Author Reply – Corrected Proof

Dr Fellman's thoughtful comments allow for an opportunity to provide clarification with regard to the message conveyed in the editorial, “Things Go Better With Cataract Surgery.” First and foremost, I agree with Dr Fellman that blebless surgery is a much awaited advance in glaucoma care and the fact that it is so difficult to prove a benefit with such surgery owing to the complex nature of assessing intraocular pressure (IOP) reduction in combination with cataract surgery is not the fault of those charged with making these novel procedures available to the practitioner. Although undoubtedly helpful, I do not believe that an outcome marker similar to a bleb, as proposed by Dr Fellman, is absolutely essential for widespread acceptance of blebless surgical procedures. What is necessary, however, is to show that there is a measurable, incremental benefit of such surgery when it is added to cataract surgery, another IOP-lowering procedure. Practitioners generally add glaucoma therapy based on the IOP level rather than the appearance of a bleb. There are eyes that seem to have functioning blebs where the IOP is too high and others where the bleb is barely visible and the IOP is optimal. The latter scenario is unquestionably preferable to the former. Traditional glaucoma drainage devices, for which the bleb created by the explant is far posterior to the limbus, continue to increase in use despite bleb appearance not being a very useful marker for IOP reduction. As mentioned in the editorial, “it is hard to argue against the benefit of a safe glaucoma procedure that can add 2 to 3 mmHg of IOP lowering beyond phacoemulsification” and such a benefit is meaningful regardless of whether or not an outcome marker is present or what the IOP-lowering effect of the procedure may be as a standalone operation.