We appreciate the interest of Petrou and associates in our paper. They raised important points for discussion to better understand the mechanism of macular hole (MH) formation secondary to handheld blue laser as well as the interpretation of some of the clinical findings. First, our speculation that the effect of this kind of laser may be photodisruptive was based on clinical observations, which include the lack of both thermal burn acutely and later scar formation at the retinal pigment epithelium (RPE) level, as well as recovery of good visual acuity after surgery in successfully closed macular holes. Therefore, although a photocoagulative component is possible, some RPE permanent effects should have been noticed clinically, especially given that it is difficult to justify that the absorption of laser energy by the macular pigment on its own can completely protect the RPE from laser damage. Hence, we speculated that photodisruption may be the predominant underlying mechanism.

Second, regarding the hyperreflectivity of the RPE on optical coherence tomography (OCT) in the bed of the MH, we agree with the correspondents that this is an interface phenomenon. It is well known that the absence of overlying tissue leads to increased reflectivity of the remaining subjacent layers on OCT. With respect to the hyperreflective excrescences, we discussed in our paper what has been described histologically in cases of idiopathic full-thickness MH as being RPE proliferations or lipofuscin-laden macrophages. Clumps of remnants of photoreceptors, as mentioned by Petrou and associates, is also a plausible explanation as to the nature of excrescences.

Finally, we couldn’t agree more that public education, perhaps on a national and international level, is necessary to try to limit this form of ocular injury, which, if not addressed, may become an “epidemic.” Again, we thank the correspondents for their valuable comments.