1The First Clinical Medical College, Fujian University of Traditional Chinese Medicine, Fuzhou, People’s Republic of China; 2Department of Ophthalmology, Shangrao Central Hospital, Shangrao, Jiangxi, People’s Republic of China; 3Department of Ophthalmology, The People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, People’s Republic of China; 4Institute of Ophthalmology, Integrative Medicine of Traditional Chinese and Western Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, People’s Republic of China

We read with great interest the review by Belletti et al on the safe use of corticosteroids in noninfectious uveitis (NIU).1 The section on steroid-associated glaucoma (SAG) is highly relevant to day-to-day decisions. As this is a narrative review, we suggest targeted refinements to make the message both evidence aligned and clinic ready:

1) Causality wording aligned to evidence. Signals of glaucoma progression despite on-target intraocular pressure (IOP) in eyes receiving long-acting intraocular steroids should be framed as associations from longitudinal data rather than established causality; mechanisms remain to be proven prospectively. Recent long-term analyses of modern fluocinolone acetonide implants underscore sustained inflammation control while highlighting vigilance for IOP events.2,3

2) Close the loop with a concrete surveillance pathway. To operationalize indefinite monitoring, we propose a closed-loop algorithm specifying time points, metrics, and action thresholds (Figure 1). Contemporary evidence syntheses on uveitic macular edema (UME) management emphasize structured surveillance paired with route de-escalation when risk emerges.4

Figure 1 Closed-loop surveillance and intervention for steroid-associated glaucoma in NIU.

3) Risk-weighted route selection. Quantified IOP and glaucoma risks reported for intravitreal steroids should feed directly into the route algorithm (intravitreal greater than periocular for IOP events; higher risk with long-acting implants). In historical fluocinolone 0.59 mg implant cohorts, IOP-lowering medication was required in roughly 70–80% and glaucoma surgery in about 30–40% of eyes, whereas modern 0.18–0.2 mg inserts achieve durable recurrence control with markedly lower—yet nontrivial—IOP event rates (IOP-lowering medication in approximately 30–40% and surgery in about 5–10%). High-risk phenotypes—prior steroid responder, filtering surgery, narrow or closed angle, pediatric or young age, myopic small disc—should therefore favor systemic therapy with or without short-acting local steroid, reserving long-acting implants for unilateral disease or systemic contraindication with intensified surveillance.4

4) Alternative local route positioning. Suprachoroidal triamcinolone acetonide may be presented as a lower-IOP-risk option for prior steroid responders or glaucoma suspects with the explicit caveat of shorter follow-up; recent systematic evidence supports this positioning.5

These refinements can be incorporated without altering the thrust of the review while substantially improving its translational value.

No new data were generated or analyzed.

Luxing Xu AND Xin Chen: Conceptualization, Writing – original draft, Writing – review & editing. Guanghui Liu: Conceptualization, Investigation, Writing – review & editing.

All authors gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

The authors declare that no funding was received for this paper.

The authors declare no conflicts of interest.

1. Belletti M, Izquierdo-Escamez R, Tornero C, et al. Safe use of corticosteroids in noninfectious uveitis. J Inflamm Res. 2025;18:14441–14455. doi:10.2147/JIR.S540821

2. Sisk RA, Riemann CD. Fluocinolone acetonide 0.18 mg implant for noninfectious uveitis affecting the posterior segment: an evidence update. Clin Ophthalmol. 2024;18:2237–2251. doi:10.2147/OPTH.S424857

3. Biswas J, Banker A, Das D, et al. The 0.2 µg/day fluocinolone acetonide intravitreal implant for noninfectious uveitis: long-term outcomes. Ophthalmol Sci. 2024;4(4):100431. doi:10.1016/j.xops.2024.100431

4. Smith JR, Rosenbaum JT, Thorne JE, et al. Treatment of noninfectious uveitic macular edema with corticosteroids and steroid-sparing agents: an evidence-based update. Ophthalmology. 2024;131(10):e47–e66. doi:10.1016/j.ophtha.2024.06.012

5. Rahman S, Shehata A, Hamid A, et al. Suprachoroidal triamcinolone acetonide injection for uveitic macular edema: a systematic review and meta-analysis. Ophthalmol Ther. 2024;13:inpress. PMCID: PMC11556382.