We appreciate the comments by Drs Gönül and Öztürk regarding our published article. Our study reviewed the clinical findings associated with an outbreak of toxic anterior segment syndrome (TASS) after the implantation of one-piece intraocular lenses (IOLs; HOYA iSert 251 and 255, HOYA, Japan). To enroll many cases, the questionnaire did not include results of ophthalmic examinations such as electroretinography (ERG), which examines retinal function, and optical coherence tomography (OCT), which observes the retinal morphology.

We can consider several possibilities regarding the pathology of late-onset TASS in our study. We postulated that inflammation induced by the aluminum could damage ocular tissues. As Drs Gönül and Öztürk suggested, aluminum toxicity might have caused a toxic retinopathy in our cases. We divided the patients into those who underwent surgical treatment (109 patients) and those who received only medical treatment (142 patients), and analyzed the initial and final best-corrected visual acuities (BCVA), and compared the difference between the initial and final BCVA. The BCVA data were analyzed using Student’s t -tests. A P value < .05 was taken to indicate statistical significance. The mean initial BCVA in the surgery and medicine groups was 0.334 ± 0.477 and 0.196 ± 0.372, respectively, and was significantly better in the medicine group ( P < .05). The mean final BCVA was also significantly better in the medicine group (0.007 ± 0.137 vs 0.077 ± 0.328, P < .05). The difference in the initial and final BCVA in the surgery and medicine groups was 0.276 ± 0.416 and 0.187 ± 0.324, respectively, and was greater in the surgery group, although this was not statistically significant ( P = .08).

These results suggest that the surgery group suffered greater retinal damage, although the recovery of BCVA after treatment was better in that group. Perhaps the reduction in aluminum levels in the eyes of these patients improved their recovery. Therefore, aluminum toxicity could affect retinas in patients with IOLs that had been contaminated with aluminum, as Drs Gönül and Öztürk postulated. The inflammation induced by the aluminum might also influence ocular tissues, similar to a previous report, and our cases seem to involve very complicated pathology. Because our study was an observational retrospective study, it is difficult to understand the exact pathology. To do so, ERG, OCT, and further investigations are needed.

Regarding patient gender, there were 89 male (89 affected eyes) and 162 female patients (162 affected eyes). The order of the genders in Table 1 was wrong. We apologize for our mistake.

We again thank Drs Gönül and Öztürk for their thoughtful comments and for giving us the opportunity to add the important information about aluminum toxicity to our published article.