Sir,
We thank Dr Clearkin for his comments1 on our recent editorial with regard to the implementation of shingles vaccine in UK.2 Our intention was to comment on the potential benefits of vaccination rather than provide an overview of evidence-based practice for the management of zoster-associated anterior uveitis.
However, we mention in the paper the use of topical steroids in the treatment of zoster-associated anterior uveitis, a practice that is recommended in the current Oxford Handbook of Ophthalmology.3
This is a contentious area and differences of opinion remain in the use of topical steroids in the treatment of zoster-related anterior uveitis. It is sadly not as clear cut as Clearkin’s comments would suggest. The papers cited from Marsh and Cooper4 and McGill and Chapman5 refer to studies evaluating topical acyclovir vs topical steroid in the treatment of zoster keratouveitis and not just zoster-related anterior uveitis. Although they show a statistical benefit of topical antiviral over topical steroid in the management of keratitis, the data for those with anterior uveitis did not show a statistical benefit. The authors themselves agree that there remains a role for topical steroids in patients who do not respond adequately to topical acyclovir.4, 5
As Clearkin mentions, Herbort et al6 show that the use of oral acyclovir in the treatment of early zoster is beneficial, has extensive external evidence to support, and has been generally adopted as best practice by all. Many other authors7, 8, 9 however continue to advocate the use of topical steroids in the treatment of zoster-related anterior uveitis. We therefore feel this area will remain open for discussion until more robust data, specific for zoster-associated anterior uveitis, are available.
We would however agree about Clearkin’s comments on the potential benefits of the use of gabapentin for pain control in post-herpetic neuralgia.10
References
Clearkin L . Comment on ‘Herpes zoster ophthalmicus reduction: implementation of shingles vaccination in the UK’. Eye 2014; 28 (12): 1522–1523.
Potts A, Williams GJ, Olson JA, Pollock KG, Murdoch H, Cameron JC . Herpes zoster ophthalmicus reduction: implementation of shingles vaccination in the UK. Eye (Lond) 2014; 28 (3): 247–248.
Oxford Handbook of Ophthalmology. Oxford University Press, 2009 Print ISBN-13 9780199552641. 10.1093/med/9780199552641.001.0001.
Marsh RJ, Cooper M . Acyclovir and steroids in herpes zoster keratouveitis. Br J Ophthalmol 1984; 68 (12): 904–905.
McGill J, Chapman C . A comparison of topical acyclovir with steroids in the treatment of herpes zoster keratouveitis. Br J Ophthalmol 1983; 67 (11): 746–750.
Herbort CP, Buechi ER, Piguet B, Zografos L, Fitting P . High-dose oral acyclovir in acute herpes zoster ophthalmicus: the end of the corticosteroid era. Curr Eye Res 1991; 10 (Suppl): 171–175.
Van der Lelij A, Ooijman FM, Kijlstra A, Rothova A . Anterior uveitis with sectoral iris atrophy in the absence of keratitis. A distinct clinical entity among herpetic eye diseases. Ophthalmology 2000; 107: 1164–1170.
Cunningham ET Jr . Diagnosing and treating herpetic anterior uveitis. Ophthalmology 2000; 107 (12): 2129–2130.
Miserocchi E, Nadia K, Waheed NK, Dios E, Christen W, Jesus Merayo J et al. Visual outcome in herpes simplex virus and varicella zoster virus uveitis: a clinical evaluation and comparison. Ophthalmology 2002; 109 (8): 1532–1537.
Dworkin RH, Schmader KE . Treatment and prevention of postherpetic neuralgia. Clin Infect Dis 2003; 36 (7): 877–882.
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Williams, G., Olson, J. Response to Dr Clearkin. Eye 28, 1523 (2014). https://doi.org/10.1038/eye.2014.205
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DOI: https://doi.org/10.1038/eye.2014.205