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Severity of Pediatric
Blepharokeratoconjunctivitis in Asian
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 compari-
son among races in this article, the title should have been
“Manifestations and Management of Pediatric Blepharokera-
toconjunctivitis 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, phlyctenu-
losis, atopic blepharitis or keratoconjunctivitis, or herpetic
keratitis, we should label it as such, instead of dumping it
in a poorly demarcated category of blepharokeratoconjunc-
tivitis. It would help to specify and standardize the treat-
ment 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 con-
sultation is necessary when there are skin ﬁndings; how-
ever, 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.
KHAWAJA KHALID SHOAIB
Khyber Pakhtoon Khawa, Pakistan
CONFLICT OF INTEREST DISCLOSURES: ALL AUTHORS
have completed and submitted the ICMJE Form for Disclosure of
Potential Conﬂicts of Interest and none were reported.
1. Teo L, Mehta JS, Htoon HM, Tan DT. Severity of pediatric
blepharokeratoconjunctivitis in Asian eyes. Am J Ophthalmol
WE ARE GRATEFUL FOR THE INTEREST SHOWN BY DR
Shoaib in our study.
In our series, none of the cases had
been treated with steroids—appropriately or otherwise—
before seeking treatment at our center. As such, the
severity of corneal thinning or perforation at the time of
initial presentation clearly is unlikely to be the result of
excessive steroid use.
With regard to a standardized treatment approach or
criteria for treatment, in view of the signiﬁcant range of
disease severity of corneal involvement, a standardized
approach toward frequency of steroids would not be real-
istic, but we would like to bring the author’s attention to
the general overview and principles of therapy, as laid out
in our “Methods” section.
We respectfully defend the use of the adjective severity in
the title of our article, simply because our clinical data
revealed that corneal involvement was disproportionately
more severe in our series of Asian patients as compared with
other published studies, and this was extensively addressed in
our “Discussion” section. Because corneal involvement may
be more immediately sight-threatening than lid involvement,
we also believed it appropriate to grade overall disease
primarily on the more sight-threatening corneal changes.
Because our data also revealed that few, if any, of the
relatively mild lid changes seen were sight threatening, it was
evident that lid changes were less important in our series.
It is well established in the literature that inﬂammatory
lid margin disease with accompanying secondary corneal