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We appreciate the comments of Cereda et al regarding our article, “Highly reflective foveal region in optical coherence tomography in eyes with vitreomacular traction or epiretinal membrane.”They suggested that the hyperreflective regions at the fovea of eyes with vitreomacular traction and epiretinal membrane (ERM) reported in our study1Tsunoda K. Watanabe K. Akiyama K. et al.Highly reflective foveal region in optical coherence tomography in eyes with vitreomacular traction or epiretinal membrane.Ophthalmology. 2012; 119: 581-587Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar represented the accumulation of bisretinoids of lipofuscin following the loss of apposition between cone outer segment and retinal pigment epithelium (RPE). This was based on their idea that the ‘cotton ball sign’ in our study is similar to reported findings in eyes with ERM; that is, “subfoveal pigment changes,”2Gomes N.L. Corcostegui I. Fine H.F. Chang S. Subfoveal pigment changes in patients with longstanding epiretinal membranes.Am J Ophthalmol. 2009; 147: 865-868Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar “acquired vitelliform lesions,”3Freund K.B. Laud K. Lima L.H. et al.Acquired vitelliform lesions: correlation of clinical findings and multiple imaging analyses.Retina. 2011; 31: 13-25Crossref PubMed Scopus (110) Google Scholar and “subfoveal deposits.”4Dupas B. Tadayoni R. Erginay A. et al.Subfoveal deposits secondary to idiopathic epiretinal membranes.Ophthalmology. 2009; 116: 1794-1798Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar They provided further evidences by surveying their own cases and presented 1 optical coherence tomographic image that had a highly reflective region at the fovea.We believe that the etiologic background of the “cotton ball sign” is different from that in earlier studies. In these studies, the highly reflective regions lay directly on the RPE at the fovea and were clearly separated from the low-reflectivity background. Moreover, these findings were observed in cases with longstanding ERM,3Freund K.B. Laud K. Lima L.H. et al.Acquired vitelliform lesions: correlation of clinical findings and multiple imaging analyses.Retina. 2011; 31: 13-25Crossref PubMed Scopus (110) Google Scholar were significantly correlated with low visual function,3Freund K.B. Laud K. Lima L.H. et al.Acquired vitelliform lesions: correlation of clinical findings and multiple imaging analyses.Retina. 2011; 31: 13-25Crossref PubMed Scopus (110) Google Scholar and were more frequently observed in older patients.4Dupas B. Tadayoni R. Erginay A. et al.Subfoveal deposits secondary to idiopathic epiretinal membranes.Ophthalmology. 2009; 116: 1794-1798Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar These observations support the idea that the highly reflective regions in these earlier studies are from cellular debris resulting from photoreceptor damage or RPE proliferation,2Gomes N.L. Corcostegui I. Fine H.F. Chang S. Subfoveal pigment changes in patients with longstanding epiretinal membranes.Am J Ophthalmol. 2009; 147: 865-868Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar shed outer segments, pigment-laden macrophages and RPE cells,3Freund K.B. Laud K. Lima L.H. et al.Acquired vitelliform lesions: correlation of clinical findings and multiple imaging analyses.Retina. 2011; 31: 13-25Crossref PubMed Scopus (110) Google Scholar and accumulation of photoreceptor debris.4Dupas B. Tadayoni R. Erginay A. et al.Subfoveal deposits secondary to idiopathic epiretinal membranes.Ophthalmology. 2009; 116: 1794-1798Abstract Full Text Full Text PDF PubMed Scopus (22) Google ScholarIn our study, the location of the highly reflective regions is different from that in early studies; the regions lie between the photoreceptor inner/outer segment junction and cone outer segment tip lines, and are separated from the RPE. This is clearly shown in case 1 in Figure 1, case 25 in Figure 2, and case 5 in Figure 3. In most cases, they are not as clearly demarcated from the background as in earlier studies. The subfoveal deposit was not observed in these cases. In case 5 in Figure 3, the cotton ball sign disappeared within 30 days after spontaneous release of vitreous traction. Moreover, the cotton ball sign was often subclinical and observed in eyes which had good vision; 4 of 7 eyes with vitreomacular traction and 9 of 30 eyes with an ERM with the cotton ball sign had best-corrected visual acuity of ≥0.8. These findings suggest that the highly reflective regions in our study were present before the photoreceptor and RPE were severely damaged, and can be categorized as a different finding and are due to mechanical inward traction at the fovea.The only exception was case 41 in Figure 2. The cotton ball sign in this eye appeared as a dome-shaped, hyperreflective region directly attached to the RPE, and a yellow, round-shaped deposit was observed in the fundus photograph. We believe that this case can be classified with those reported by earlier studies and should have been excluded from this study. We appreciate the comments of Cereda et al regarding our article, “Highly reflective foveal region in optical coherence tomography in eyes with vitreomacular traction or epiretinal membrane.” They suggested that the hyperreflective regions at the fovea of eyes with vitreomacular traction and epiretinal membrane (ERM) reported in our study1Tsunoda K. Watanabe K. Akiyama K. et al.Highly reflective foveal region in optical coherence tomography in eyes with vitreomacular traction or epiretinal membrane.Ophthalmology. 2012; 119: 581-587Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar represented the accumulation of bisretinoids of lipofuscin following the loss of apposition between cone outer segment and retinal pigment epithelium (RPE). This was based on their idea that the ‘cotton ball sign’ in our study is similar to reported findings in eyes with ERM; that is, “subfoveal pigment changes,”2Gomes N.L. Corcostegui I. Fine H.F. Chang S. Subfoveal pigment changes in patients with longstanding epiretinal membranes.Am J Ophthalmol. 2009; 147: 865-868Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar “acquired vitelliform lesions,”3Freund K.B. Laud K. Lima L.H. et al.Acquired vitelliform lesions: correlation of clinical findings and multiple imaging analyses.Retina. 2011; 31: 13-25Crossref PubMed Scopus (110) Google Scholar and “subfoveal deposits.”4Dupas B. Tadayoni R. Erginay A. et al.Subfoveal deposits secondary to idiopathic epiretinal membranes.Ophthalmology. 2009; 116: 1794-1798Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar They provided further evidences by surveying their own cases and presented 1 optical coherence tomographic image that had a highly reflective region at the fovea. We believe that the etiologic background of the “cotton ball sign” is different from that in earlier studies. In these studies, the highly reflective regions lay directly on the RPE at the fovea and were clearly separated from the low-reflectivity background. Moreover, these findings were observed in cases with longstanding ERM,3Freund K.B. Laud K. Lima L.H. et al.Acquired vitelliform lesions: correlation of clinical findings and multiple imaging analyses.Retina. 2011; 31: 13-25Crossref PubMed Scopus (110) Google Scholar were significantly correlated with low visual function,3Freund K.B. Laud K. Lima L.H. et al.Acquired vitelliform lesions: correlation of clinical findings and multiple imaging analyses.Retina. 2011; 31: 13-25Crossref PubMed Scopus (110) Google Scholar and were more frequently observed in older patients.4Dupas B. Tadayoni R. Erginay A. et al.Subfoveal deposits secondary to idiopathic epiretinal membranes.Ophthalmology. 2009; 116: 1794-1798Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar These observations support the idea that the highly reflective regions in these earlier studies are from cellular debris resulting from photoreceptor damage or RPE proliferation,2Gomes N.L. Corcostegui I. Fine H.F. Chang S. Subfoveal pigment changes in patients with longstanding epiretinal membranes.Am J Ophthalmol. 2009; 147: 865-868Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar shed outer segments, pigment-laden macrophages and RPE cells,3Freund K.B. Laud K. Lima L.H. et al.Acquired vitelliform lesions: correlation of clinical findings and multiple imaging analyses.Retina. 2011; 31: 13-25Crossref PubMed Scopus (110) Google Scholar and accumulation of photoreceptor debris.4Dupas B. Tadayoni R. Erginay A. et al.Subfoveal deposits secondary to idiopathic epiretinal membranes.Ophthalmology. 2009; 116: 1794-1798Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar In our study, the location of the highly reflective regions is different from that in early studies; the regions lie between the photoreceptor inner/outer segment junction and cone outer segment tip lines, and are separated from the RPE. This is clearly shown in case 1 in Figure 1, case 25 in Figure 2, and case 5 in Figure 3. In most cases, they are not as clearly demarcated from the background as in earlier studies. The subfoveal deposit was not observed in these cases. In case 5 in Figure 3, the cotton ball sign disappeared within 30 days after spontaneous release of vitreous traction. Moreover, the cotton ball sign was often subclinical and observed in eyes which had good vision; 4 of 7 eyes with vitreomacular traction and 9 of 30 eyes with an ERM with the cotton ball sign had best-corrected visual acuity of ≥0.8. These findings suggest that the highly reflective regions in our study were present before the photoreceptor and RPE were severely damaged, and can be categorized as a different finding and are due to mechanical inward traction at the fovea. The only exception was case 41 in Figure 2. The cotton ball sign in this eye appeared as a dome-shaped, hyperreflective region directly attached to the RPE, and a yellow, round-shaped deposit was observed in the fundus photograph. We believe that this case can be classified with those reported by earlier studies and should have been excluded from this study. Optical Coherence Tomography in Eyes with Vitreomacular TractionOphthalmologyVol. 120Issue 7PreviewWe read with interest the article “Highly reflective foveal region in optical coherence tomography in eyes with vitreomacular traction or epiretinal membrane” by Tsunoda et al.1 The authors reported the presence of a highly reflective deposit (named “cotton ball sign”) on spectral-domain optical coherence tomography (SD-OCT) scanning in 63.8% of the eyes (30/47) with an epiretinal membrane (ERM) and in 100% (7/7) of eyes with vitreomacular traction (VMT). They stated that related articles were searched on PubMed and none was found describing the same feature. Full-Text PDF