Department of Health and 1 Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, People's Republic of China.
Correspondence to: D. T. L. Liu, Department of Ophthalmology & Visual Sciences, The Chinese University of Hong Kong, University Eye Center, Hong Kong Eye Hospital, 147K, Argyle Street, Hong Kong. E-mail: david_tlliu{at}yahoo.com
SIR, We read with interest the article by Sakellariou et al. [1] about a patient with Behçet's disease having scleromalacia perforans. However, the authors proposition concerning the progression of episcleritis into scleromalacia perforans seemingly contravenes our current understanding of the pathogenesis of episcleritis, scleritis and scleromalacia perforans.
In a retrospective review of 266 patients, Sainz de la Maza et al. [2] have clearly indicated the overt disparities between episcleritis and scleritis in terms of pathological classification, clinical manifestation, systemic association and visual prognosis. Scleromalacia perforans is recognized as a subtype of scleritis, representing a terminal pathological sequel as a result of unchecked scleral inflammation [2]. Contrary to the suggestion by Sakellariou et al. [1], there has been no association between episcleritis and scleromalacia perforans ever reported in literature [2, 3]. This may be due to the fact that scleromalacia perforans actually involves fibroblastic transformation of the scleral cells but not the episcleral tissue [4]. Progression of episcleritis to scleromalacia perforans is neither pathologically nor clinically feasible.
In view of the ominous visual prognosis and likelihood of underlying systemic inflammatory diseases in scleritis, systemic immunosuppressants are required most of the time to dampen the inflammation [3]. Conversely, 83.3% of episcleritis cases can be managed successfully with topical steroid eye drops while the minority are in need of oral non-steroidal anti-inflammatory drugs only [3]. Interestingly, if we take a look at the management plan, which comprised solely systemic immunosuppressants in this case, it may be inferred that scleritis, rather than episcleritis, was the most dominant ocular presentation, even in the mind of authors.
A reply from the authors would certainly enlighten us with regard to this.
The authors have no financial or proprietary interests.
References
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