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Reply: Posterior continuous curvilinear capsulorhexis with anterior vitrectomy vs optic capture buttonholing without anterior vitrectomy in pediatric cataract surgery

Kohnen, Thomas MD, PhD, FEBO; Davidova, Petra MD; Lambert, Martin MD; Wenner, Yaroslava MD; Zubcov, Alina A. MD, PhD

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Journal of Cataract & Refractive Surgery: July 2022 - Volume 48 - Issue 7 - p 869-870
doi: 10.1097/j.jcrs.0000000000000968
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We thank Sukhija and Kaur for their interesting annotations to our paper. As the study started in 1997, the eyes were prospectively randomized to 1 of the 2 operation techniques and then reexamined between 2008 and 2010. Since the data were evaluated and analyzed in 2021, the charts of the participants were evaluated retrospectively. In the context of this study, the desired operation technique was achieved in all patients, so that no participant had to be excluded.

Your annotation concerning the participants with bilateral cataract is very interesting. Unfortunately, each eye of the participants was saved as an independent, anonymous file after the patients were randomized to one of the techniques so that a more detailed retrospective analysis in terms of bilateral cataracts was not possible and is an interesting remark for further studies.

As we mentioned in the paper, a shortcoming of our study was that we did not examine subgroups based on age. Throughout the age groups, no modifications were made during posterior continuous curvilinear capsulorhexis. In terms of primary posterior capsulorhexis, we evaluated each individual case preoperatively, whether to perform it in children older than 8 years or not. For example, we already considered the child's ability to cooperate for a potential Nd:YAG laser capsulotomy and the caretaker's compliance concerning regular ophthalmological appointments postoperatively. In general, our clinic tends to do a primary posterior capsulorhexis with posterior buttonholing. As Menapace stated, primary posterior capsulorhexis combined with posterior optic buttonholing is a promising technique also in adult cataract surgery, for example, with multifocal intraocular lenses (IOLs).1

Our 2 groups were not age-matched but show a quite homogenous distribution to the 2 techniques. In cases with myopic shift or other issues with the implanted IOL, we would explant the IOL by loosening the fused capsular leaflets with an ophthalmic viscosurgical device and then rotating the IOL out of the capsular bag to ease the haptics and explant it through a 6 mm scleral tunnel afterward. Depending on the stability of the capsular bag and a possible, persistent partial fusion of the capsular leaflets, I would reimplant a new IOL into the capsular bag or in the sulcus.

We could not agree more that an IOL with a board optic–haptic junction is not an ideal lens for this technique. That is why we emphasized the angle of the optic–haptic junction, the thin optic–haptic junction, and posterior haptic angulation of the used poly(methyl methacrylate) IOL in our paper.

We look forward to read your further contributions to this subject.


1. Menapace R. Posterior capsulorhexis combined with optic buttonholing: an alternative to standard in-the-bag implantation of sharp-edged intraocular lenses? A critical analysis of 1000 consecutive cases. Graefes Arch Clin Exp Ophthalmol 2008;246:787–801
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