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abilityof the respondents to recall a fair amountof clinicaldata. Amore complicated questionnaire would result inless accurate data and might have significantly reducedthehigh response rateweachieved. Furthermore, clinicaldecisions are frequently based on a complex interplay offactors of varying importanceand tailored to theneeds ofindividual patients and, possibly, surgeon preferences.Teasing out such individual risk factors in a retrospectivequestionnaire is inaccurate.

We specifically chose not to ask about knowledge ofthe national guidelines to avoid introducing bias. Wewished to observe the current practice of surgeonswho had access to the guidelines and assess whetherthe guidelines influenced clinical practice in the waythey were designed to do.

Kadyan and Edmunds state a need to address thereason for the apparent poor compliance with nationalguidelines. We agree that this would be a useful nextstage. We speculate that the most likely reasons fornot adhering to the guidelines are (1) lack of awarenessof the guidelines, (2) disagreement that the guidelinesrepresent best practice generally, and (3) clinical judg-ment tailored to the needs of each patient and shapedby previous experience and perhaps by specificresearch data. As an example of the last reason, thequestionnaire asked whether previous experience ofhemorrhagic complications had led to a change inclinical practice; of the 10 respondents experiencingsuprachoroidal hemorrhages, one now stops warfarinpreoperatively and 2 operate only below an INRthreshold of 2.5. Professional independence andavoiding harm to patients will by necessity meansuch personal experience will influence the wayclinicians follow even clear guidelines. However, it isimportant that where complications/risks are rare, weas clinicians accept that our personal experience is quitelikely to deviate from the overall ‘‘real’’ risks.

We do not recommend anything that deviates fromthe national guidelines. In our discussion, we men-tioned that it may be possible for apprehensive sur-geons to collaborate with the patient’s physician andaim to modify the INR to the lower end of the thera-peutic range desired for that patient. We do not recom-mend this, butwe think this approach fallsmore in linewith the college guidelines than having a blanket tar-get INR above which surgery ‘‘cannot’’ occur. This lat-ter approach not only appears to specifically ignore theguidelines but actually appears to ignore patient-specific risk factors (ie, the reason they are warfarinzedin the first place and, by definition, how high their riskfor systemic coagulopathy is likely to be).

We did consider including clopidogrel and aspirinas part of the questionnaire but decided that it might re-sult in a lower response rate with less clarity inresponses. We agree this is an important aspect of

J CATARACT REFRACT SURG

perioperative coagulability that needs further investiga-tion.We hope further workwill answer some of the im-portant questions raised by Kadyan and Edmunds.dRuchika Batra, MRCOphth, Anna Maino, FRCOphth,Sun Ch’ng, MB BS, Ian B. Marsh, FRCOphth

How Quickly We ForgetI wish to compliment Shingleton, Crandall, and

Ahmed for their wonderful review article on pseudoex-foliation.1 What a comprehensive and scholarly work.Iwould, however, like topoint out anomission in the ref-erences. The March 1993 issue of the European Journal ofImplant and Refractive Surgery included an important ar-ticle entitled ‘‘Cataract Surgery in Patients with Pseu-doexfoliation Syndrome.’’2 In this collaborative study,it was first established that certain principles loweredthe incidence of complications. Techniques includedcapsulorhexis by Howard Gimbel, MD, slow-motionphacoemulsification byme, and zonular respect by Rob-ert Cionni, MD. Ironically, the current president of theAmerican Society of Cataract and Refractive Surgery,Alan Crandall, MD, served as the fourth coauthor.Alan, how could you forget this article?

Robert H. Osher, MDCincinnati, Ohio, USA

REFERENCES1. Shingleton BJ, Crandall AS, Ahmed K II. Pseudoexfoliation and

the cataract surgeon: preoperative, intraoperative, and postoper-

ative issues related to intraocular pressure, cataract, and intraoc-

ular lenses. J Cataract Refract Surg 2009; 35:1101–1120

2. Osher RH, Cionni RJ, Gimbel HV, Crandall AS. Cataract surgery

in patients with pseudoexfoliation syndrome. Eur J Implant

Refract Surg 1993; 5:46–50

REPLY: WeappreciateOsher’s kindwords about thecomprehensive and scholarly nature of our work. Heappropriately brings his paper dealing with cataractsurgery in pseudoexfoliation to readers’ attention.We regret omitting this article from our bibliography,but his letter highlights the difficulties intrinsic to thepreparation of review articles. Osher’s is one of manysuperb articles that could have been cited; however,due to practical limitations associated with such a re-view, we could not include them all. We thank Osherfor highlighting the fact that the literature base fora complex subject such as pseudoexfoliation extendswell beyond a single review.dBradford J. Shingleton,MD, Alan S. Crandall, MD, Iqbal Ike K. Ahmed, MD

Intraepithelial Flap Creation During Epi-LASIKIn reference to the article describing histological ex-

amination of epi-LASIK flaps,1 we report a unique

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