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In Reply: The Quantitative Measurements of Vascular Density and Flow Area of Optic Nerve Head Using Optical Coherence Tomography Angiography.

defined their recruited subjects with cup/disc ratios from 0.2 to 0.7 as normal without having objective evidence of visual field and retinal nerve fiber layer thickness. This is a very important issue in the methodology of a study claiming to provide a normative database for a measurable quantity such as vessel density. (2) The Optovue software does not remove large blood vessels when calculating vessel density. However, large vessels remain at very late stages of glaucoma, though they are attenuated.16,17 Studies have already shown the correct way to calculate vessel density when using OCT angiography.18,19 Therefore, calculating vessel density without removing the large vessels, overestimates the vessel density in any peripapillary quadrants that have those large vessels. It becomes even more problematic when considering the normal variation of retinal vessel location in different subjects, for example, vessels being located at 12 to 1 o’clock versus 1 to 2 o’clock position in oculus sinister, left eye, will affect vessel density in superonasal and superotemporal areas, respectively. This is usually the case for superior and inferior temporal arcades. Consequently, any amount of vessel density measured without removing the large vessels from the calculations is not reliable. (3) The low number of subjects in each age group (eg, <10 subjects of the age above 50 y category and only 1 person above 60 y) will not make a “normative database from second to seventh decades of life.” (4) Inclusion of subjects with refractive errors from −3D to +3D range without providing a rationale creates a selection bias, particularly because the authors claim to provide a normative database. (5) Although the authors have rightfully mentioned some of the shortcomings of the study in the discussion, they failed to point out the major methodology issues.