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Response to Sanchez-Thorin

Readers would benefit from further scientific backup on the assumption mentioned under "Ophthalmologic assessment," which states that "[f]or purposes of classification, if retinopathy severity could not be graded in an eye, this eye was considered to have the same score as the participant's other eye" (1). Surprisingly, visual acuity was graded utilizing Snellen visual acuity charts, ignoring the benefit of using better and more well-known charts for testing visual acuity. The Standardized Visual Acuity Chart (e.g., Bailey-Lovie or Early Treatment Diabetic Retinopathy Study) (2,3) was designed specifically to correct the deficiencies of the Snellen chart, offering the same number of letters per line, a logarithmic progression in the size of the letters, and an equivalent difficulty for reading among lines. Measurements with the Standardized Visual Acuity Chart provide reproducible visual acuity information in a format that facilitates quantitative data analysis (3). Very useful guidelines on the standardization of visual acuity measurements in clinical research have been recently published (4). Tables 1 and 5 of Emanuele et al. (1) pretend to establish the absence of a confounding role of several baseline variables. These tables disclose P values as a proof that no significant differences between the standard and intensive treatment groups existed at baseline. The use of P values in this context is misleading, since these are strictly dependent on sample size and their role in evaluating confounding is pointless. Methods to evaluate the role of baseline variables as confounding factors include restriction, pairing, and multivariate analysis. The sample size calculations indicated that the study had an 80% power to detect a 1.5-2.0 difference in retinopathy levels between treatment groups. The study showed that at baseline, the retinopathy levels were 3.2 ± 0.4 in the standard treatment group and 2.9 ± 0.3 in the intensive treatment group. Readers would also benefit by knowing why a 1.5-2.0 difference was chosen as the clinically significant difference to be detected by the study. By treating a group of patients with a relatively low level of baseline retinopathy, on whom treatment compliance was to be expected in both treatment groups (based on the eligibility criteria) and following them for 24 months, it may be likely that the minimal difference to be detected between the two groups might have been large, and a smaller difference between groups may have gone undetected. Until these points are addressed, it is my impression that a conclusion that states that the study "showed that meticulous metabolic control did not prevent the onset or the progression of retinopathy, or affect visual acuity over the course of 18 months after good glycemic control was achieved" may not be warranted.