot be fully distinguished from progression of pre-existing, unreported disease. None of the patients received immunomodulatory therapy at any point, so all outcomes reflect corticosteroid treatment alone.

The authors are unusually explicit that the study cannot support claims of equivalence. Because treatment allocation was guided by disease severity and systemic involvement, confounding by indication is substantial, and similarity in measured baseline variables does not establish comparable overall disease severity. With only 15 patients per group, no a priori sample-size calculation, and no prespecified equivalence or non-inferiority margin, non-significant p-values cannot be interpreted as evidence of comparable efficacy; wide confidence intervals indicate that clinically meaningful differences in either direction cannot be excluded. Only seven recurrence events occurred, limiting precision. Inflammation was graded qualitatively rather than with standardized instruments such as the SUN scale, and subretinal fluid resolution was assessed qualitatively rather than quantified by height, area, or volume.

Two further caveats shape how the findings should be read. First, the oral prednisolone regimen was abbreviated: patients received an estimated cumulative dose of roughly 18 to 28 mg/kg over four to seven weeks, far below the prolonged six-month taper recommended in international VKH literature, where shorter courses are associated with higher relapse rates. The study therefore compares PST/STA with a shortened systemic strategy, not with standard contemporary systemic treatment. Second, structural OCT reflects retinal recovery but cannot establish resolution of choroidal inflammation; choroidal thickness measurements and indocyanine green angiography were not systematically performed, so persistent subclinical choroidal activity could not be assessed. Additionally, six-month outcomes for the seven rescued patients reflect mixed treatment exposure, and the six-month follow-up is too short to capture late recurrences or progression to chronic disease.

The authors conclude that the results represent descriptive observations from two differently selected real-world treatment strategies rather than evidence of therapeutic equivalence. They suggest that localized corticosteroid therapy may have a role in carefully selected patients with predominantly ocular disease and limited systemic involvement, particularly when minimizing systemic corticosteroid exposure is clinically desirable, while emphasizing that PST/STA should not be regarded as a substitute for systemic therapy in patients with significant extraocular manifestations. Larger prospective, multicenter studies with standardized severity assessment, multimodal imaging including quantitative choroidal measurements, longer follow-up, predefined rescue criteria, and early immunomodulatory therapy strategies are needed to determine the optimal approach to acute VKH disease.

Subject of Research: Short-term outcomes of oral prednisolone versus posterior sub-Tenon triamcinolone acetonide as initial treatment for acute ocular Vogt–Koyanagi–Harada disease

Article Title: Short-term outcomes associated with oral prednisolone versus posterior sub-Tenon triamcinolone acetonide in acute ocular Vogt-Koyanagi-Harada disease

Article References: Saad, E. M. E., Abouelela, M. I., & Elsayed, M. A. (2026). Short-term outcomes associated with oral prednisolone versus posterior sub-Tenon triamcinolone acetonide in acute ocular Vogt-Koyanagi-Harada disease. BMC Ophthalmology, 26(1), Article 685. https://doi.org/10.1186/s12886-026-05448-7

Image Credits: AI Generated

DOI: 10.1186/s12886-026-05448-7

Keywords: Vogt-Koyanagi-Harada disease, uveitis, oral prednisolone, triamcinolone acetonide, posterior sub-Tenon injection, corticosteroids, optical coherence tomography, retina, recurrence, retrospective cohort study, ophthalmology, visual acuity