Vogt-Koyanagi-Harada disease under the lens: Insights from multimodal ocular imaging

Vogt-Koyanagi-Harada (VKH) disease is a multisystem autoimmune condition targeting melanocyte-rich ocular tissues, with inflammation primarily affecting the choroid. Despite advances in diagnostic criteria, disease staging and therapeutic decisions still rely heavily on clinical observation, with limited integration of imaging biomarkers. This review examines the evolving role of multimodal ocular imaging (MMI) in the diagnosis, monitoring, and prognostication of VKH. We critically appraise the utility and limitations of color fundus photography, fluorescein angiography (FFA), indocyanine green angiography (ICGA), optical coherence tomography (OCT), OCT angiography (OCTA), fundus autofluorescence, B-scan ultrasonography, ultrasound biomicroscopy and anterior segment photography. These modalities provide complementary insights into disease activity, from subclinical choroiditis and retinal pigment epithelium disruption to chronic sequelae such as subretinal fibrosis and choroidal atrophy. Key imaging features-such as choroidal thickening, hypofluorescent dark dots, RPE undulations, and flow voids-are described in the context of VKH pathophysiology and disease stage. We identify critical gaps in current practice, including the lack of standardized imaging-based definitions for relapse and remission, limited use of anterior segment imaging, and variability in access to advanced modalities. To address these challenges, we propose a stage-specific imaging framework to guide VKH assessment from prodromal to chronic phases. MMI has transitioned from a supportive to a central role in VKH management. Future efforts should prioritize the development of quantitative imaging biomarkers, standardization of grading systems, and integration of imaging into therapeutic algorithms to support timely, personalized care and prevent irreversible visual loss.