letters to the editor

Steroid Use With EKC

I read the case report on adenoviral conjunctivitis in the January 2010 Treatment Plan column titled “Device Helps With Diagnosis of Acute Conjunctivitis,” by Jamie C. Reid, OD, and Leo Semes, OD, FAAO, with great interest. While I applaud the use of both the RPS Adeno Detector (Rapid Pathogen Screening) and Betadine (Purdue Pharma) in adenoviral patients, it is the steroid use that concerns me. Twenty-six years of practice have taught me that premature, automatic use of topical steroids in presumed adenoviral illness can lead to a prolonged use of these agents, with possible adverse consequences.

I believe the authors present a flawed reference in the Pelletier study's support of the steroid argument. Viral titres cited in this reference may have no relevance in considering the use of topical steroids. To the credit of the authors of the six-patient Pelletier study, they do propose a controlled study on this issue.

In addition, let's not get ahead of ourselves on the RPS test itself. The multi-center FDA study of the device reported that “false-positive results were obtained for 3 of 12 culture-negative samples.”

I propose that the classical approach to treatment is still indicated, in conjunction with Betadine therapy. Our 14-doctor ophthalmology/optometry practice defers steroid use unless there are central corneal infiltrates that reduce acuity to 20/40, pseudomembranes, or intractable discomfort. Mild antibiotic coverage is seldom a bad idea. Many cases of adenoviral keratoconjunctivitis resolve without steroids and their inherent risks. Steroids are used with the indications I listed, per our professional preference and classic teaching. Steroid concerns are well-stated in Onofrey's Ocular Therapeutics Manual.

My practice has had many patients who started steroids for adenoviral illness and found it impossible to do a “quick tapering schedule.” A better suggestion is to take a chance that the patient's immune system alone will eradicate the virus in adenoviral disease, which is found to occur in about half of our closely monitored cases. Yes, the other half may indeed require judicious use of steroids.

In summary, the treatment of adenoviral keratoconjunctivitis is still a clinical decision, until stronger research evidence is attained. A Betadine-without-steroid study would be welcomed.

William B. Potter, OD
Hamilton Square, N.J.

Dr. Reid's and Dr. Semes' Response: We thank Dr. Potter for his input concerning the management of the EKC case presented in our January Treatment Plan column and we welcome the opportunity to respond. In his letter, Dr. Potter makes us aware of the respect that we all must exercise in the judicious use of topica corticosteroids. In the absence of controlled clinical trials for the use of topical corticosteroids in EKC, clinical judgment and experience serve as guidance. This is what Dr. Potter describes in his courses of action as well as what was invoked in the present case. There is considerable debate on the topic, and classic teaching in some instances suggests applying topical steroids (Sambursky et al 2006; Reinhard, 2005). In fact, a well-respected optometric source (www.eyeupdate.com) considers topical steroids valuable, as we did in this case.

We made the decision to apply topical steroids for this patient to quickly minimize discomfort and inflammation. This goal was achieved. The Betadine therapy alone will eradicate the virus. Taking into account a careful documentation of intact cornea and the absence of dendritic figures, the presentation of inflammation and discomfort swayed the decision for steroid use.

Therefore, each eyecare professional should examine patients closely when considering the indication for steroid therapy. This is the essence of the art and science of vision care.

For references, please visit www.clspectrum.com/references.asp and click on document #172.