The authors appreciate the questions posed by Drs. Carifi, Zygoura, Deshmuck, and Kopsakilis regarding the issues of capsule-optic overlap and whether intraoperative bleeding, iris trauma, or postoperative inflammation were considered as exclusion criteria.
Regarding capsular overlap: Lacking circular capsule-optic overlap in one eye at the conclusion of the surgery would definitely have led to the exclusion of the patient; as presented in the article, the cases of incomplete overlap observed 3 years after surgery resulted from secondary retraction of the anterior capsule or rhexis leaf caused by fibrotic contraction of the rhexis edge. In fact, no patient who had entered the study primarily had to be excluded for incomplete primary overlap because in cases with large corneal and pupil diameters that made estimation of the rhexis diameter difficult, the surgeon dimensioned the capsulorhexis at first considerably smaller than 6 mm to then secondarily enlarge and trim it to the optic circumference with the intraocular lens (IOL) already implanted and with the ophthalmic viscoelastic device (OVD) behind the IOL having been already aspirated and the anterior chamber refilled with the OVD to stabilize the capsule-IOL-diaphragm for this secondary rhexis adjustment.
Regarding bleeding, iris trauma or inflammation: Any eye with an intraoperative problem that may have caused such sequelae would also have led to the exclusion of the affected patient. However, none of these complications occurred in any eye, and iris hooks were never used. Although we did not call in the patients to look particularly at the condition of the eyes on the first day after surgery, we know from other large series of patients operated by the same surgeon investigating the impact of different phaco tips and fluidics on corneal thickness and chamber cell and flare counts 1 day after surgery that there is only minimal response with the surgical technique used.
Regarding the percentage of patients lost to follow-up: Considering the average age of the patients and the length of the follow-up, a drop-out rate of 26% is not exceptional. Post hoc power analysis of the observed standard deviation of the residual 74 patients revealed that a difference in posterior capsule opacification (PCO) score of 0.5 (ie, 5%) could be calculated with a 92% power at a level of 5%. This validates the results and justifies the conclusions drawn.