Author Response: Comment on Surgically induced necrotizing scleritis (SINS): Is it a standalone condition or a variant of necrotizing scleritis?

Dear Editor, We thank Ruiz-Lozano et al.[1] for their insightful comment on our article "Surgically induced necrotizing scleritis (SINS): Is it a standalone condition or a variant of necrotizing scleritis?".[2] The authors, citing their recently published study, emphasized that non-autoimmune SINS cases were associated with less severe inflammation compared to SINS with an autoimmune cause.[3] They found that 60% of eyes with non-autoimmune SINS could achieve remission with non-steroidal anti-inflammatory drugs (NSAIDs), with only 8% requiring immunosuppressives.[3] Non-infective scleral necrosis, defined as an area of avascular scleral thinning or tissue melting with uveal show following any surgical intervention, should be considered a ‘red flag sign’ and treated aggressively regardless of autoimmune aetiology.[4] We believe it is better not to consider NSAIDs as first-line therapy in such destructive forms of scleritis. Despite the less severe inflammation, the rate of complications was significantly higher: four eyes required tectonic grafts, two eyes progressed to phthisis, and overall decreased visual acuity was noted in 11.8% of patients in the non-autoimmune group. In our series, all patients received systemic corticosteroids, with 53% requiring additional immunosuppressives. None of the patients in our series developed phthisis or required a tectonic graft, and none had worsening visual acuity from baseline, with 40% showing an improvement in vision.[2] None of our patients with SINS had any established autoimmune or rheumatological association. Compared to data from the Western world, case series from India have reported relatively fewer systemic associations in non-surgery-related necrotizing scleritis patients. In a case series of necrotizing scleritis from a tertiary eye care centre in India, only 37% of the patients had a systemic association.[5] It is possible that the development of SINS after ocular surgery can be the first manifestation of a systemic autoimmune disease, which may be apparently in remission with negative biomarkers and absent systemic manifestations in those patients. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.