Comment on “Clinical Outcomes of Implantable Collamer Lenses for the Treatment of Myopia in Eyes with Anterior Chamber Depth (<3.0 mm) at a Single Center in the United States” [Response to Letter]

Dear editor

We would like to thank Chaurasiya et al for their thoughtful commentary on our recently published article.¹ We appreciate the authors’ recognition of our effort to explore the safety and efficacy of ICL implantation in eyes with anterior chamber depths (ACD) below the conventional 3.0 mm threshold and welcome the opportunity to address their concerns.

Selection Bias and Case Stratification

We acknowledge that our study was retrospective in nature and that case selection was influenced by clinical discretion. However, the use of strict preoperative screening protocols including angle assessments, endothelial cell counts when we felt warranted, and sulcus-to-sulcus measurements ensured we avoided high-risk anatomical configurations through surgeon judgement. While stratification by narrower ACD subgroups (eg, 2.5–2.7 mm) would be of interest, the limited sample size in this initial dataset precluded meaningful subgroup analysis. This is a valuable direction for future investigation.

Long-Term Follow-up and Safety Monitoring

The authors correctly note that long-term surveillance is essential in evaluating delayed complications. While our follow-up period captured short-term outcomes, patients continue to be monitored postoperatively by referring providers at a minimum basis of annual eye exams. We agree that future studies should include prospective, longitudinal designs with standardized evaluations of vault, endothelial health, and angle dynamics using modalities such as gonioscopy and UBM/VHF ultrasound. We maintain excellent communications with these referring providers and the patients themselves so even to date, there have been no changes to the longer term data from referring providers or new problems arising in any patients from the study.

Device and Measurement Considerations

We appreciate the suggestion to incorporate multi-modal imaging for confirming ACD measurements near the threshold. While the Pentacam AXL was chosen for its reproducibility and integration with our existing workflow, we agree that future protocols could benefit from supplemental imaging for borderline cases.

On Interpretation of Safety

We concur that the lower complication rate in the sub-3.0 mm ACD group likely reflects careful patient selection rather than a true intrinsic safety advantage. Our intent was not to suggest universal applicability, but to present early evidence that, in select eyes, ICL implantation can be performed safely and effectively even below the traditional ACD cutoff with the admitted caveat of careful patient selection, which we expect would be present in any case if ICL planning regardless of surgeon or ACD.

We thank Chaurasiya et al again for their engagement with our work. Continued dialogue and collaboration in this area will be essential as the refractive community works to refine patient selection and expand access to vision correction surgery.

Disclosure

Matthew Hirabayashi MD, Taj Nasser MD, and Greg Parkhurst MD are consultants for STAAR Surgical. The authors report no other conflicts of interest in this communication.