Sir,

We thank Takkar and Azad1 for their astute observations on our recent paper2 which focused on the outcomes of phakic patients who developed cataract after receiving fluocinolone implant and underwent cataract surgery in the FAME trial. It is quite correct of them to comment that the visual improvement seen in this group of patients could represent an over-estimation or bias if these patients had significant cataract at baseline before receiving implant. However, this is unlikely to be the case as any cataract which either prevented assessment of the fundus or which had a significant impact on visual acuity was an exclusion criterion.3 In addition, the baseline acuities and central retinal thickness of these patients were very similar to those who were pseudophakic at baseline as shown in Table 1 (baseline characteristics) in our paper. Moreover, it would have been unlikely that small lenticular aberrations would have affected the baseline visual acuity measurements of this group of patients due to the use of high-contrast ETDRS charts and protocol refraction techniques for the measurement of visual acuities in the FAME study. The important message from our study was that patients who were phakic before receiving fluocinolone implant but developed cataract after fluocinolone implant were able to recover visual acuity well after subsequent cataract surgery. We felt it was important to highlight this finding following analysis of the long-term follow-up data on this subgroup of patients following cataract surgery, as the use of fluocinolone implant for diabetic macular oedema in UK is currently restricted by NICE guidance to only those patients who are pseudophakic. Although these guidelines have enabled patients with eyes that are pseudophakic and with persistent diabetic macular oedema following anti-vascular endothelial growth factor (VEGF) therapy to benefit from fluocinolone implant,4 there is still an unmet need for those with diabetic macular oedema which is unresponsive to laser or anti-VEGF therapy in phakic eyes. We also agree that it would be interesting to investigate the effects of cataract surgery on steroid-induced ocular hypertension or glaucoma, but this was unrelated to the tight remit and scope of our study question and objective, and therefore, we did not include this analysis in our design.

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