Sir,

We congratulate the authors Johnston et al for their very informative paper on the risk of posterior capsular rupture among grades of surgeons with varying levels of experience.1 We are in full agreement about the benefits of electronic medical record (EMR) in a cataract service and we routinely use the software application used in the study, in our own practice. However, EMR is yet to be widely taken up across the country and we do observe differences in their uptake even within the same region as ours.

We are concerned about the selection bias in these studies as adoption of EMR and regular data input in the UK tends to currently favour highly geared and well-resourced departments alone. Many units where high-volume surgery happens, demographically higher risk (eg, ethnicity,2 increased age3) patient groups and late presentation exist, have not contributed to the dataset owing to the non-availability of EMR. The headline figure of posterior capsular rupture rate of less than 2%, therefore, might be less rosy in reality when compared with the data generated from the contributors to the dataset.

It, nevertheless, is a very good effort and largely in concordance with results available from centres with comparable populations,4 and we would recommend more wider uptake of the EMR, preferably, in a standardised software platform which when linked to a national body as the Royal College of Ophthalmologists could then act as a data guardian and provide a more realistic and accurate benchmark for everyone to compare their standards against.