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Keratitis and topical steroids

01 November 2004

Mr C began experiencing problems with his left eye in 1985, when he was in his early twenties. He suffered an episode of keratitis, which was successfully treated with steroid eye drops, but the condition flared up at intervals over the next decade.

During this time, Mr C attended the local hospital’s eye clinic on several occasions, and it seems that the chronic inflammation was attributed to herpes simplex. On each of Mr C’s visits to the eye clinic, he was prescribed short courses of topical ocular steroid and anti-viral agents, which appeared to alleviate the problem.

In 1995, Mr C consulted his GP, Dr J, and received a prescription for topical ocular steroids. After using these for a few weeks, he needed surgery to repair a perforated corneal ulcer. In his ensuing claim against Dr J, Mr C alleged that the GP had prescribed steroid eye drops when he knew, or ought to have known, that they are contraindicated in the presence of herpes simplex infection.

As Dr J had not recorded the consultation, it was difficult to confirm or dispute the allegation. However, the available evidence supported Mr C’s claim. According to Dr J’s appointment book, Mr C did attend a consultation at around this time. Furthermore, hospital notes from two weeks later record a two-week history of eye disease for which Mr C was being treated with chloramphenicol and steroid eye drops.

Expert opinion

The GP expert we consulted took the view that Dr J could be criticised for prescribing the eye drops without the advice of a specialist in ophthalmology. ‘The past history was documented as due to recurrent keratitis and this is simply not a condition that GPs should handle alone … I could not defend the decision, regardless of whether he knew that herpes was (or may have been) involved.’

We also consulted an ophthalmologist. He reported that ‘the very deep corneal ulceration which later perforated was almost certainly caused by the prescription of steroid drops, which are specifically contraindicated in the case of corneal disease associated with the herpes simplex virus. Steroids may be used on occasion in a carefully controlled manner together with anti-viral ointment protective cover, by ophthalmologists.’

As there were no grounds on which this claim could be defended, we sought an out-of-court settlement on the best possible terms. Mr C received compensation with costs.

Learning points

The treatment of keratitis is not straightforward and should be overseen by someone with specialist ophthalmic knowledge. For an overview of keratitis from a UK general practice perspective see the GP notebook website.

A more in-depth tutorial, with useful references, is available at the review of optometry website.

A recent review article, Tullo A, ‘Pathogenesis and Management of Herpes Simplex Virus Keratitis’, Eye, 17(8):919-22 (2003), is recommended to those wanting the latest information about HSV-associated keratitis.