Sir,
The endorsement of topical steroid use in Herpes zoster uveitis in your editorial1 is inappropriate and not supported by any evidence whatsoever.
It is now more than 30 years since the received wisdom2 of routine topical steroid use in zoster uveitis was shown to be inferior to that of topical acyclovir (ACV) in randomised controlled trials.3 High-dose oral ACV is even more effective. Announcing ‘the end of the corticosteroid era’, Herbort et al4 noted ‘Steroid treatment was not necessary in any of the (oral) ACV-treated patients’.
Those clinicians who adopt a policy of using high-dose oral ACV in the treatment of acute herpes zoster and eschew topical steroids soon come to realise that the ‘tendency to relapse when steroid treatment is tapered….become chronic or take on a relapsing nature over many years, with tissue damage, scarring and necrosis, and potential visual impairment’1 is entirely the iatrogenic consequence of topical steroid usage, and note a further benefit in amelioration of post-herpetic neuralgia particularly if high-dose oral ACV is prescribed in combination with Amitryptiline or Gadapentin.5
I share the hope that vaccination will eventually reduce the number of patients who experience the scourge that is zoster. In the meantime it is important to disseminate and implement existing knowledge on effective-evidence-based treatment and avoid making the problem worse by using topical steroids in zoster uveitis.
References
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.
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.
Dworkin RH, Schmader KE . Treatment and prevention of postherpetic neuralgia. Clin Infect Dis 2003; 36 (7): 877–882.
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Clearkin, L. Comment on ‘Herpes zoster ophthalmicus reduction: implementation of shingles vaccination in the UK’. Eye 28, 1522–1523 (2014). https://doi.org/10.1038/eye.2014.204
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DOI: https://doi.org/10.1038/eye.2014.204
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