Sir,

We thank Aghaji et al1 for their interest in our article.2 We would like to point out, however, that this letter is discussing an entirely separate issue, namely, the need to improve the access to care for children with cataract worldwide, especially in underprivileged areas. Our paper is a quality assurance study driven by factors imposed in a developed country in which patients and payers expect to see quality outcome reports that may be reflective of the surgical and institutional quality of service. In this study, we utilized exclusion criteria that would eliminate confounding factors that might impact visual acuity outcomes. One example is the exclusion of children with congenital cataract who had significant delays in presentation, since the visual outcomes would not be reflective of the surgical care provided, but, rather, the result of irreversible deprivation amblyopia. By eliminating as many confounding factors as possible, it allowed us to examine outcomes that are more directly influenced by quality of care. Our study is like adult benchmark papers that report only on populations with ‘uncomplicated’ acquired cataract. In contrast, the patients that are reported in the letter represent children who would be expected to have poor visual outcome by common standards, because of the late presentation, even though quality of the surgical care was good. As the authors point out, the outcomes are biased because the study population consists of children with cataract who were enrolled in a school for the blind. There is no information in the letter about quality of surgical care or quality assurance in general. The population and outcomes are similar to those reported by Ganesh et al.3

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