We appreciate the insightful comments of Dr Shekhar and associates on our published article. As the primary goal of this study was to assess the demographics and clinical outcomes, including the patient’s symptoms, the reasons for selecting this method, and the patient satisfaction with multifocal intraocular lens (IOL) explantation as a retrospective questionnaire survey in a large cohort of patients, it is reasonable that some of the patients may have undergone IOL explantation in another institution, and that patient satisfaction was calculated based on records supplied by referring ophthalmic surgeons.
We additionally assessed the patient satisfaction in eyes undergoing monofocal IOL implantation as a control group. Although we did not routinely assess contrast sensitivity after monofocal IOL implantation, the baseline characteristics such as visual and refractive outcomes in monofocal IOL-implanted eyes were similar to those in multifocal IOL-implanted eyes. As we emphasized that it was conducted as a retrospective questionnaire survey in this article, we did not have the data of personality and professional needs, quantitative assessment of subjective symptoms, or the individual reasons for early or late IOL explantation.
Five of 10 patients, who had incorrect multifocal IOL power, underwent multifocal IOL explantation, possibly because the amount of residual refractive error was relatively large. Eyes with epiretinal membrane and macular atrophy had visual symptoms such as waxy vision (2 eyes) and glare/halos (1 eye). As mentioned in the results, 3 eyes (6%) required triamcinolone-assisted anterior vitrectomy, and 1 eye (2%) developed a slight, asymptomatic IOL dislocation attributable to partial zonular dehiscence. No particular protocol was followed for multifocal IOL explantation, since this is a retrospective multicenter study.
Since it is known that IOL exchange frequently involves a complex decision-making process and is often associated with immense technical challenge, the surgeons might consider that subjective symptoms and dissatisfaction at that time were largely attributed to posterior capsular opacification in 5 eyes (10%), but not to the multifocal IOL itself.
We assume that the surgeons who have implanted multifocal IOLs are less likely to advise the patient for multifocal IOL explantation, especially when the trust of such dissatisfied patients in the surgeons had not been properly established, or when the IOL exchange technique is not very familiar to the surgeons. Judged on the basis of this questionnaire survey, we believe that multifocal IOL explantation is a feasible surgical option for dissatisfied patients with persistent visual symptoms in multifocal IOL-implanted eyes.