Sir,

Prolonged hypotony in uveitis patients is often regarded as the end stage of a chronic disease from which recovery is improbable if not impossible. However, not all hypotony cases are alike. Hypotony resulting from active inflammation will respond to adequate immunosuppression, and as indicated in our article an attempt should be made to treat it medically before considering a surgical approach. The question then is how long should one wait to observe a response.

As indicated by Dr Liu and co-workers, periocular steroids can have a prolonged effect. In certain forms of uveitis, a single periocular injection can provide a beneficial effect for 8–12 weeks. However, one would expect to see a response to steroids within the first 10–14 days. To take into account a possible delay in this initial response, we followed patients for 2 months prior to surgery. The patients included in this series did not show a pressure rise on intensified immunosuppression.

There is no doubt that steroids and other immunosuppressants contribute to the surgical result. However, the effect will not be sustained once a taper is initiated. Management in this series of patients became easier following surgery with fewer and less immunosuppressants being required. Hypotony in chronic uveitis patients is often characterized by a protracted course requiring frequent reinjections, or modifications to the immunosuppressive regimen.

For all the reasons mentioned above, and our results, we feel that a surgical approach should be considered in this group of patients. With time, we should be able to determine the place and timing of surgery in the management of this severe complication of uveitis.