We thank Mataftsi and associates for their interest in our article. We agree with the authors that usage of a polymethyl methacrylate (PMMA) intraocular lens (IOL) has many drawback and hence is not the first choice of IOL to be used in children. However, after the hydrophobic acrylic IOLs, these are the second most preferred IOLs in children. In our study a high number of PMMA lens implantations could be attributed to the fact that the study involved children operated over a decade, from January 1, 2000 to December 31, 2010, when the PMMA IOLs were still very prevalent. In addition, in the patients who could not afford the hydrophobic acrylic lenses, PMMA IOLs were chosen. Currently we prefer a 3-piece or single-piece hydrophobic acrylic foldable IOL in children undergoing secondary/primary IOL implantation. However, in children undergoing secondary IOL implantation in sulcus, PMMA IOLs also have an advantage over single-piece hydrophobic IOLs in terms of greater stability and less iritis and pigment dispersion.

In a series involving 218 eyes of 138 children who had undergone cataract extraction with primary IOL implantation at our institute using a clear corneal or scleral tunnel incision, we found no significant difference in the level of postoperative astigmatism between the clear corneal and scleral incision groups.

We have published the “refractive outcomes of secondary IOL implantation” elsewhere in detail. In summary, values of refraction (spherical equivalent) at 3 months postoperatively were considered for analysis and the spherical equivalent (SE) of the residual refractive error was recorded in diopters (D). The mean postoperative refraction in SE was −0.19 ± 2.39 D (range: −7 to 6 D), whereas the predicted postoperative refraction was 1.49 ± 1.89 D (range: 0–7.5 D). The mean prediction error (PE) was 1.65 ± 2.46 D (range: −3.25 to 7.5 D) and mean absolute PE was 2.15 ± 1.68 D (range: 0–7.5 D) at 3 months. Hence PE contributed to significant refractive error postoperatively. Hence we conclude that, in spite of using PMMA IOLs in the majority, the refractive outcome was still satisfactory and was affected more by prediction error than by astigmatism due to a large incision.