We thank Drs. Garcia-Gonzalez and Teus for their interest and discussion of our recent publication. In response to their first comment that the visual outcomes in the KAMRA group may have been overestimated as a result of mild myopia in the inlay eye, we refer to Figure 4 of our article, which shows the cumulative percentages and means of monocular distance-corrected far, intermediate, and near visual acuities. Distance-corrected visual acuity accounts for refractive error, making the patients essentially emmetropic, and no clinically significant difference was found between distance-corrected and uncorrected visual acuities at intermediate or near. Further, the mean binocular uncorrected distance visual acuity with KAMRA inlay was 1.40 decimal (range, 0.95–1.40), which is better than that reported by the authors for laser in situ keratomileusis (LASIK)-induced monovision at 1.08 decimal (range, 0.7–1.25).

When the visual acuity results are stratified by preoperative refractive error (myopic: manifest refraction spherical equivalent [MRSE] < 0.0 diopter, n = 101; emmetropic: MRSE = 0.0 diopter, n = 42; and hyperopic: MRSE > 0.0 diopter, n = 184), the uncorrected visual acuities (logMAR) at intermediate are 0.15 ± 0.13, 0.19 ± 0.14, and 0.21 ± 0.14, respectively. Uncorrected visual acuities at near are 0.15 ± 0.13, 0.21 ± 0.16, and 0.24 ± 0.16, respectively. These differences in visual acuity between the myopic and the hyperopic groups approximate only 1 line of acuity, whereas the difference in near visual acuity before and after KAMRA implantation is between 3 and 4 lines of acuity. Therefore, the improvement in intermediate and near visual acuity with KAMRA is primarily due to the extended depth of focus provided by the small-aperture inlay; mild myopia adds a nominal benefit. However, pairing the KAMRA inlay with a small magnitude of myopia optimizes the intermediate and near visual acuity range while maintaining excellent uncorrected visual acuity at far (mean 0.009 ± 0.11 logMAR). Monovision LASIK with sufficient offset (add) between the two eyes to improve near vision to a clinically meaningful degree degrades far vision quality as well as binocularity.

Postoperative stereopsis in KAMRA patients has been demonstrated to be no different than preoperative stereopsis. Regarding the second comment on vision with KAMRA inlay being comparable to monovision, we refer to the article on the impact of small aperture on stereoacuity with monovision. Fernandez and associates showed that introducing a small aperture to +0.75 D monovision improved stereopsis compared to +0.75 D of traditional monovision.

Finally, the article published by Alió and associates, from which the authors cited loss of best-corrected visual acuity after inlay removal, was an observational case series on patients implanted with a hydrogel corneal inlay. In distinction, the KAMRA inlay (ACI7000PDT) is made of polyvinylidene fluoride, is much thinner at 6 μm, and harbors 8400 microperforations in the annulus to further enhance the flow of glucose and other metabolites. Recently, Alió and associates reported on topographic and aberrometric changes 6 months after KAMRA inlay removal. Alió and associates concluded the KAMRA inlay to be safe, with good recovery of corneal topography and aberrometry after removal.