W e share the authors’ view that immunomodulatory therapy (IMT) should not be delayed in patients with clinically progressive cicatrizing conjunctivitis suggestive of ocular mucous membrane pemphigoid (oMMP), despite a negative direct immunofluorescence (DIF) result.
We acknowledge that the value of conjunctival biopsy extends beyond DIF confirmation. Biopsy with routine histopathologic evaluation may identify alternative or concurrent diagnoses, including ocular surface neoplasia, sarcoidosis, and other pathologies. Our intention was not to diminish the importance of conjunctival biopsy but rather to emphasize that treatment should not be deferred solely because of a negative DIF result when the clinical presentation is strongly suggestive of oMMP.
A comprehensive diagnostic evaluation is an important patient safety measure before committing patients to long-term systemic IMT. However, in patients with a typical clinical presentation of oMMP, this evaluation should not delay treatment initiation. , When clinical suspicion is high, IMT can be initiated while conjunctival biopsy and other diagnostic investigations are underway, with the results subsequently informing ongoing management should an alternative diagnosis be identified.
We also agree that routine light microscopic examination should accompany DIF whenever conjunctival biopsy is performed. Conventional histopathology complements DIF by providing additional clinicopathologic information and may facilitate the identification of alternative or concurrent pathology that may not be evident on immunofluorescence alone. We appreciate the authors for further emphasizing the additional value of routine histopathologic evaluation in assessing the extent of inflammation and fibrosis.
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