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Is Your Administrator each arm, while PXF patients had significantly less mydriasis and needed greater ultrasound time (but equal total ultrasound power), there was no significant further ECC loss. In another study by Ostern and Drolsum, while the 46 PXF patients had fewer ECC preoperatively, postoperative ECC loss and CCT remained similar with controls.12 Finally, Kaljurand and Teesalu presented a regression analysis demonstrating that the greater ECC loss among 27 PXF patients was more attributable to longer phacoemulsification energy time and greater irrigation volumes, but not due to the presence of PXF itself preoperatively. Therefore, it would have been quite useful for the current study's authors to present a similar multilinear regression analysis on their data set to compare their finding to the above reports.13 Our final comments relate to two of the specific recommendations from the study. The authors state, "Thus, because the corneal endothelium in eyes with PXF is vulnerable to cataract surgery, careful surgical procedures are necessary." We would instead argue that what is necessary is not "careful surgical procedures" as the degree to which a surgeon is careful should not change from one surgery to another. Instead, given the possibility of endothelial cell loss and other issues associated with PXF, what the surgeon should be more careful about is preoperative planning in terms of: • risk disclosure to the patient; • preparedness to deal with intraoperative complications by ensuring access to iris retractors, capsular tension ring, or other capsular fixation devices, appropriate backup intraocular lens implants for sulcus placement and instrumentation needed to perform a thorough automated anterior vitrectomy; and • timely referral to a subspecialist colleague for DSAEK or other corneal endothelium replacement surgery. Furthermore, we challenge the authors' concluding, "Accordingly, for more challenging cases with PXF, including those with poor mydriasis or zonular instability, surgeons should use special surgical devices and procedures to prevent endothelial cell injury, including the softshell technique, pupil-enlargement devices, and capsule-supporting devices." No part of their research actually dealt with studying whether such techniques would be of help and, thus, recommending the use of all of these techniques in such defin- itive and categorical terms is unwarranted and should be reserved for research that actually investigates the utility of such techniques. Regardless of the etiology behind the increased risk of postoperative PXF endotheliopathy, and our disagreement with some of the recommendations, the results of this study will help raise awareness from cataract surgeons to provide safe operative and postoperative management for our PXF patients. EW Certified? References Leaders in Managing the Business of Ophthalmology 1. Naumann GOH, Schlotzer-Schrehardt U. Keratopathy in pseudoexfoliation syndrome as a cause of corneal endothelial decompensation. Ophthalmology. 2000;107(6):1111-1124. 2. Ringvold A. Corneal endothelial involvement in pseudoexfoliation syndrome. Arch Ophthalmol. 1994;112(3):297-298. 3. Schlotzer-Schrehardt UM, Dorfler S, Naumann GO. Corneal endothelial involvement in pseudoexfoliation syndrome. Arch Ophthalmol. 1993;111(5):666-674. 4. Wang L, Yamasita R, Hommura S. Corneal endothelial changes and aqueous flare intensity in pseudoexfoliation syndrome. Ophthalmologica. 1999;213(6):387-391. 5. Miyake K, Matsuda M, Inaba M. Corneal endothelial changes in pseudoexfoliation syndrome. Am J Ophthalmol. 1989;108(1):49-52. 6. Asano N, Schlotzer-Schrehardt U, Naumann GO. A histopathologic study of iris changes in pseudoexfoliation syndrome. Ophthalmology. 1995;102(9):1279-1290. 7. Helbig H, Schlotzer-Schrehardt U, Noske W, Kellner U, Foerster MH, Naumann GO. Anteriorchamber hypoxia and iris vasculopathy in pseudoexfoliation syndrome. Ger J Ophthalmol. 1994;3(3):148-153. 8. Kuchle M, Nguyen NX, Hannappel E, Naumann GO. The blood-aqueous barrier in eyes with pseudoexfoliation syndrome. Ophthalmic Res. 1995;27 Suppl 1:136-142. 9. Hayashi K, Manabe SI, Yoshimura K, Kondo H. Corneal endothelial damage after cataract surgery in eyes with pseudoexfoliation syndrome. J Cataract Refract Surg. 2013;39:882888. 10. Hayashi K, Hayashi H, Nakao F, Hayashi F. Risk factors for corneal endothelial injury during phacoemulsification. J Cataract Refract Surg. 1996;22(8):1079-1084. 11. Wirbelauer C, Anders N, Pham DT, Wollensak J. Corneal endothelial cell changes in pseudoexfoliation syndrome after cataract surgery. Arch Ophthalmol. 1998;116(2):145149. 12. Ostern AE, Drolsum L. Corneal endothelial cells 6-7 years following cataract surgery in patients with pseudoexfoliation syndrome. Acta Ophthalmologica. 2012;90(5):408-411. 13. Kaljurand K, Teesalu P. Exfoliation syndrome as a risk factor for corneal endothelial cell loss in cataract surgery. Ann Ophthalmol. 2007;39(4):327-333. Contact information Pyatetsky: d-pyatetsky@northwestern.edu +ORTQXGRTQƂVCDKNKV[CPFUVCHH GHƂEKGPE[YKVJC%GTVKƂGF 1RJVJCNOKE'ZGEWVKXG %1' r%1'KUVJGPCVKQPCN UVCPFCTFHQTQRJVJCNOKE RTCEVKEGOCPCIGOGPV r%1'TGEQIPK\GU KPFKXKFWCNUYJQCEJKGXG VJG0$%1'GNKIKDKNKV[ TGSWKTGOGPVUHQT QRJVJCNOKEMPQYNGFIG CPFUMKNNU r%1'RTQOQVGU GZEGNNGPEGCPF RTQHGUUKQPCNKUO Get Certified. YYYCUQCQTIEQG 6JG%1' JCPFDQQMUCORNG GZCOCPFUVWF[ TGUQWTEGUCTG CXCKNCDNGQPNKPG %GTVKƂGF1RJVJCNOKE 'ZGEWVKXG Questions: EQG"CUQCQTI or 703-788-5778 YYYCUQCQTIEQG