We appreciate the interest of Drs Kim and Jampel in our work. The purpose of our systematic review and meta-analysis was to collect and summarize the results of previous randomized controlled trials (RCTs) on the prevention of cystoid macular edema (CME) after cataract surgery. We agree with Drs Kim and Jampel that several factors may influence the interpretation of our results. Therefore, we provided a detailed evaluation of the study results in the discussion section, which includes the factors mentioned by Drs Kim and Jampel, and discussed below.

We agree with Drs Kim and Jampel that visual acuity (VA) is of great clinical importance in the follow-up after cataract surgery. However, many factors may influence postoperative VA. Therefore, we think that VA alone cannot be used as a primary outcome in studies investigating the prevention of CME after cataract surgery. Nevertheless, VA should be incorporated in any definition of clinically significant CME. Unfortunately, we identified numerous definitions in previous studies.

Topical corticosteroids increased the odds of developing CME as compared to nonsteroidal anti-inflammatory drugs (NSAIDs) or combination treatment. Previously, Kessel and associates showed that both potent and weaker corticosteroids were less effective than NSAIDs in prevention of CME. Results of ten individual RCTs suggest that topical NSAIDs should be used after cataract surgery in all patients. Whether the use of corticosteroids can be avoided cannot be concluded from our study.

Drs Kim and Jampel refer to a recent study of Tzelikis and associates, who compared topical prednisolone to combination treatment in a mixed population. The authors did not find any differences in mean foveal thickness or VA, which is in line with the results of our meta-analysis. Furthermore, Zaczek and associates recently compared topical combination treatment to topical dexamethasone in non-diabetics and found comparable results. Mechanisms of action of anti-inflammatory treatments are beyond the scope of this review.

Finally, Drs Kim and Jampel emphasize the different conclusions reported by the AAO Ophthalmic Technology Assessment Panel. Different conclusions are drawn because both reviews did not include the same original RCTs. The current study provides a complete overview of all relevant RCTs. We performed an extensive literature search, reviewed 161 full-text articles, and included 30 individual RCTs. Only 27 full-text articles have been reviewed by the AAO Ophthalmic Technology Assessment Panel, who included 15 trials. Moreover, the panel included many studies investigating the incidence of CME after intracapsular or extracapsular cataract extraction. We decided to exclude these RCTs from our study, since phacoemulsification cataract surgery is the standard of care in most ophthalmic practices.

We excluded one study from our quantitative analysis “because no patient in either treatment group developed CME.” This study also did not report mean VA, macular volume, or foveal thickness, which is why it could not be included in any meta-analysis.

We agree with Drs Kim and Jampel that systematic reviews and meta-analyses cannot fully account for variations between individual studies. Additionally, the quality of included RCTs was moderate to low. We hope that the results of the ESCRS PREvention of Macular EDema after cataract surgery (PREMED) study will provide more evidence-based guidelines.