I would like to thank Drs Johnson and Chu for their article “Evaluation of Sub-Tenon Triamcinolone Acetonide Injections in the Treatment of Scleritis. It brings to our attention the new approach to treatment of nonnecrotizing scleritis, which is characterized by severe pain and a high relapse rate. The authors conclude that sub-Tenon triamcinolone acetonide (TA) may be a useful adjunct to achievement of transient, partial improvement of subjective pain and objective inflammation while waiting for systemic medications to take effect. Although the study is simple and concise, I have the following comments and questions.
The authors reported that 10 of 11 patients reported subjective improvement and that 10 patients showed improvement in objective inflammation at the time of the initial follow-up (range, 2 to 5 weeks). All patients received simultaneous systemic medications: prednisone, methotrexate, nonsteroidal anti-inflammatory drugs, celecoxib, and so forth. I am wondering how to conclude that sub-Tenon TA injections may be a useful adjunct for achievement of subjective and objective improvement in patients with scleritis while waiting for systemic medications to take effect without exclusion of the preexisting effect of systemic treatment. In addition, there were wide discrepancies in the time designated for evaluation of initial improvement of symptoms and signs associated with scleritis: minimum 2 weeks and maximum 5 weeks.
The authors commented that in the “Results,” 2 patients were excluded because they were lost to follow-up; however, it seemed that the authors included them in their data and in the Table. Furthermore, I found a few instances of missed proofreading; for example, SCI (subconjunctival corticosteroid injections) in the “Results,” line 2, is not correct, and SCI in the “Discussion,” page 80, left paragraph, line 28, may cause misunderstanding among readers.
I highly appreciate the report by these authors, which provided us with valuable information on new, challenging treatment methods for retractable nonnecrotizing scleritis. They reported that adverse events from sub-Tenon TA injections were few and manageable: 2 ocular hypertension cases and 1 cataract case. We recently reported in our retrospective analysis that posterior sub-Tenon TA injections for treatment of posterior uveitis, diabetic macular edema, and macular edema secondary to retinal vein occlusion, resulted in no severe complications, such as endophthalmitis or retinal detachment, and relatively less risk of complications because of intraocular pressure (11.3%) and cataract progression (2.1%). Our study showed a much lower incidence of side effects than this study, because our study included a large case series with more long-term follow-up. In conclusion, sub-Tenon injection is a safe procedure and can be applied repeatedly to eyes, as in this study.
Although it involved a small case series, findings from this study demonstrated that sub-Tenon TA injections should be considered as a useful adjunct in treatment of nonnecrotizing scleritis and that further studies are warranted.