Rainer Sundmacher – Color Atlas of Herpetic Eye Disease

Автор: Rainer Sundmacher
Название книги: Color Atlas of Herpetic Eye Disease
Формат: PDF
Жанр: Медицина
Качество: Изначально компьютерное, E-book

This well-structured atlas offers practical advice for the recognition and management of each Herpetic Eye problem. It is based on nearly four decades of practical and scientific work and experience with follow-ups in thousands of herpes patients

When I started ophthalmologic residency in 1970, the knowledge
of herpetic eye diseases was very limited. Its pathophysiology
was mostly only suspected. Medical antiviral therapy had
just started (idoxuridine eye drops), and prophylaxis against
the frequent viral recurrences was not available. Steroids appeared
to be the only remedy against the downhill course of
the disease in many individuals, though this remedy was a
rather double-edged one. In quite a number of cases, eyes were
blinded from herpetic corneal scars and secondary glaucoma.
Attempts to restore vision by keratoplasty were equally frustrating
because various risks of such a surgical procedure were
at most borderline understood, and if they would have been,
no drugs except for steroids would have been available to successfully
deal with the numerous complications.
Nowadays, after decades of medical and surgical progress,
the outcomes are much more positive. Effective topical and
systemic antiviral drugs, ever improving systemic immunosuppressive
agents, and clinical herpes specialists who are experts
in their field allow prevention of blindness in herpes patients.
While this ideal description may hold true at present for
some of the “developed” areas of the world, it is certainly not
the case for the major part of the world population which does
not have access to qualified ophthalmologists and advanced
medical and surgical care.
However, the population in the “developed” countries cannot
be sure to maintain its current high standard in herpes care.
Ironically, it is just the high level of herpes control achieved in
the last decades that now exerts a negative feedback: topical
and systemic antiviral agents combined with steroids seem to
be so effective and readily available that disastrous downhill
courses have become rare, and, if they do occur, specialists are
available to offer helpful advice. The pharmaceutical industry
is highly content with the status achieved, seeing no need to invest
into further development of anti-herpetic agents. Consequently,
research money for herpes projects has become rather
scarce. Young scientists prefer to start out on different, currently
better funded research grounds, and the still practicing
older herpes specialists are mostly left alone with no successors
to devote themselves to further development of this area.
While this situation has certainly not yet been noted by the
majority of practicing ophthalmologists, university clinicians
clearly suggest that we have a shortage not only of herpes specialists
but of anterior segment specialists in general: seven out
of ten ophthalmological chairs in Germany have lately been
given to retinal surgeons. Anterior segment specialists may become
increasingly rare. It will presumably take years before we
can expect a turnaround of clinical herpes research and the
emergence of a new research and teaching generation.
Meanwhile, the only thing we can do is to document our
current understanding of treatment and prophylaxis of herpetic
ocular diseases in such a way that it would serve the general
ophthalmologist seeking help for patients’ actual problems
and the potential science candidate looking out for interesting
unsolved topics to work on. Both items are addressed in
this atlas. The practitioner may use it like a cook book. To find
help, continuous reading from the beginning to the end is not
necessary, although it is, of course, recommended for a better
understanding of the topic. Depending on one’s individual
level of knowledge in these fields, one may either start directly
from the index and follow on to the page offering a solution to
the problem, or – if the problem in itself is still undetermined –
one may find the solution by quickly referring to the pictures.
From there, the picture-associated text with the headings clinic,
diagnosis, differential diagnosis, and therapy, provides detailed
information. Reference is frequently made to pictures, which
are relevant for differential diagnosis.
For those interested in the evidence for the statements or
recommendations provided or problems and phenomena that
are currently unsolved, I have included my judgement either
expressis verbis or by the chosen wording, e. g., study-proven,
is, can be, may be, probably, speculative, general experience, personal
experience, etc. Primarily for these readers, some selected
references are included at the end of each chapter. Using these
as a starting point for individual literature search, it should
be easy to obtain quick access to the complete scientific background
of most but not all herpes problems. Some topics, such
as neonatal herpes and vaccination, have been omitted. They
would have been out of the scope of an atlas.
Being one of the clinical herpes specialists who performed
quite a number of double-blind controlled therapy studies, I
may say that evidence-based medicine is, of course, of utmost
importance, but only in areas where adequate studies are practically
feasible. In the herpes field, this has sufficiently been the
case with dendritic keratitis only. Unfortunately, dendritic keratitis
is the least significant clinical problem we face in ocular
herpes. A much larger number of other herpetic eye diseases
Introduction
have still to be managed by practical experience and “personal
conviction” only. This “unscientific” situation becomes even
more critical as many details of our view of herpes pathophysiology
must still be classified as “speculative belief ”, irrespective
of how probable they may be. This makes this atlas partly a
personal creed based on four decades of practical and scientific
work and on experiences from the follow-up of thousands of
herpes patients.