Sir,

We would like to thank Dr Gregory and Dr Bibby for the valuable inputs from their side in order to make the technique of dye-assisted small incision cataract surgery more effective in eyes with corneal opacity.

Persistent severe superficial punctate keratitis in an eye means that the ocular surface is not stable. No surgery is acceptable in such a situation. This eye requires intensive preservative-free lubricant drops and gel and, if needed, an amniotic membrane graft. Cataract surgery should be performed only when the ocular surface becomes stable. However, if the ocular surface does not improve despite all efforts and cataract surgery is very essential for the patient owing to visual handicap or maturity of the cataract as was the present case, care should be taken while injecting the trypan blue dye for staining the anterior capsule. A small amount of dye should be directly applied onto the anterior capsule, so that there is minimal extra dye in the anterior chamber thereby preventing a large spill over during dye washout. This is a sort of painting the anterior capsule. We do it under the air bubble, however, as suggested it can be performed under viscoelastic to prevent further spill over.

There was an uptake of trypan blue dye by the corneal epithelium because of the presence of severe punctate keratitis in the present case. To avoid this, it is a novel idea to put viscoelastic over the corneal epithelium before dye washout. We prefer keeping a layer of viscoelastic on wet cornea throughout the procedure instead of continuously wetting the cornea with saline even in eyes with stable ocular surface as it also improves visualization. We did not mention this point in the paper by mistake and it has been rightly pointed out by Dr Gregory and Dr Bibby and we fully agree with them.

Postoperatively, these patients should be put on intensive lubricants and less frequent topical steroids in order to minimize drug-related epithelial toxicity and corneal melting.