Re: Hagstrom et al.: Pharmacogenetics for genes associated with age-related macular degeneration in the comparison of AMD treatments trials (CATT) (Ophthalmology 2013;120:593-9).

They compared our approach with their technique 2 and described some advantages with their technique. They opined that our technique did not take advantage of the intrascleral fixation of the IOL because a 25-gauge vitrectomy was performed before IOL fixation. With their technique, an anterior vitrectomy was performed using 25-gauge trocars for haptic externalization. We recommend performing a vitrectomy (not only an anterior vitrectomy) with intrascleral fixation and transscleral suturing of the IOL to avoid postoperative complications (such as retinal detachment). If the surgeon believes that an anterior vit-rectomy is sufficient, it can be performed through the corneal par-acentesis. The transconjunctival technique is simple and less invasive. We have modified our technique to incorporate the transconjunctival method using a double-needle technique. However , with the transconjunctival technique it is sometimes difficult to manage the length of the scleral tunnel. In addition, a long scleral tunnel sometimes warps the cornea and reduces visualization during intraocular manipulation through the tunnel. Karadag et al worried about the risk of trauma from the first needle. The first needle has never hit the retina, iris, or ciliary body in this author's experience (about 70 cases). The movement of the needle is limited, and it is difficult to impale the needle into the surrounding tissues after haptic insertion. If surgeons are concerned about this problem, they can rotate the needle so that the sharp tip faces the center of the eye. We reported 3 cases (8.6%) with iris capture. 1 Karadag et al supposed that these incidents arose from weak axial stability secondary to decreased scleral support. However, we observed good axial stability when this point was evaluated using anterior segment optical coherence tomography. 1 In addition, the IOL tilt in the eyes with iris capture was not large, compared with that in the cases without iris capture. Karadag et al stated that the scleral tunnel was too short (1.5 mm) in our technique. However, the haptic was supported by both the sclerotomy and the scleral tunnel (Figure 3B; available at www.aaojornal.org). 1 We speculated that the cause of the iris capture was a floppy iris and fluid flow as a result of eye movement and hard blinking. In some cases, the iris capture was improved by a supplemental iridotomy. The insertion of the haptic into the scleral tunnel is sometimes difficult because the surgeon cannot see the entrance of the tunnel. The tunnel should be …