We read with great interest the recent article by Sheppard et al1 demonstrating that punctal occlusion and topical cyclosporine reduce the frequency and duration of herpes simplex virus (HSV) stromal keratitis. To better interpret this study, however, some additional information is needed.
First, concerning disease assessment, the type of HSV keratitis being studied is unclear. The title of the article implies stromal keratitis yet the methods section suggests all types of HSV keratitis were included. If both epithelial and stromal keratitis cases were included, then it would be important to know if there were differences in outcomes between these groups. There are articles indicating that topical cyclosporine may actually worsen epithelial HSV keratitis.2 How was active HSV stromal keratitis defined? What type of stromal keratitis (interstitial, “disciform” endotheliitis, or necrotizing stromal keratitis) did these patients have, and how was disease duration measured? In the article, recurrence was defined as “the clinical need for increased topical steroid” but what criteria were used to determine if there was a “clinical need” to increase steroid? Was the end point of disease defined as return to baseline minimal maintenance therapy, and was this definition applied the same in the before-treatment year as it was to the treatment year? Also, for the before-treatment year, was information obtained from medical record review, patient report, or both?
Regarding the treatment procedure, was punctal occlusion carried out on the lower, upper, or both punctae? How was it determined that the punctae were in fact occluded, and did any of the punctae reopen? If a punctum reopened, was it then retreated, and how did this affect outcome?
Regarding the study design, was all data collected retrospectively or was the after treatment–year data collected prospectively? If the second part was prospectively collected, it would have been a stronger study design to collect all data prospectively and compare patients with a control group, ensuring similar clinical decision making for both groups.
The results of the study indicate that using topical cyclosporine alone is equally as effective as performing punctal occlusion but is there a clinical advantage to using both treatment modalities together? The authors would suggest that there is an advantage to using both treatments because in the group of patients who had previous punctal cautery and subsequent topical cyclosporine, there was a statistically significant reduction in recurrence by adding this second treatment modality. However, it would be important to know if there was a difference between this group, which received both treatments, and the other 2 groups, which only received 1 treatment. If punctal cautery alone is as effective as topical cyclosporine or both treatments together, then it would be more cost-effective to only perform punctal occlusion rather than chronically treat patients with topical cyclosporine.
Answers to these questions are needed to fully evaluate the management implications of this intriguing study.
Correspondence: Dr Weisberg, Department of Ophthalmology, University of Illinois at Chicago, 1855 W Taylor St, Room 3.164, Chicago, IL 60612 (michael.weisberg@gmail.com).
Financial Disclosure: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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