Letters to the Editor
space.’ We are unclear whether the author proposes the
opening to extend into the subconjunctival space (i.e.,
external to the Tenon’s capsule) or only into the episcleral
(i.e., sub-Tenon’s) space. Clearly, any manipulation of
the Tenon’s capsule risks scarring, and therefore the least
amount of surgical disturbance to the tissues is appro-
priate. If the illustrations are to be believed rather than
the text, the opening does not enter the subconjunctival
space, but only extends into the episcleral space. This
may account for bending the needle toward the bevel to
yield a short tip.
We look forward to these issues being specifically clar-
ified to alleviate uncertainty and, more importantly, to
avoid inadvertent errors and complications when at-
tempting to duplicate the surgical steps described.
IZAK F. WESSELS, MMed, FRCSE
JEMISON BOWERS,MD
Chattanooga, Tennessee
References
1. Jaffe NS, Jaffe MS, Jaffe GF. Cataract Surgery and its
Complications,5th ed., St Louis: Mosby, 1990;268.
2. Bron AJ, Tripathi RC, Tripathi BJ. Wolff’s Anatomy of
the Eye andOrbit, 8th ed., London:Chapman& Hall Medi-
cal, 1997; 82.
Author’s reply
Dear Editor:
The roof of a superficial scleral pocket can be incised
with a short cutting edge cystotome, while a deeper pocket
may need a long edge cystotome. I tend to perform super-
ficial pockets, thus a short tip for the cystotome is usually
enough. In fact, as it is described in the article, the surgeon
can be sure that the roof of the pocket was incised if
injection of balanced salt solution through the cystotome
forms a bleb.
The opening is intended to enter only the sub-Tenon’s
space (episcleral space) and not the subconjunctival
space, in order to avoid manipulating Tenon’s capsule.
S. FABIAN LERNER,MD
Buenos Aires, Argentina
Posterior Capsule Opacification after Cataract
Surgery
Dear Editor:
In the article by Dana et al, entitled, “Posterior Capsule
Opacification after Cataract Surgery in Patients with Uve-
itis” (Ophthalmology 104;1387-94) it is important to
point out that a fundamental error in multivariate analysis
is the most likely reason that no postadjusted relationship
between uveitic cataracts and postoperative posterior cap-
sule opacification (PCO) was found. This relationship was
masked by adjusting for age. When choosing covariates
upon which to adjust in a multivariate model, it is impera-
tive that the covariate (age in this case) is not a close
proxy for the predictor variable. By adjusting for age, we
are essentially adjusting for the presence of uveitis itself,
since uveitic cataracts almost by definition occur at
younger ages than senile cataracts.
To take a more obvious example, what would happen
if we adjusted for age in a study involving retinopathy
of prematurity (ROP)? To be sure, we would mask the
effects of ROP because age and ROP are so intimately
linked.
Reading between the lines of the article by Dana et al
convinces me that uveitic cataracts are more likely than
senile cataracts to develope PCO.
WILLIAM G. HODGE,MD, MPH
Ottawa, Ontario, Canada
Authors’ reply
Dear Editor:
The issue raised by Dr. Hodge is whether age should be
considered a confounder in the association between uve-
itis and the development of PCO. As summarized by
Greenland and Robins,’ a confounder must possess three
properties: 1) it must be predictive of risk of the outcome
among the unexposed (in our context this means that age
must predict the development of PC0 in the absence of
uveitis); 2) it must be associated with exposure in the
study population (in our context this means that age must
be associated with having uveitis in our study population);
and 3) it must not be an intermediate factor in the causal
sequence from exposure to outcome or a consequence of
the outcome (in the present context, this means that age
must not be an intermediate variable on the causal path-
way from uveitis to PC0 development or a consequence
of it). Some authors would add a fourth property: ’ a con-
founder must not be caused in part by the exposure (in
our context this means that age must not be caused in
part by uveitis).
Rapid development of PC0 after cataract surgery in
young patients without uveitis is a well-known clinical
observation,3B4 and, as we stated in our paper,’ a number
of previous authors have shown age to be predictive of
the development of PC0 in the absence of uveitis.6-8 In
our study as well, there was a strong association between
age and PC0 development among those without uveitis
(the relative risk of PC0 was 0.69%, 95% confidence
interval 0.54 to 0.87, for increasing age in IO year age
groups). Thus, age possesses the first property of a con-
founder. Age also possesses the second property: it was
clearly associated with uveitis in our study population.’
It is also important to understand that age was not, as
Dr. Hodge contends, merely a proxy measure for uveitis.
There was a substantial overlap in the age ranges of the
uveitis group and the nonuveitis group (age range, 6 to
81 years in those with uveitis and 27 to 96 years in those
without uveitis); therefore, age alone would be a very
poor predictor of which patients had uveitis and which
did not. The third and fourth properties of a confounder
are also plainly satisfied by age in our study.
It is clear from the discussion above that, in order for
age to be a confounder of the association between unveitis
and PC0 development, it must be associated with uveitis
in our study population. Thus, the fact that age and having
943