possibly with preoperative testing with customizedwavefront-glasses or some such modality, will allowone to perform customized wavefront-guidedLASIK to neutralize their optical aberrations andprovide improved BCVA. Thus, similar to conven-tional hyperopia, myopia, and astigmatism, whichare corrected with spherocylinders, this HOA-induced loss of vision would be a new refractiveentitydaberropiadwhich could be corrected byalteration of the aberrations. In this scenario, theinterest that these 2 articles have generated willhopefully stimulate further research into this ex-tremely under-researched new refractive entity. Itwould be interesting to perform wavefront studiesin patients with so-called idiopathic amblyopia tosee whether wavefront correction would lead to im-proved BCVA.

Amar Agarwal, MS, FRCS, FRCOphthSoosan Jacob, MS, FRCS, DNB, MNAMS

Athiya Agarwal, MD, DOChennai, India

REFERENCES1. Prakash G, Sharma N, Chowdhary V, Titiyal JS. Association

between amblyopia and higher-order aberrations. J Cataract

Refract Surg 2007; 33:901–904

2. de Faber J-THN. Higher-order aberrations: explanation of idio-

pathic amblyopia? [guest editorial]. J Cataract Refract Surg

2007; 33:753

1836 LETTERS

REPLY: Aberropia, first described by Agarwal et al.(A. Agarwal, FRCS, et al. ‘‘Aberropia: A New Refrac-tive Entity.’’ Ocular Surgery News, October1, 2002, pages 14–19. Available at: http://www.osnsupersite.com/view.asp?rIDZ13444. Accessed July23, 2007), is an enlightening perspective for lookingat the affect HOAs can have on optimization of visualacuity. It is indeed a matter worth further research.

After looking at the study by Agarwal et al., we re-alized that aberropia, although associated with loss ofBCVA, is different fromHOA-associated amblyopia asdescribed by us. The patients presented by Agarwalet al. were myopic and had BCVAs worse than 6/9,which improved after wavefront-guided LASIK. Thiscaused them to conclude that these patients were mis-takenly identified as amblyopic, and we fully agreewith this.

However, it should be noted that the patient re-ported by us had associated signs of amblyopia; ie,crowding phenomenon, better vision with single letteroptotypes, and reduced stereoacuity. Also, the differ-ence in the BCVA was first reported in childhood,when he was diagnosed as an idiopathic amblyope.

J CATARACT REFRACT SURG

Amblyopia normally develops only when a differencein the retinal image quality in both eyes is present atthe critical age.

Laser interferometry (LI) showed some overestima-tion (known to be associated with amblyopic eyes) butdid not return a value of 20/20, which would havebeen the case with an irregular cornea (or aberropia)with a clear media because LI is unaffected by the re-fractive status of the eye. We hope that all patientswith aberropia discovered by Agarwal et al. have LIsof 20/20 or more because it is essentially a type ofrefractive error.

The loss of BCVA on a high-contrast resolutionacuity chart alone does not account for amblyopia ormany irregular astigmatics who may or may notimprove completely with contact lenses would be clas-sified as amblyopes. It would be helpful to knowwhether in the authors’ experience, patients with aber-ropia do not show other signs of amblyopia.

Therefore, cases of aberropia are those with previ-ously undiagnosed unilaterally high HOAs, leadingto a reversible loss of vision in that eye. In contrast, am-blyopia secondary to a difference in HOAs may ormay not develop in the eye with higher total HOAs,as individual Zernike modes of the same eye may in-teract to even increase the vision, despite an increasedtotal RMS value for HOA.1 In an ongoing study, wehave noticed that the bilateral difference in the patternof interaction of Zernike modes is more critical for pos-sible amblyopiogenesis than overall total HOA RMS.

In the study by Agarwal et al., both eyes of only 3 ofthe 10 patients were included. We presume that in theother 7 patients, the fellow eyes had pre-LASIKBCVAsbetter than 6/9 and were thus excluded. We assumethis because the other possibility would have beenhigh unilateral myopia (�5.4 diopters [D] or higherin all cases, lowest values of myopia in their studygroup), which would have made myopic defocus theprimary determinant of the difference in wavefrontprofiles instead of the difference in HOAs, promptingthe authors to think of causes related to lower-orderaberrations and not HOAs. Considering the first possi-bility, it would be very helpful to know whether theHOAs in the excluded fellow eyes (with BCVAs betterthan 6/9) also reduced in similar ranges the eyes in-cluded in the study and whether this resulted ina gain of BCVA (maybe beyond 20/20) after surgery.

Another very interesting trend seen by the authors isthe absence of a major effect of image magnification,which is different for the current understanding. Reti-nal image magnification has been considered one ofthe reasons for improvement in BCVA after LASIKand after phakic intraocular lens implantation fortreatment of myopia.2,3 Therefore, despite the factthat for the refractive error range of their patients

- VOL 33, NOVEMBER 2007

As I mentioned in my guest editorial furtherresearch is needed to determine whether HOAs cancause amblyopia. This has not been proven beyonda reasonable doubt. I would rather not use the termaberropia before this entity has been tested in a pro-spective, well-designed, and peer-reviewed study.dJan-Tjeerd H.N. de Faber, MD

Successful treatment of cystoid macular edemawith valdecoxib

We would like to discuss a few points in the articleabout treating cystoidmacular edema (CME) with val-decoxib by Reis et al.1 In this study, treatment outcomewas measured by the best corrected visual acuity aswell as by the reduction in clinically significant macu-lar edema evaluated by slitlamp biomicroscopy. How-ever, the authors mention that reduction in macularedema was hard to assess when evaluated by slitlampbiomicroscopy. It is recognized that an improvementin vision may reflect an ameliorating effect of treat-ment, which is not synonymous with elimination ofthe edema.2 To achieve a better relationship betweenvisual improvement and the anatomical counterpart,we suggest the use of objective tools, such as fluores-cein angiography, to evaluate the effectiveness ofa CME treatment.

With the use of fluorescein angiography, we can de-termine whether there is a decrease in leakage andpooling of fluorescein in the macular cystoid spacesor whether the angiographic CME persists despite animprovement in vision. Optical coherence tomogra-phy (OCT) may also provide a noninvasive, objectivealternative to measure the central retinal thicknessfollowing treatment in pseudophakic CME.3

Finally, patients with clinically significant visual

1837LETTERS

(�15 D to �5.4 D), magnifications achieved wouldhave normally ranged from 30.0% to 10.8% afterLASIK, no major effect of magnification was noticed.This makes aberropia all the more interesting. This ex-ceptional trend could be further consolidated by dem-onstration of a gain in BCVA after customized (LASIK)in cases that have coexistent aberropia and a hyperopicrefractive error. This would mean that an aberropiacorrection-related gain in BCVA was large enoughto offset the loss in BCVA known to occur afterhyperopia correction due to image minification.4

We fully agree with Agarwal et al. that more re-search into this enigmatic corner of wavefront analysisis required. Patients with both disease entities, HOA-associated amblyopia and aberropia (mistaken as am-blyopia), should be identified, more so in the pediatricpopulation and evaluated in the future. We thankAgarwal et al. for their input and for sharing theirperspective onHOA-associated vision loss and believethat the awareness of existence of both entities andtheir differences could be an important founda-tion for further research.dGaurav Prakash, MD,Namrata Sharma, MD, Vandana Chowdhary, BSc(Hon),Jeewan S. Titiyal, MD

REFERENCES1. Applegate RA, Marsack JD, Ramos R, Sarver EJ. Interaction

between aberrations to improve or reduce visual performance.

J Cataract Refract Surg 2003; 29:1487–1495

2. Garcia M, Gonzalez C, Pascual I, Fimia A. Magnification and vi-

sual acuity in highly myopic phakic eyes corrected with an anterior

chamber intraocular lens versus by other methods. J Cataract

Refract Surg 1996; 22:1416–1422

3. Applegate RA, Howland HC. Magnification and visual acuity in

refractive surgery. Arch Ophthalmol 1993; 111:1335–1342

4. Waring GO III. A cautionary tale of innovation in refractive

surgery. Arch Ophthalmol 1999; 117:1069–1073

REPLY: In their letter, Agarwal et al. try to convincethe reader to accept a new refractive entity, aberropia,a term they coined in 2002 in a non-peer-reviewedmedical periodical (A. Agarwal, FRCS, et al, ‘‘Aberro-pia: A New Refractive Entity. Ocular Surgery News,October 1, 2002,pages14-19.Availableat: http://www.osnsupersite.com/view.asp?rIDZ13444. Accessed July23, 2007). The problem with this new entity is that itis based on a retrospective study that has not been scru-tinized by critical peer reviewers.

I agreewith the authors that it might be a convenientway to explain some ‘‘fascinating’’ improvement in theBCVA after wavefront-guided LASIK. However, am-blyopia resides in the brain and cannot be treated inadulthood once the eye dominance column domainshave been determined for the right and left eyes atthe end of the critical period.

loss from macular edema after cataract surgery wereconsecutively enrolled in this cohort study. Active gas-trointestinal, coronary artery, or hepatic diseases wereruled out. We would like to know whether patientswith other systemic conditions such as diabetes melli-tus, ocular diseases such as uveitis, or preexisting mac-ular conditions were excluded in these consecutivecases to ensure that the pseudophakic macular edemawas not related to other causes.

This cohort study illustrates the apparent efficacy ofvaldecoxib in treating 10 patients with pseudophakicCME. However, spontaneous resolution of edemais possible even without treatment. In addition, theevidence of the effectiveness of nonsteroidal antiin-flammatory drugs for both acute and chronic CMEis inconclusive.4 We agree with Reis et al. that a pro-spective randomized clinical trial with a large samplesize is important to determine the effectiveness of

J CATARACT REFRACT SURG - VOL 33, NOVEMBER 2007