We read with great interest the article “Use of Infliximab in the Treatment of Peripheral Ulcerative Keratitis in Crohn Disease,” published in August 2011 issue of the Journal. We appreciate the authors for highlighting the importance of biologics and the newer immunosuppressives in the management of peripheral ulcerative keratitis in Crohn disease refractory to conventional immunosuppressive therapy. We also agree with the authors’ comments that infliximab similarly may be effective in diseases with similar mechanisms of action like rheumatoid arthritis.

One important aspect that we believe also could have been mentioned in the article is the activity of the systemic disease with the use of infliximab. The authors did not comment on whether the Crohn disease of the patients was under control with the use of infliximab alone or whether additional immunosuppression used to maintain the systemic disease in remission. Also, patients who were intolerant or refractory to treatment with conventional immunosuppression were started on infliximab, but it would have been interesting to know the dose and duration of previous immunosuppressive treatment, that is, if immunosuppression had been used in adequate doses previously. Probably response to adequate doses of conventional immunosuppression may have been achieved. Also, adequate doses of conventional immunosuppression could be useful in the maintenance phase of the disease. It would have been nice to use relapse rates or periods of remission with the use of infliximab as an outcome measure, too. The first case had 5 exacerbations in 1 year while receiving infliximab; also, the second case in the article underwent multiple sequential lamellar keratoplasties. The third case had a follow-up of only 3 months. Therefore, how can we conclude that infliximab was effective in controlling the disease process? Long-term outcomes in patients with peripheral ulcerative keratitis with the use of this drug are not known. The cost of the drug also is an important concern, and cost effectiveness with the use of infliximab needs to be examined. Thus, a multicenter, prospective randomized study will probably provide us with more insight into the subject.

The authors have not mentioned whether they evaluated for any demyelinating diseases before starting infliximab in their patients, which is an important concern with the use of infliximab, especially in the white population. Also, a pain scale could have been used to provide an objective grading of the pain and its response to medication. It also would have been useful to provide the clinical photographs of both eyes of all the 3 patients that the authors described.