The authors state that staphyloma formation is a “fundamental” feature of what they call “pathologic” myopia, a term Drs Byeon and Chu do not define. Let’s be consistent and use the more commonly used term high myopia as used, and defined, in our article. Fundamental can mean a basic fact or principle. Fundamental can also mean an essential component; if fundamental is used in this manner, which the authors seem to imply, then that statement is not accurate. A staphyloma is not an essential component of high myopia. Curtin found staphyloma formation in 1.4% of eyes with axial lengths of 26.5 to 27.4 mm. Even among the few extremely long eyes (33.5 to 36.6 mm) examined, only 71.4 % had a staphyloma.

By definition, a staphyloma is an outpunching of the eye containing uveal tissue. In a staphyloma, there often is localized tessellation of the fundus. Optical coherence tomography (OCT) or contact B-scan ultrasonography shows the eye wall having 2 different radii: one corresponding to the general curvature of the eye outside of the staphyloma and a second with both a smaller radius and a different center point corresponding to the staphyloma. The authors stated they thought the patients in our study specifically had inferior staphylomas as defined by Curtin. The authors made the diagnosis of inferior staphyloma not by any fundus changes, optical coherence tomography data, or ultrasonography they observed in the cases illustrated in our article, but because they claim all eyes of a different paper showed tilted discs. First, only 3 of 15 eyes were shown in that article (by Gaucher and associates), so it is difficult to ascertain how Drs Byeon and Chu knew all eyes had tilted discs. Second, the patient illustrated in Figure 1 showed a mis-shaped, but not necessarily tilted, disc and the third eye, shown in Figure 3, did not have a tilted disc. Third, although tilted discs occur in myopia, they can be found in eyes without staphylomas or even without myopia. So, the contention by Drs Byeon and Chu is incorrect by more than one line of reasoning.

Dome-shaped macula causes an elevation of the central macula that is radially symmetrical around the center of the macula, and, as shown in our article, the scleral contour is smooth. This radially symmetrical appearance therefore rules out not only the supposition by Drs Byeon and Chu that there was an inferior staphyloma, but also their contention the eyes may have had some variation of Curtin type VI, VII, or IX staphyloma. Drs Byeon and Chu point out that in the complicated types of staphyloma, there may be elevations seen by optical coherence tomography; however, it is misleading to suggest this is what was illustrated in our article, because the elevations are actually vertical septae appearing as ridges between the posterior extensions of the surrounding staphylomas. In dome-shaped macula, the local radius at the top of the dome is larger than the surrounding general curvature of the eye. This is not true for any type of staphyloma.

In conclusion, they propose a new term, scleral compression maculopathy , which is an odd choice of terms because their underlying contention is that these patients have a macular staphyloma, which by default would cause excessive stretching of tissue, not compression. Drs Byeon and Chu do not correctly address many features clearly illustrated in our article (as well as that by Gaucher and associates ); they make unsupported claims and several demonstrably incorrect statements. They do not address the fact these patients have a relative thickening of the sclera under the fovea, which is diametrically opposed to the expected finding of scleral thinning if these patients really had a staphyloma, as Drs Byeon and Chu suggest.