We appreciate the comments by Onal and associates in reference to the recently published interventional case series describing sub-Tenon corticosteroid injections in the treatment of scleritis. We agree with the comment that the purpose of corticosteroids therapy in patients with scleritis is to control the acute inflammation. To reiterate, we reported that this approach is useful as adjunctive therapy in anterior, nonnecrotizing, noninfectious scleritis, not as the primary method in the treatment armamentarium. The injections are helpful in achieving rapid control of pain and inflammation. We would not anticipate a change in recurrence rate in these patients, because the treatment should not influence the disease course.

However, we disagree with Onal and associates in their preferential selection of methotrexate (MTX) as the initial systemic immunomodulatory therapy in treatment of anterior scleritis. Nonsteroidal anti-inflammatory drugs (NSAIDs) are routine first-line agents in the treatment of scleritis with a concurrent but a short course of oral corticosteroids, if needed. However, if NSAIDs fail or the patient has contraindication for such therapy, MTX then should be considered as the second-line agent. During the preparation of our previously published article on use of MTX in scleritis, we found a scarcity of publications on the subject. We agree that MTX is an extremely effective agent for scleritis, but in comparison with NSAIDs, it carries a less favorable profile of potential side effects. Furthermore, we believe that the onset of effect seems more rapid in NSAIDs than in MTX.

Scleral melting is a serious potential side effect of subconjunctival corticosteroid injections. There are case reports in the published literature, but the incidence and risk factors of such a catastrophic complication are not understood clearly. Although our patients received sub-Tenon space injections differing from subconjunctival injections, we hope to add to the discussion on this subject. We do not advocate regional steroid injections in the management of necrotizing scleritis, but we believe that it is appropriate for patients with Wegener’s granulomatosis or those who are suspected to have this disease, because there is no clear evidence that these patients are more likely to progress to necrotizing scleritis after regional steroid injections compared with patients with nonnecrotizing scleritis associated with rheumatoid arthritis, systemic lupus erythematosus, or other autoimmune vasculitides.

In summary, sub-Tenon corticosteroid injection is a useful adjunctive therapy in the management of the acute inflammation and pain associated with anterior nonnecrotizing scleritis.