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Successful Treatment of Postherpetic Neuralgia with Capsaicin
758
AMERICAN JOURNAL OF OPHTHALMOLOGY
efforts at contact lens fitting, and underwent penetrating keratoplasty of the left eye six months after his initial visit. Eight months after his initial visit, the patient's uncorrected visual acuity in the right eye declined to 20/30, and two months later had further declined to 20/40. He was correctable to 20/25 with a manifest refraction of +1.00 +6.00 x 120. The right cornea was noted to have some stress lines in the inferotemporal midperiphery and mild stromal thinning. Keratometry readings were 53.00 x 170/44.00. Photokeratoscopy demonstrated dramatic changes in the corneal topography of the right eye (Figure, right) interpreted as indicative of keratoconus. The patient admitted to continued vigorous application of his fist to the right eye despite being cautioned against this practice. The patient was successfully fitted with a rigid contact lens and the patient was warned about the possible effects of pressing on the eye. His left eye has remained stable after penetrating keratoplasty with uncorrected visual acuity of 20/40. Many reports suggest an association of eye rubbing and keratoconus, 1,2 and development of keratoconus has been reported following blunt trauma. 3 Much more impressive than the keratoconus of the left eye is the advanced keratoconus of the right eye, developing about 11 months after the right cornea had been documented to be normal in terms of keratometry, pachymetry, and photokeratoscopy. Aside from the patient's practice of vigorously massaging his corneas with his fists, no other known associations were found, including a history of atopy. It cannot be proved that the rapid development of keratoconus in this patient's right eye was induced by his ritual ocular massage, but the dramatic changes demonstrated in the right cornea are suggestive of an association.
References 1. Krachmer, J. H., Feder, R. S., and Berlin, M. W.: Keratoconus and related noninflammatory corneal thinning disorders. Surv. Ophthalmol. 28:293, 1984. 2. Karseras, A. G., and Ruben, M.: Aetiology of keratoconus. Br. J. Ophthalmol. 60:522, 1976. 3. Beuchat, L., and Metager, P.: Acquired keratoconus following ocular blunt trauma. J. Fr. Ophtalmol. 10:501, 1987.
December, 1988
Successful Treatment of Postherpetic Neuralgia With Capsaicin Frank A. Bucci, Jr., M . D . , Christopher F. Gabriels, B . S . , and Gregory B. Krohel, M . D . Department of Ophthalmology, Albany Medical College. This study was supported in part by an unrestricted grant from Research to Prevent Blindness, Inc. Inquiries to Gregory B. Krohel, M.D., Samaritan Hospital, Troy, NY 12180. Postherpetic neuralgia is a common and frequently debilitating complication of herpes zoster ophthalmicus. Postherpetic neuralgia is especially common in patients over 65 years of age. Current treatment modalities are generally unsuccessful. Persistent and severe pain often leads to profound depression, and reports of suicide are not rare. In two patients with prolonged history of unsuccessfully treated postherpetic neuralgia pain relief was achieved within seven days after treatment with Zostrix, a topical analgesic cream containing 0.025% of the natural chemical capsaicin. For two years the first patient, a 72-year-old woman, had had postherpetic neuralgia unresponsive to treatment with carbamazepine and amitriptyline. After discontinuing all other medications, Zostrix was applied to the skin of the forehead and upper eyelid four times per day. The patient reported almost total relief of her debilitating pain within one week. Her pain relief has been sustained with continued use of this topical analgesic four times a day. The second patient, a 65-year-old woman, had had postherpetic neuralgia for seven months. Intermittent usage of narcotic analgesics was unsuccessful in controlling the pain. Pain relief was achieved after one week of topical application of Zostrix four times a day. Sustained pain relief has been maintained with continued use of this medication over the past six months. Zostrix contains 0.025% capsaicin (trans-8methyl-N-vanillyl-6-nonenamide), a natural substance derived from plants of the Solanaceae family. Capsaicin is believed to inhibit nociceptive impulses from the peripheral to the central nervous system through the depletion of the endogenous neuropeptide substance P. 1 Bernstein and associates reported substantial pain relief in 75% of 12 patients with postherpetic neuralgia treated with Zostrix for one month. 2
Letters to the Journal
Vol. 106, No. 6
References 1. Jessell, T. M., Iversen, L. L., and Cuello, A. C : Capsaicin-induced depletion of substance P from primary sensory neurons. Brain Res. 152:183, 1978. 2. Bernstein, J. E., Bickers, D. R., Dahl, M. V., and Roshal, J.Y.: Treatment of chronic postherpetic neuralgia with topical capsaicin. Am. Acad. Dermatol. 17:93, 1987.
An Aspiration-Irrigation Soft Contact Lens for Maintenance of the Anterior Chamber Kazuo Tsubota, M . D . Department of Ophthalmology, National Tochigi Hospital and Keio University School of Medicine. The author has a proprietary interest in the lens described herein. Inquiries to Kazuo Tsubota, M.D., Department of Ophthalmology, National Tochigi Hospital, 1-10-37 Nakatomatsuri, Utsunomiya, Tochigi, Japan 320. O n e of t h e few d i s a d v a n t a g e s of t h e techn i q u e c u r r e n t l y u s e d for e x t r a c a p s u l a r cataract extraction is t h e n e e d for t e m p o r a r y s u t u r e s to
Fig. 1 (Tsubota). Diagram of the aspirationirrigation soft contact lens for maintenance of the anterior chamber in extracapsular cataract extraction. The large window is for observation of the anterior chamber; the small hole is for insertion of the aspiration-irrigation needle (units are in millimeters).
759
p e r f o r m i r r i g a t i o n - a s p i r a t i o n of t h e lens cortex for m a i n t e n a n c e of t h e a n t e r i o r c h a m b e r after r e m o v a l of t h e n u c l e u s . In o r d e r to solve this p r o b l e m , I d e v e l o p e d a c o n t a c t lens for the m a i n t e n a n c e of t h e a n t e r i o r c h a m b e r . T h e a s p i r a t i o n - i r r i g a t i o n soft contact lens is m a d e of 40% h y d r o x y e t h y l m e t h a c r y l a t e . The lens* r e s e m b l e s a d o u g h n u t w i t h a large w i n d o w in t h e c e n t e r (Fig. 1). T h e a n t e r i o r c h a m b e r c a n be o b s e r v e d t h r o u g h this w i n d o w d u r i n g t h e a s p i r a t i o n - i r r i g a t i o n of t h e cortex. T h e a s p i r a t i o n - i r r i g a t i o n lens is 16.5 m m in d i a m e ter, w h i c h is w i d e e n o u g h to cover t h e c o r n e o scleral incision. A small hole located in the p e r i p h e r y is for t h e i n s e r t i o n of the a s p i r a t i o n irrigation n e e d l e . After d e l i v e r y of t h e n u c l e u s , a r u n n i n g sut u r e is p l a c e d over half of the corneoscleral incision u s i n g 10-0 n y l o n . T h e n t h e a s p i r a t i o n irrigation lens is p l a c e d over the c o r n e a to cover t h e incision. T h e a s p i r a t i o n - i r r i g a t i o n n e e d l e is i n s e r t e d t h r o u g h t h e small hole a n d a s p i r a t i o n irrigation of t h e lens cortex is p e r f o r m e d (Fig. 2). U s i n g this l e n s , t h e a n t e r i o r c h a m b e r can be m a i n t a i n e d w i t h o u t t e m p o r a r y s u t u r e s . The
T h e lens is manufactured by Hoya Corporation, Takadanobaba 1-29-9, Shinjuku-ku, Tokyo, Japan 160.
Fig. 2 (Tsubota). Aspiration-irrigation of the lens cortex using the aspiration-irrigation lens. The anterior chamber is maintained during the procedure without temporary sutures.
AMERICAN JOURNAL OF OPHTHALMOLOGY
efforts at contact lens fitting, and underwent penetrating keratoplasty of the left eye six months after his initial visit. Eight months after his initial visit, the patient's uncorrected visual acuity in the right eye declined to 20/30, and two months later had further declined to 20/40. He was correctable to 20/25 with a manifest refraction of +1.00 +6.00 x 120. The right cornea was noted to have some stress lines in the inferotemporal midperiphery and mild stromal thinning. Keratometry readings were 53.00 x 170/44.00. Photokeratoscopy demonstrated dramatic changes in the corneal topography of the right eye (Figure, right) interpreted as indicative of keratoconus. The patient admitted to continued vigorous application of his fist to the right eye despite being cautioned against this practice. The patient was successfully fitted with a rigid contact lens and the patient was warned about the possible effects of pressing on the eye. His left eye has remained stable after penetrating keratoplasty with uncorrected visual acuity of 20/40. Many reports suggest an association of eye rubbing and keratoconus, 1,2 and development of keratoconus has been reported following blunt trauma. 3 Much more impressive than the keratoconus of the left eye is the advanced keratoconus of the right eye, developing about 11 months after the right cornea had been documented to be normal in terms of keratometry, pachymetry, and photokeratoscopy. Aside from the patient's practice of vigorously massaging his corneas with his fists, no other known associations were found, including a history of atopy. It cannot be proved that the rapid development of keratoconus in this patient's right eye was induced by his ritual ocular massage, but the dramatic changes demonstrated in the right cornea are suggestive of an association.
References 1. Krachmer, J. H., Feder, R. S., and Berlin, M. W.: Keratoconus and related noninflammatory corneal thinning disorders. Surv. Ophthalmol. 28:293, 1984. 2. Karseras, A. G., and Ruben, M.: Aetiology of keratoconus. Br. J. Ophthalmol. 60:522, 1976. 3. Beuchat, L., and Metager, P.: Acquired keratoconus following ocular blunt trauma. J. Fr. Ophtalmol. 10:501, 1987.
December, 1988
Successful Treatment of Postherpetic Neuralgia With Capsaicin Frank A. Bucci, Jr., M . D . , Christopher F. Gabriels, B . S . , and Gregory B. Krohel, M . D . Department of Ophthalmology, Albany Medical College. This study was supported in part by an unrestricted grant from Research to Prevent Blindness, Inc. Inquiries to Gregory B. Krohel, M.D., Samaritan Hospital, Troy, NY 12180. Postherpetic neuralgia is a common and frequently debilitating complication of herpes zoster ophthalmicus. Postherpetic neuralgia is especially common in patients over 65 years of age. Current treatment modalities are generally unsuccessful. Persistent and severe pain often leads to profound depression, and reports of suicide are not rare. In two patients with prolonged history of unsuccessfully treated postherpetic neuralgia pain relief was achieved within seven days after treatment with Zostrix, a topical analgesic cream containing 0.025% of the natural chemical capsaicin. For two years the first patient, a 72-year-old woman, had had postherpetic neuralgia unresponsive to treatment with carbamazepine and amitriptyline. After discontinuing all other medications, Zostrix was applied to the skin of the forehead and upper eyelid four times per day. The patient reported almost total relief of her debilitating pain within one week. Her pain relief has been sustained with continued use of this topical analgesic four times a day. The second patient, a 65-year-old woman, had had postherpetic neuralgia for seven months. Intermittent usage of narcotic analgesics was unsuccessful in controlling the pain. Pain relief was achieved after one week of topical application of Zostrix four times a day. Sustained pain relief has been maintained with continued use of this medication over the past six months. Zostrix contains 0.025% capsaicin (trans-8methyl-N-vanillyl-6-nonenamide), a natural substance derived from plants of the Solanaceae family. Capsaicin is believed to inhibit nociceptive impulses from the peripheral to the central nervous system through the depletion of the endogenous neuropeptide substance P. 1 Bernstein and associates reported substantial pain relief in 75% of 12 patients with postherpetic neuralgia treated with Zostrix for one month. 2
Letters to the Journal
Vol. 106, No. 6
References 1. Jessell, T. M., Iversen, L. L., and Cuello, A. C : Capsaicin-induced depletion of substance P from primary sensory neurons. Brain Res. 152:183, 1978. 2. Bernstein, J. E., Bickers, D. R., Dahl, M. V., and Roshal, J.Y.: Treatment of chronic postherpetic neuralgia with topical capsaicin. Am. Acad. Dermatol. 17:93, 1987.
An Aspiration-Irrigation Soft Contact Lens for Maintenance of the Anterior Chamber Kazuo Tsubota, M . D . Department of Ophthalmology, National Tochigi Hospital and Keio University School of Medicine. The author has a proprietary interest in the lens described herein. Inquiries to Kazuo Tsubota, M.D., Department of Ophthalmology, National Tochigi Hospital, 1-10-37 Nakatomatsuri, Utsunomiya, Tochigi, Japan 320. O n e of t h e few d i s a d v a n t a g e s of t h e techn i q u e c u r r e n t l y u s e d for e x t r a c a p s u l a r cataract extraction is t h e n e e d for t e m p o r a r y s u t u r e s to
Fig. 1 (Tsubota). Diagram of the aspirationirrigation soft contact lens for maintenance of the anterior chamber in extracapsular cataract extraction. The large window is for observation of the anterior chamber; the small hole is for insertion of the aspiration-irrigation needle (units are in millimeters).
759
p e r f o r m i r r i g a t i o n - a s p i r a t i o n of t h e lens cortex for m a i n t e n a n c e of t h e a n t e r i o r c h a m b e r after r e m o v a l of t h e n u c l e u s . In o r d e r to solve this p r o b l e m , I d e v e l o p e d a c o n t a c t lens for the m a i n t e n a n c e of t h e a n t e r i o r c h a m b e r . T h e a s p i r a t i o n - i r r i g a t i o n soft contact lens is m a d e of 40% h y d r o x y e t h y l m e t h a c r y l a t e . The lens* r e s e m b l e s a d o u g h n u t w i t h a large w i n d o w in t h e c e n t e r (Fig. 1). T h e a n t e r i o r c h a m b e r c a n be o b s e r v e d t h r o u g h this w i n d o w d u r i n g t h e a s p i r a t i o n - i r r i g a t i o n of t h e cortex. T h e a s p i r a t i o n - i r r i g a t i o n lens is 16.5 m m in d i a m e ter, w h i c h is w i d e e n o u g h to cover t h e c o r n e o scleral incision. A small hole located in the p e r i p h e r y is for t h e i n s e r t i o n of the a s p i r a t i o n irrigation n e e d l e . After d e l i v e r y of t h e n u c l e u s , a r u n n i n g sut u r e is p l a c e d over half of the corneoscleral incision u s i n g 10-0 n y l o n . T h e n t h e a s p i r a t i o n irrigation lens is p l a c e d over the c o r n e a to cover t h e incision. T h e a s p i r a t i o n - i r r i g a t i o n n e e d l e is i n s e r t e d t h r o u g h t h e small hole a n d a s p i r a t i o n irrigation of t h e lens cortex is p e r f o r m e d (Fig. 2). U s i n g this l e n s , t h e a n t e r i o r c h a m b e r can be m a i n t a i n e d w i t h o u t t e m p o r a r y s u t u r e s . The
T h e lens is manufactured by Hoya Corporation, Takadanobaba 1-29-9, Shinjuku-ku, Tokyo, Japan 160.
Fig. 2 (Tsubota). Aspiration-irrigation of the lens cortex using the aspiration-irrigation lens. The anterior chamber is maintained during the procedure without temporary sutures.