Dear Editor, We read with great interest the article titled “Impact of intraocular lens decentration and tilt on higher-order aberrations in patients with high and super-high myopia following cataract surgery,” published by Wang Y et al.1 The authors offer valuable insights into a challenging population subset. However, we wish to highlight several methodological limitations and clinical considerations that warrant caution in interpreting and generalizing the results. The relatively small sample size, particularly in the super-high myopia group (n = 17), limits statistical power and may obscure meaningful associations. Furthermore, the 24% loss to follow-up (16 out of 66 patients) introduces potential attrition bias, which may skew the outcome measures.2 The short follow-up period of only 3 months may not be sufficient to capture long-term changes in intraocular lens (IOL) position. Capsular contraction and zonular instability, especially in highly myopic eyes, often cause late decentration or tilt, affecting visual outcomes over time.3 Although the use of CASIA2 anterior segment OCT system (Tomey Corporation, Nagoya, Japan) is commendable for its high-resolution measurements, assessments were conducted under photopic, undilated conditions. Higher order aberration (HOA)s were analyzed at a fixed 3 mm pupil size using the iTrace system, which does not reflect real-world mesopic or scotopic scenarios, where pupils dilate and visual symptoms such as glare and halos are more pronounced.4 The study lacks stratification based on the severity of IOL malposition. Without categorizing outcomes by decentration or tilt magnitude, it becomes difficult to evaluate threshold effects or establish clinical guidelines.5 Another notable limitation is the absence of subjective visual quality measures. Incorporating tools like the National Eye Institute Visual Function Questionnaire (NEI VFQ-25) or other patient-reported outcome metrics would better reflect functional vision and satisfaction, which do not always correlate with objective visual acuity or Modulation transfer function (MTF) scores.6 The study exclusively evaluated a single IOL model (A1-UV), thereby limiting generalizability. Optical tolerance to decentration and tilt varies among different IOL design—monofocal, aspheric, multifocal, and toric—and some are specifically engineered to reduce HOAs under decentered conditions.7 In conclusion, while the study emphasizes the critical role of IOL centration in visual quality for high myopes, future investigations should include larger, more diverse cohorts, longer follow-up durations, subjective patient-reported data, and comparative IOL models. These refinements will contribute to a more comprehensive understanding of IOL positioning effects and guide individualized surgical planning.
Bandyopadhyay et al. (Thu,) studied this question.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: