Sir,

I read with interest the article by Mercieca et al1 describing a higher incidence of subconjunctival haemorrhage in a cohort of uveitic patients who were on long-term topical steroid therapy compared with a comparison group of patients using glaucoma medication. Although they describe systemic hypertension as a risk factor for subconjunctival haemorrhage, they did not record if hypertension was present or whether anti-hypertensive medication was being used in their methods. In the 24 patients who developed a subconjunctival haemorrhage, was hypertension present as a confounding factor? If so, was it well controlled or prone to wide fluctuations? This is particularly important to know in the five patients who had recurrent episodes. Diabetic patients are also prone to developing subconjunctival haemorrhage and this would be important to exclude in the uveitic subgroup of patients, some of whom may have been on oral steroid therapy at a certain point.

Without excluding co-existing hypertension or diabetes, the conclusion that steroid-induced vascular fragility is the sole cause of subconjunctival haemorrhage in this study is less valid. Perhaps it is the patients with a background of hypertension or diabetes and long-term topical steroid use who are most at risk.