Dear Editor, We are delighted to receive the readers’ comments on our manuscript,1 which highlight the growing recognition of cataract surgery in highly myopic patients as a topic of significant clinical interest. The discussion surrounding postoperative visual quality in this special population is both timely and valuable. Our team has carefully considered all the suggestions and provided point-by-point responses below: Sample Size and Attrition BiasResponse: We acknowledge that the limited sample size (particularly in the extremely high myopia subgroup) and the risk of attrition bias are inherent limitations of this study. The loss to follow-up was primarily due to challenges during the COVID-19 pandemic, and the reasons for dropout were unrelated to the study intervention. Thus, the likelihood of significant attrition bias is low. Although the extremely high myopia subgroup was small, the observed effect sizes and trends remain exploratory and may guide future research.Follow-up DurationResponse: We selected the 3-month timepoint to assess early IOL stability—a critical phase in postoperative evaluation. This decision was based on prior studies demonstrating that IOL position and capsular shrinkage tend to stabilize by 3 months in patients with long axial lengths.2 Capsular contraction syndrome (CCS), which is closely associated with IOL displacement, most frequently occurs within the first 6 weeks postsurgery.3,4 Nevertheless, we fully agree that longer-term follow-up would be valuable in assessing late capsular changes.Measurement ConditionsResponse: We recognize that photopic measurements may not fully reflect real-world visual symptoms. Our criteria for higher-order aberration (HOA) measurements under standardized pupil conditions were based on Ju et al.’s5 methodology. For IOL tilt and decentration measurements, we followed Kimura et al.’s6 protocol, which demonstrated that CASIA2 provides highly reproducible measurements of IOL tilt and decentration regardless of pupil dilation status. These findings are clinically relevant as they suggest that CASIA2 can reliably assess IOL misalignment even in cases of poor pupillary dilation, independent of pupil size or shape.Stratification by Severity of Decentration/TiltResponse: A previous study of 334 highly myopic patients established a grading system for clinically significant IOL decentration (≥0.4 mm) and tilt (≥7°), confirming a strong correlation between these parameters and axial lengths ≥30 mm.7 Since this concept has already been well documented, we did not reintroduce it in our analysis.Patient-Reported OutcomesResponse: This is an excellent suggestion. Our study primarily focused on objective metrics to complement existing literature as many prior studies have already employed subjective questionnaires to assess visual quality. We plan to incorporate patient-reported outcomes alongside objective data in future research.Generalizability of IOL SelectionResponse: Our study focused on monofocal IOLs to minimize confounding variables. While multifocal IOLs offer advantages in reducing HOAs, their use in highly myopic patients remains controversial due to concerns over suboptimal visual quality and retinal complications. High myopia is often accompanied by retinal pathologies (e.g., epiretinal membranes, chorioretinal atrophy), which may compromise the optical performance of premium IOLs.8 Additionally, complex IOL designs (e.g., aberration-correcting or multifocal lenses) are more sensitive to decentration, with studies showing that their visual performance degrades more significantly with misalignment compared to standard monofocal IOLs.9 Furthermore, the light-splitting nature of multifocal IOLs may reduce contrast sensitivity, a particular concern in myopic patients who may already have compromised retinal function. Although long axial length is not an absolute contraindication for multifocal IOLs, careful case-by-case evaluation is essential, and monofocal IOLs often remain the safer choice. We sincerely appreciate the readers’ thoughtful critiques, which have undoubtedly strengthened our manuscript. Academic progress thrives on constructive dialog, and we hope our responses clarify our perspectives. We look forward to further productive discussions on this important topic and thank the readers for their contributions to the scientific community. Best Regards, Zixi Zhou.
Wang et al. (Thu,) studied this question.