We greatly appreciate the interest of Drs Zygoura, Kopsachilis, and Carifi in our study and are happy to address their comments below.

First, regarding methodology, the original Ophthalmic Surgery Outcomes Database (OSOD) Pilot Project was a quality improvement program conducted by the Veterans Health Administration (VHA). This program reviewed preoperative, intraoperative, and postoperative information of patients undergoing cataract surgery at 5 VHA sites in the United States. Specific data elements, predetermined by the OSOD Committee, were abstracted from preoperative, intraoperative, and postoperative records of eligible patients by nurse reviewers and entered into a database. After the quality improvement program was completed, the National Surgery Office within the VHA compiled the data generated by the OSOD into a data set devoid of any patient identifiers. With Institutional Review Board approval and a Data Use Agreement, the de-identified data set was analyzed for this retrospective study.

Second, approximately 150 data elements were collected in the original OSOD. Intraoperative floppy iris syndrome (IFIS) was collected as a dichotomous variable (ie, present or not). It is not possible to determine from this data set the degree of IFIS (mild to complete), since this information was not included. The same applies for the phacoemulsification platform, incision size, type of irrigation/aspiration devices, and the ophthalmic viscosurgical device type used.

Third, in accordance with Department of Veterans’ Affairs policy, an attending surgeon was present during all surgical procedures and many cases also involved a resident surgeon. The de-identified data set did not include surgeon-specific information other than whether the major portions of the case were performed by an attending or a resident surgeon.

Fourth, as demonstrated in Table 1 of the study, the overall prevalence of posterior capsule rupture was 4.1%; in patients with IFIS it was 6.9% and in patients without IFIS it was 3.7%. As discussed above, the OSOD included a wide variety of surgeons and is in line with posterior capsule tear rates at academic medical centers. The overall prevalence of anterior capsule tears was 3.2%; in patients with IFIS it was 3.9% and in patients without IFIS it was 3.1%. These rates are similar to those published in peer-reviewed literature for cases at similar institutions. The commentators report complication rates for their institution that have not been published. We encourage them to submit such data for peer review and look forward to seeing it in the future literature.

Fifth, the data set noted the use of pupil expansion devices, but not at which time these were employed during the surgery. In some cases, as the commentators suggest, pupil expansion devices are used for limited dilation and not necessarily for IFIS.

Finally, our group is indeed examining several other specific outcomes in the data set, of which cystoid macular edema is an example. Several of these other reviews have been presented at recent meetings and are being prepared for publication.