We thank Dr Clearkin for his comments 1 on our recent editorial with regard to the implementation of shingles vaccine in UK. 2 Our intention was to comment on the potential benefits of vaccination rather than provide an overview of evidence-based practice for the management of zoster-associated anterior uveitis. However, we mention in the paper the use of topical steroids in the treatment of zoster-associated anterior uveitis, a practice that is recommended in the current Oxford Handbook of Ophthalmology. 3 This is a contentious area and differences of opinion remain in the use of topical steroids in the treatment of zoster-related anterior uveitis. It is sadly not as clear cut as Clearkin's comments would suggest. The papers cited from Marsh and Cooper 4 and McGill and Chapman 5 refer to studies evaluating topical acyclovir vs topical steroid in the treatment of zoster keratouveitis and not just zoster-related anterior uveitis. Although they show a statistical benefit of topical antiviral over topical steroid in the management of keratitis, the data for those with anterior uveitis did not show a statistical benefit. The authors themselves agree that there remains a role for topical steroids in patients who do not respond adequately to topical acyclovir. 4,5 As Clearkin mentions, Herbort et al 6 show that the use of oral acyclovir in the treatment of early zoster is beneficial, has extensive external evidence to support, and has been generally adopted as best practice by all. Many other authors 7-9 however continue to advocate the use of topical steroids in the treatment of zoster-related anterior uveitis. We therefore feel this area will remain open for discussion until more robust data, specific for zoster-associated anterior uveitis, are available.We would however agree about Clearkin's comments on the potential benefits of the use of gabapentin for pain control in post-herpetic neuralgia. 10 References

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Anterior capsular opacification and contraction syndrome is a well-recognised complication of uneventful phacoemulsification. It often results in a clinically significant reduction in vision secondary to central opacification, intraocular lens decentration and tilt. We report 3 cases of anterior capsular phimosis, which we treated using a new technique, where long, fine pointed scissors are used to cut the anterior capsule radially towards the edge of the lens optic and the edge is then grasped with capsulorrhexis forceps and the anterior capsule is torn away. The tear occurs at the edge of the optic because the anterior and posterior capsules are fused at this point. We believe that our technique offers a superior alternative for the effective, safe and quick management of anterior capsular phimosis, thereby improving the intraoperative fundus view for vitreoretinal surgery or delivery of laser treatment.

We evaluated the efficacy and safety of ‘punctal switch’ grafting, a proposed new technique for permanent punctal occlusion. We prospectively evaluated the results and complications in 22 patients (5 males and 17 females) who underwent the procedure in our department over a period of 3 years. Patients’ ages ranged from 41 to 81 years. The average follow-up was 12.8 months. Subjective and clinical improvement was documented in 91% of the cases with a low rate of recanalization (9%). Only 1 patient developed epiphora postoperatively, and the operation has been successfully reversed in that case. There were no serious complications. As a conclusion, punctal switch grafting is an effective technique for permanent punctal occlusion. The complication rate is low, recanalization is rare and the occlusion can be reversed if symptomatic epiphora develops.