Diagnosis and treatment of chronic hepatitis C infection

Editor – we write in relation to your recent review article on
hepatitis C infection (HCV). Patel et al1 present an excellent overview
but overlook the eye in their discussion of the non-hepatic manifestations
of infection and do not mention the recent debate over interferon therapy
possibly causing retinopathy.

HCV infection has been associated with a dry eye syndrome and
ischaemic retinopathy, both thought to be secondary to a HCV-induced
vasculitis2. Interferon treatment has traditionally been associated with a
significant incidence of retinopathy, as characterised by cotton wool
spots and retinal haemorrhages, in several prospective case series3,4,5.
Despite these retinal changes, patients rarely reported subjective
problems and visual function is generally maintained. Anterior ischaemic
optic neuropathy and macular oedema have also been described as rarer
complications of interferon treatment. In view of this, ophthalmic
assessment at baseline and during the interferon treatment period has
generally been advocated for such patients.

We have recently completed a prospective study of 52 patients (104
eyes) on a standardised 48-week regimen of pegylated interferon-alpha-2a
(Pegasys) and Ribavirin6. We found no significant difference between
baseline and follow-up LogMAR visual acuity, contrast sensitivity, colour
vision or automated visual field analysis up to 30months. 3 patients (4
eyes) developed a transient retinopathy with no associated deterioration
in visual function. It is postulated that recent introduction of pegylated
forms of interferon (covalent attachment of a protein to increase
molecular weight and plasma half-life of a drug) somehow protects against
previously seen interferon-associated retinopathy. We conclude that
despite being previously advocated, routine ophthalmic screening is no
longer required and that this will reduce inconvenience to patients and
reduce demand on NHS ophthalmic services.

Hiten G Sheth specialist registrar

Nabeel N Malik specialist registrar / fellow

Nigel Davies consultant

Suzanne M Mitchell consultant

Department of Ophthalmology,
Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH

1. Patel K, Muir A, Hutchinson J. Diagnosis and treatment of chronic
hepatitis C infection. BMJ 2006;332:1013-17

2. Zegans ME, Anninger W, Chapman C, Gordon SR. Ocular manifestations
of hepatitis C virus infection. Curr Opin Ophthalmol. 2002;13(6):423-7

3. Kawano T, Shigehira, Uto H, Nakama T, Kato J et al. Retinal
complications during interferon therapy for chronic hepatitis C. Am J
Gastroenterol. 1996;91(2):309-13

4. Hayasaka S, Fujii M, Yamamoto Y, Noda S, Kurome H et al.
Retinopathy and subconjunctival hamorrage in patients with chronic viral
hepatitis receiving interferon alpha. Br J Ophthalmol 1995;79(2):150-2

5. Schulman JA, Liang C, Kooragayala LM, King J. Posterior segment
complications in patients with hepatitis C treated with interferon and
ribavirin. Ophthalmology 2003;110(2):437-42

6. Mitchell SM, Malik NN, Sheth HG, Davies N, Akerman N. Prospective
case series of changes in visual function in patients treated for
hepatitis C with peginterferon alpha. www.arvo.org 2006 poster 5174

Competing interests:
None declared