Teo and associates deserve appreciation for their article, “Severity of Pediatric Blepharokeratoconjunctivitis in Asian Eyes.” The literature available on this subject is scarce. However, a few points require elaboration. In the “Methods,” the authors describe eye scrapings, by which I believe they mean corneal scrapings. They mentioned in the “Discussion,” “All but 1 patient in our study required topical steroid therapy to control the disease,” and “in our series, 19 patients (37.3%) were noted to have corneal thinning, perforation, or both, with 4 (7.8%) patients requiring surgical intervention.” This indicates that 35% of all the patients, having corneal thinning, continued to receive steroids. Was the corneal perforation the result of the disease or the excessive use of topical steroids?

The authors concluded that the disease is more severe and that prolonged treatment is required, resulting in “higher rate of complications of treatment, which include 7 patients in whom steroid-induced raised intraocular pressure developed and 1 patient with steroid-induced cataract” in Asian eyes. However, they did not describe the criteria for treatment. In the absence of standardized treatment, it is difficult to compare the responses of different studies. The word severity in the title conveys the authors’ preconceived belief that the disease is severe in Asian eyes. Because there is no comparison among races in this article, the title should have been “Manifestations and Management of Pediatric Blepharokeratoconjunctivitis in Asian Eyes.” Disease severity was graded based only on corneal involvement, without taking into consideration lid features, which may be important in the absence of severe corneal involvement.

The authors presented symptoms and signs of many diseases affecting lids, conjunctiva, and cornea, without paying much attention to the cause. If a patient has stye or chalazion with acne rosacea, marginal keratitis, phlyctenulosis, atopic blepharitis or keratoconjunctivitis, or herpetic keratitis, we should label it as such, instead of dumping it in a poorly demarcated category of blepharokeratoconjunctivitis. It would help to specify and standardize the treatment options. Moreover, there is no mention of seborrheic dermatitis, angular blepharitis (caused by Moraxella ), or interstitial keratitis. It has been presumed that the cause is bacterial (in addition to idiopathic). Dermatologist consultation is necessary when there are skin findings; however, this was not mentioned. Despite a difference in point of view, I congratulate the authors again for bringing a very important topic to the under discussion.