SUBSPECIALTY FOCUS : CORNEA, GLAUCOMA, PEDS, REFRACTIVE, RETINA, UVEITIS
EyeNet MAGAZINE S C I E N T I F I C H I G H L I G H T S O F AT L A N TA 2 0 0 8
Friday & Saturday
TABLE OF CONTENTS FROM THE EDITOR
is here, and you
IN THIS ISSUE: Highlights of Subspecialty Day . . . . . . . . .4–7 What is the deﬁn-
This edition of Academy News itive approach to
Alan C. Bird, 2008 Academy Laureate . . . . . .8
focuses on Subspecialty Day.
25 years with the excimer laser . . . . . . . .9–10 Does eye muscle
Program directors tell what’s surgery improve
OMIC and indemnity payments . . . . . . .11–13
new at their meetings, OMIC vision in kids
lists the biggest malpractice claims, and MD pioneers Atlanta aquarium . . . . . . . . . . . . . . . . .17–18 with nystagmus?
look back at excimer laser milestones. Meet the honorary lecturers . . . . . . . . . .19–22 inlays solve presbyopia? What’s the
news from glaucoma studies?
You might ﬁnd intriguing answers
to those questions in this year’s Sub-
specialty Day programs. And this year,
in particular, we will be treated to a
bumper crop of offerings, from special
tracks in cornea, uveitis and pediatrics
to the perennial pillars of glaucoma,
retina and refractive surgery.
The presentations begin Friday with
“Refractive Surgery 2008: The Danger
Zone,” and “Retina 2008: Vistas and
Saturday is even busier, with the
addition of “Cornea 2008: Emerging
Trends: Evolution or Revolution?” “Glau-
coma 2008: The Pendulum Swings,”
”Pediatric Ophthalmology 2008: Basics
and Breakthroughs in Managing Strabis-
mus and Pediatric Eye Disease,” and
“Uveitis 2008: How Should We Diag-
nose and Treat Our Patients?”
Welcome to Atlanta, and please join
your colleagues for the best research
and clinical updates of the year.
Richard P. Mills, MD, MPH
Chief Medical Editor, EyeNet Magazine
ON THE COVER
Barnes Retina Institute
e y e n e t ’ s a c a d e m y n e w s 3
FROM CORNEA TO UVEITIS
Highlights of the Subspecialty Day Programs
by miriam karmel, contributing writer
he six Subspecialty Day programs approached some of the directors of the brief will give you a sense of what’s going
offer so much in their packed agen- programs to see what they consider the on in other areas. The pendulum swings.
das that the biggest challenge will big news in their ﬁelds and what might Example: Fifty years ago, blood ﬂow
be deciding which presentations you’ll be of greatest interest to those in other CORNEA was regarded as the culprit in glaucoma.
want to attend. In order to help you better subspecialties. Even if you prefer to stick Cornea Subspecialty Day opens on a his- That theory was superseded by intraocular
plan your Subspecialty Day, EyeNet strictly to your own subspecialty, this torical note, with a talk about the evolution pressure. Today, the notion that damage
of keratoplasty by Mark J. Mannis, MD, to the optic nerve results from an insuffi-
and concludes with experts predicting ciency of blood ﬂow is in resurgence, said
what’s in store over the next ﬁve or 10 years Henry D. Jampel, MD, MHS, a codirector
for ophthalmology in general, and cornea of the Glaucoma Subspecialty Day pro-
in particular. The audience can expect to gram. Or consider the role of central
hear “what’s current, what’s new and what corneal thickness in calculating IOP. For
may be new ﬁve years from now,” said the past six or seven years, the importance
Michael W. Belin, MD, one of the Cornea of corneal thickness “got taken to sort of
Subspecialty Day program codirectors. an extreme,” Dr. Jampel said. “Now there’s
NEWS IN CORNEA. The agenda includes a swinging back to thinking that corneal
updates on surgical techniques for DSEK, thickness is a little bit important, but not
full-thickness penetrating keratoplasty, critical.”
anterior segment reconstruction and Such swings provide the focus for this
lamellar replacement. “Each procedure year’s Glaucoma Subspecialty Day.“There’s
has its beneﬁts and limitations,” Dr. Belin an initial enthusiasm, followed by an over-
said, adding that the presenters will convey reaction, then a reassessment of where
how to ﬁnd the best procedure for each things really are,” Dr. Jampel said. “Topics
patient. go in and out of vogue.”
“We used to do full-thickness corneal Even the American Glaucoma Society
transplants. We still do. They’re still effec- Subspecialty Day Lecture by Paul P. Lee,
tive,” Dr. Belin said. But now, whenever MD, JD, about caring for glaucoma
possible, rather than replacing the entire patients has a revisionist ring to it—
cornea, doctors try to selectively replace “Back to the Future.”
layers, he said. “Maybe in the future, we’ll NEWS IN GLAUCOMA. On the late-breaking
be able to replace a single cell layer. This news front, the three-year results of the
selective approach to corneal replacement, Tube vs. Trabeculectomy study will be
still in its infancy, is what’s really new, announced. And in response to popular
what’s revolutionary.” demand, an expanded surgery section will
Also, experts will take opposing view- provide an overview of what Dr. Jampel
points on applications in corneal and ante- called “a bewildering array of surgical
rior segment imaging technologies, which techniques,” as well as newer surgical
have undergone changes in the last few approaches.
years. And you can expect new informa- OF INTEREST TO THE NONSPECIALIST. Do
tion on infectious keratitis, with high- you have an OCT in your office? Are you
lights on treatment modalities and new thinking of buying one, or some other
and emerging drugs. diagnostic device? Speakers will share
OF INTEREST TO THE NONSPECIALIST. While
surgery dominates the agenda, this year’s Subspecialties, continued on page 6
program offers a topic of widespread
interest—pigmented lesions, tumors and
nodules of the anterior segment. “We’ve
gathered a panel of international experts
to make sense out of what is, for almost
everyone—the general ophthalmologist
OPHTHALMIC IMAGES CD, VERSION 3.0
and the subspecialist—a confusing topic,”
Dr. Belin said.
The ﬁnal section, which is titled “You
May Think I’m Crazy, But . . .,” promises
to be a ﬁtting ending to an ambitious
agenda, Dr. Belin said. “We tried to put
a program together where each section
TRABECULECTOMY OR TUBE? The three-
relates to the others and gels at the end.”
year results of the Tube vs. Trabeculec-
Cornea Subspecialty Day takes place on
tomy study are to be announced at
Saturday in the Thomas B. Murphy Ball-
Glaucoma Subspecialty Day.
T I M E C H A N G E S & C A N C E L L AT I O N S
This publication was printed in advance of the Joint Meeting. Check the Ticket
Sales area in Hall A-2 for cancellations or changes in meeting times.
4 f r i d a y G
s a t u r d a y e d i t i o n
Subspecialties, continued from page 4 have widespread appeal, as glaucoma isn’t codirector for Pediatrics Subspecialty Day.
the only subspecialty confronting industry To be sure, strabismus is on the agenda.
their diagnostic testing experiences. You inﬂuence, Dr. Jampel said. The Saturday afternoon session, geared to
can expect to hear: “This is how I use the Glaucoma Subspecialty Day takes place the subspecialist, will cover “the higher-
OCT clinically for glaucoma,” said Dr. on Saturday in the Sidney J. Marcus Audi- order concepts in strabismus—for exam-
Jampel. torium. ple, when is strabismus a neurologic prob-
Finally, ﬁreworks are likely when Paul lem?” Dr. Siatkowski said.
R. Lichter, MD, and Paul F. Palmberg, PEDIATRIC OPHTHALMOLOGY Also, strabismus surgery will be high-
MD, PhD, debate the prickly question of After a three-year hiatus, the pediatric lighted in this program’s Keynote Address,
whether the pharmaceutical industry is, ophthalmologists are back, with an array when Joseph L. Derner, MD, PhD, who
or is not, beneﬁcial to patients. The “Indus- of topics. “Not just strabismus,” promised laid the groundwork for understanding
try Relations” section, new this year, should R. Michael Siatkowski, MD, a program the anatomy of extraocular muscles, dis-
cusses the implications of pulley systems LATE-BREAKING TOPIC. During Pediatric
for modern strabismus surgery. “He’ll dis- Ophthalmology Subspecialty Day, there
THE YEAR IN REVIEW: Join the Editors of cuss how that anatomy affects the surgery will be an update on retinopathy of
AJO, Archives and Ophthalmology we perform and when surgery on the pul- prematurity care in the neonatal ICU.
leys is appropriate,” said Dr. Siatkowski,
mid the demands of practice, the busy clinician doesn’t always find time to keep
adding that a goal of the session is to get NEWS IN REFRACTIVE SURGERY. In response
up with the peer-reviewed journals. The editors of the American Journal of Oph-
doctors to start incorporating pulley sys- to a question from Refractive Surgery Sub-
thalmology, Archives of Ophthalmology and Ophthalmology invite you to a review
tems into their surgery planning. specialty Day codirector Steven C. Schall-
of interesting research published during the last year that has had immediate clinical
NEWS IN PEDIATRIC OPHTHALMOLOGY. On horn, MD, seven prominent surgeons will
relevance to the profession.
tap, in the ﬁnal “Hot Topics” segment, will reveal their “No. 1 pearl.” Said Dr. Schall-
The main criteria for selection by the editors include clinical relevance, interest to
be debates on three of the most controver- horn, “They’ve got to decide what that
comprehensive ophthalmologists, and a contribution that 1) warrants consideration of
sial topics in pediatrics today. In a point- one thing is.”
a change in recommended clinical practice, 2) appears to prove or disprove something
counterpoint format, experts will consider A session titled “Refractive Surgery in
that ophthalmologists have been doing previously but based on less solid evidence or
photoscreening and whether it’s ready Unique Patients” covers refractive surgery
3) gives better insight into a disease.
for widespread implementation. They’ll in aviators, pilots and children, as well as
also discuss whether eye muscle surgery in patients with autoimmune disease, nys-
THE EDITORS’ CHOICES SYMPOSIUM Presenter: William R. Freeman, MD
can improve vision in children with nys- tagmus or handicaps. Also on the agenda,
MONDAY Discussant: Janet L. Davis, MD
tagmus. And ﬁnally, they’ll talk about experts will address the question: “What
Time: 10:15 a.m. to 12:15 p.m. Mechanism of Action of Bimatoprost, whether IOLs are appropriate in children have I done differently this year?” This
Room: Thomas B. Murphy Ballroom 4 Latanoprost, and Travoprost in Healthy younger than 12 months. “IOLs are now session promises to touch on everything
Fee: No charge Subjects: A Crossover Study well accepted for kids older than 1,” Dr. from new techniques to managing the
The line-up is as follows: Presenter: K. Sheng Lim, MD Siatkowski said. “But are we ready to use impact of the economic slowdown on the
Discussant: Douglas R. Anderson, MD them in infants?” business of refractive surgery.
Preventing Surgical Confusions in Ophthal-
On the late-breaking front, there will OF INTEREST TO THE NONSPECIALIST. Dur-
mology Prevalence of Plateau Iris in Primary Angle
be updates on refractive surgery and ing the “Business Strategies” session, the
Presenter: John W. Simon, MD Closure Suspects: An Ultrasound Biomi-
retinopathy of prematurity as it relates “experience economy” will receive special
Discussant: Joe R. McFarlane Jr., MD croscopy Study
to changing NICU practices. coverage, Dr. Schallhorn said. The next
Presenter: Tin Aung, PhD
Ten-Year Follow-up of Laser In Situ Ker- OF INTEREST TO THE NONSPECIALIST. The step beyond the service economy is the
Discussant: Jeffrey M. Liebmann, MD
atomileusis for High Myopia morning session will provide a forum for experience economy, in which business
Presenter: Jorge L. Alió, MD, PhD Systematic Internet-Based Review of Com- educating comprehensive ophthalmolo- creates a memorable experience for the
Discussant: Jay S. Pepose, MD, PhD plementary and Alternative Medicine for gists who deal with children and who treat customer, and Shareef Mahdavi, an expert
Glaucoma adult strabismus. “They’re going to get a in this area, will talk about his ﬁeld as it
A Modified Technique for Descemet-Strip-
Presenter: Daniel G. Ezra, MBBS protocol to follow, including a tool kit for relates to refractive surgery. In ophthal-
ping Automated Endothelial Keratoplasty to
Discussant: Lloyd Hildebrand, MD how to measure vision in children, as well mology, for example, the tendency is to
Minimize Endothelial Cell Loss
as the state-of-the-art treatment for think that the next level of care is better
Presenter: Massimo Busin, MD Does Pre-Verbal Photoscreening for Amblyo-
amblyopia,” Dr. Siatkowski said. “We want phaco machines, better LASIK, better
Discussant: Edward J. Holland, MD genic Factors Affect Outcomes in Amblyopia
the comprehensive ophthalmologist to feel imaging devices, Dr. Schallhorn explained.
Treatment? Early Objective Screening Yields
Rosiglitazone May Delay Onset of Prolifera- comfortable examining and evaluating Dr. Mahdavi will discuss why that’s only
tive Diabetic Retinopathy kids with a variety of problems that don’t partly true. “The real game is improving
Presenter: Robert W. Arnold, MD
Presenter: Lloyd P. Aiello, MD, PhD require the subspecialist level of care.” the patient’s experience,” Dr. Schallhorn
Discussant: Elias I. Traboulsi, MD
Discussant: Susan B. Bressler, MD Pediatric Ophthalmology Subspecialty said, drawing an analogy to Starbucks,
Keep up with AJO, Archives and Ophthalmol- Day takes place on Saturday in Room which offers aroma and ambience along
Early Bevacizumab Treatment of Central
ogy by reading EyeNet Magazine, where A412. with its coffee. “It’s a real shift in offering
Retinal Vein Occlusion
selected summaries from these publica- care,” Dr. Schallhorn said.
Presenter: Richard F. Spaide, MD
tions are featured in the Journal High- REFRACTIVE SURGERY Refractive Surgery Subspecialty Day
Discussant: Travis A. Meredith, MD
lights section. Why does one post-LASIK patient com- takes place on Friday and Saturday in the
Three-Dimensional Spectral-Domain Optical Full access to both AJO and Ophthal- plain about dry eyes and the other does Thomas B. Murphy Ballroom 1/2.
Coherence Tomography Images of the Retina mology is available to Academy members not? Who are the unhappy LASIK patients?
in the Presence of Epiretinal Membranes via the O.N.E. Network www.aao.org/one. Is there a way to prevent their dissatisfac- RETINA
Presenter: Carmen A. Puliafito, MD, MBA EyeNet is the clinical newsmagazine of tion? In one of the three Keynote Address- For two days, retina specialists are being
Discussant: Richard F. Spaide, MD the Academy and is mailed to all domes- es at Refractive Surgery Subspecialty Day, treated to the latest information on every-
OPHTHALMIC IMAGES CD, VERSION 3.0
tic members. Access to the online version Jennifer Morse, MD, a psychiatrist who thing from gene therapy for inherited dis-
CFH and LOC387715/ARMS2 Genotypes and
is available to all members, domestic and studies patient response to surgery, will eases to new instruments and innovations
Treatment With Antioxidants and Zinc for
international, at www.eyenetmagazine.org. shed light on what makes patients tick. for management of vitreoretinal diseases.
Age-Related Macular Degeneration
International members who pay a shipping Dr. Morse was among those who But if any one topic stands out, it is age-
Presenter: Michael L. Klein, MD
and handling fee of $76/year receive the addressed the FDA’s ophthalmic device related macular degeneration, which dom-
Discussant: Paul Sternberg Jr., MD
print version of EyeNet. group last spring at a meeting that made inates most of the ﬁrst day’s agenda. “A
Vision Function in HIV-Infected Individuals The EyeNet Web site and the O.N.E. the headlines in the wake of reports from great deal of this meeting will be devoted
Without Retinitis: Report of the Studies of Network are available to Academy mem- disgruntled LASIK patients. Malvina B. to discussions of treatments of exudative
Ocular Complications of AIDS Research bers with their Academy username and Eydelman, MD, director of that FDA as well as nonexudative macular degener-
Group password. group, will speak about her agency’s ation,” said M. Gilbert Grand, MD, a Reti-
LASIK concerns. na Subspecialty Day program codirector.
6 f r i d a y G
s a t u r d a y e d i t i o n
He added that much of the AMD discus- uveitis, and in spite of all the publications out quickly.” But they guarantee side effects, OF INTEREST TO THE NONSPECIALIST. Much
sion will focus on new methods for man- in peer-reviewed literature over the past so in the many instances in which the of the program is geared to the nonspe-
aging AMD, particularly pharmacologic 25 years, “The vast majority of ophthal- uveitis is stubborn, the preferred practice cialist, said Dr. Foster, who hopes that by
therapy, which has provided dramatic mologists around the world are stuck with is to move beyond corticosteroids. Experts day’s end the audience will understand
improvement in achieving stability and just one string on the guitar—and that’s will discuss those practices. Also on the that the uveitis armamentarium contains
sometimes even visual improvement. corticosteroids,” Dr. Foster said. agenda is a report on new drugs, including more than steroids. By early referral to an
NEWS IN RETINA. Among the highlights The consequence of not heeding pre- intravitreal ﬂuocinolone and an update ocular immunologist or chemotherapist
are presentations on the use of ciliary ferred practices has led to needless disabil- on the Systemic Immunosuppressive trained to deliver novel treatments, or by
neurotrophic factor to treat a number of ity and blindness, which will be covered in Therapy for Eye Diseases (SITE) study. teaming up with a specialist, we can reduce
retinal diseases. Also in the lineup are pre- the talk “Prevalence of Visual Disability Quan Dong Nguyen, MD, codirector of the “shockingly disgraceful” prevalence of
sentations of the results of studies using and Blindness: It’s a Disgrace!” the event, will review drugs in the pipeline. blindness from uveitis, he said.
gene therapies to manage inherited retinal NEWS IN UVEITIS. “Steroids are wonder- There also will be an update on surgical Uveitis Subspecialty Day takes place on
diseases, such as Leber’s congenital amau- ful,” Dr. Foster added. “They put the ﬁre care of patients with uveitis. Saturday in Room A411.
rosis. “Those are critically important
papers,” Dr. Grand said.
The agenda also includes retinal imag-
ing, as well as a comprehensive review of
management of choroidal melanomas and
OF INTEREST TO THE NONSPECIALIST.
“While the program is really designed for
the retina specialist,” said Dr. Grand, “the
Saturday afternoon session on uveitis
promises to have universal appeal.”
And for those interested in the history
of ophthalmology, Harvey A. Lincoff, MD,
a pioneer in the management of retinal
detachment, will give a personal account
of the evolution of retinal surgery, when he
delivers the ﬁrst annual Charles L. Schep-
ens, MD, Lecture early Friday morning.
“A great deal of effort has been made to
include presentations that are clinically
signiﬁcant and on the cutting edge,” said
Dr. Grand, adding that the hope is to pre-
sent the most recent data regarding the
current management of vitreoretinal dis-
eases, including macular degeneration,
hereditary retinal disorders, vascular
occlusion, pediatric retinal abnormalities,
diabetic retinopathy, uveitis and tumors.”
Retina Subspecialty Day takes place on
Friday and Saturday in the Hall A-3 Ses-
Maybe this year will be different. Maybe
this year the message will sink in. The key
message that C. Stephen Foster, MD, one
of the directors of Uveitis Subspecialty
Day hopes to deliver: “When treating idio-
pathic or autoimmune-related uveitis,
there’s a lot more out there than steroids.”
Despite texts emphasizing the impor-
tance of moving beyond corticosteroids,
and courses given at the Academy on the
Preferred Practice Patterns for treating
RICHARD E. HACKEL, CRA, FOPS
AMD TAKES THE DAY. Age-related macu-
lar degeneration will command a large
portion of the Friday agenda during
Retina Subspecialty Day.
e y e n e t ’ s a c a d e m y n e w s 7
THE ACADEMY HONORS A PIONEER IN RETINAL RESEARCH, TEACHING AND CLINICAL MEDICINE
Alan C. Bird, MD, Named 2008 Laureate
by gabrielle weiner, contributing writer
he Academy takes special pride in laboration with IO Professor Shomi Bhat- thy. He has worked in Jamaica recording
honoring Alan C. Bird, MD—a tacharya, the team identiﬁed numerous the retinal changes in sickle cell disease
world-renowned expert on the eye disease genes and cemented the stand- over a 21-year period using a rigorous
treatment of retinal vascular disease and ing of the IO (which became a school of cohort generated by hematologist Graham
genetic and degenerative retinal disorders University College, London) and Moor- Serjeant. Together, the team has docu-
—as recipient of the 2008 Laureate Recog- ﬁelds Eye Hospital as one of the top eye mented the relatively benign nature of
nition Award. research and care centers worldwide. sickle cell, thus obviating the need for
Professor Bird has been one of the most Over the years, Professor Bird developed prophylaxis.
proliﬁc and innovative minds of the past a multidisciplinary and talented research Today, Professor Bird is involved in a
40 years in the ﬁeld of medical retina. His team for studying monogenic retinal dis- number of important clinical trials. Most
research has included the clinical and orders and age-related macular disease. recently, he chaired the Independent Data
genetic documentation of families with Investigative techniques have included Safety and Monitoring Committee for the
retinal disorders and the identiﬁcation of molecular genetics, electrophysiology, pegaptanib (Macugen) trial for AMD.
the genes responsible for those patholo- psychophysics, specialized imaging and “The development of biological treatment
gies. This research has also led to the morphology. “In part because of the for choroidal neovascularization has been
development of new technology to deﬁne tremendous clinical load and in part extremely exciting to watch,” he remarked.
both the clinical characteristics of retinal because of the sophisticated level of sci- In addition to having worked with
disease and the correlation of abnormal ence,” said Professor Bird, “the clinical the U.K.’s Medical Research Council and
gene expression with metabolic dysfunc- and research activity at Moorﬁelds and Wellcome Trust, the U.S.’s National Eye
tion at the cellular level. the IO has attracted gifted post-residency Institute, France’s INSERM and Germany’s PROFESSOR BIRD is an internationally
Born in London, Professor Bird received fellows from all over the world, many of Deutsche Forschungsgemeinschaft, Pro- recognized expert on the treatment of
his medical degree from Guys Hospital, whom have made major contributions to fessor Bird is involved in advising industry retinal vascular disease and genetic
University of London, where he trained in the ﬁeld.” from a clinical perspective. Professor Bird and degenerative retinal disorders.
both neurology and neurosurgery before With the help of two of his fellows from has earned the Duke-Elder, Doyne and
his ophthalmic residency at Moorﬁelds Germany, Professor Bird’s team was the Bowman medals in the United Kingdom from my colleagues at Moorﬁelds and the
Eye Hospital. He then had a one-year ﬁrst to demonstrate that the accumulation and the Prix Chauvin in France. He has numerous fellows who were attracted to
fellowship in neuro-ophthalmology at the of lipids in Bruch’s membrane was an inte- given numerous eponymous lectures the Institute of Ophthalmology in London
Bascom Palmer Eye Institute in Miami gral part of AMD. “This was a concept that throughout Europe and North America from countries around the world.”
and spent a brief period at the University derived originally from Dr. Dean Bok at and has received the Alcon Research In October 2005, Professor Bird retired
of California, San Francisco. UCLA,” Professor Bird said. Along with Award, the Helen Keller Prize, the Paul from full-time clinical practice and was
Professor Bird returned to London in the assistance of one of his fellows and Kayser Award and the Jules François appointed emeritus professor of medical
1969 and was appointed to the staff at the IO’s Professor Frederick Fitzke, Professor Medal. In 2006, he was honored by the ophthalmology at London University and
Institute of Ophthalmology (IO) and Bird also developed a novel technique to Macula Society with a lifetime achieve- honorary consultant at Moorﬁelds Eye
Moorﬁelds Eye Hospital, where he has document autoﬂuorescence in the retinal ment award. Hospital. He and his wife, Sarah, have two
remained ever since. In the late 1970s, he pigment epithelium for monitoring its “The essence of my career has been sons and one grandson, all of whom live
established one of the ﬁrst clinics in the health along with the health of photore- cooperative research between myself as in England. Professor Bird enjoys gardening
world for inherited retinal disease. In col- ceptor cells. “For the ﬁrst time, we record- a clinician and talented colleagues in the and playing golf when he can ﬁnd time
ed changes in disease involving the pig- laboratory who have been very generous and is an avid Rugby Union fan, rooting
ment epithelium, something we had not in supporting clinically driven research,” for the London Wasps. He would want us
PA S T AWA R D E E S been able to do prior to that time, at least said Professor Bird. “I have been so fortu- to mention that the Wasps recently won
not accurately,” said Professor Bird. “We nate to receive constant and crucial support the 2008 Guinness Premiership Final.
Every year, ophthalmologists distin- could not only look at drusen changes at
guish themselves and the profession the level of Bruch’s membrane, but we
by making exceptional scientific con- could also start observing changes in the WORDS FROM A FORMER FELLOW
tributions toward preventing blindness pigment epithelium, an integral aspect of
and restoring sight worldwide. The AMD.”
worked for Alan Bird in the early between basic retinal science and the
board of trustees of the Academy rec- When asked what he feels is his greatest 1990s and have always felt it was clinic, and greatly enhancing our knowl-
ognize these extraordinary contributions contribution to ophthalmology, Professor the most exciting year of my entire edge of retinal disease and therapies.
with its Laureate Award, the Academy’s Bird doesn’t hesitate: “The most impor- ophthalmic training. Professor Bird is a caring and compas-
single, highest honor. tant thing I’ve ever done was in river One of the things that made Professor sionate physician who is wonderful with
blindness.” In the 1970s, he traveled to Bird special was his gift as both a clini- patients, never taking away hope from
Africa to help a clinical team in Cameroon cian and a basic research scientist. With a the many patients with blinding retinal
Claes H. Dohlman, MD
with research. “The most notable ﬁnding detailed knowledge of basic retinal physi- diseases that have no treatment.
2006 was the identiﬁcation that retinal and ology and molecular biology, he can speak As my teacher, “Prof” Bird—as we all
Lorenz E. Zimmerman, MD optic nerve disease was the main cause of the language of the basic scientist while called him—was downright fun to work
2005 blindness rather than corneal scarring, providing critical analysis of findings from with and was always eager to share his
Arnall Patz, MD and that the standard treatment of that the perspective of an astute and observant knowledge and passion for his work. And
time—diethylcarbamazine—accelerated clinician. He has thus influenced the as a person, he’s simply a great guy, easy
visual loss,” Professor Bird said. “This gave direction of research in retinal disorders, to relax and enjoy a good laugh with.
Daniéle S. Aron Rosa, MD, PhD
rise to the introduction of ivermectin as collaborating with some of the most influ- I’m very proud that I had the chance
J. Donald M. Gass, MD
the new treatment for onchocerciasis.” As ential retinal scientists of his time. to spend one of my most formative years
Marshall M. Parks, MD
a direct result, river blindness, which at Moorfields Eye Hospital has provided with Prof Bird. The 2008 Laureate Award
2003 the time was classiﬁed as one of the major him with a volume and variety of clinical is truly deserved.
Charles D. Kelman, MD causes of blindness in the world, is now a pathology that few other institutions have Jack Wells, MD
Robert Machemer, MD far smaller problem. had, and Professor Bird has not squan- Palmetto Retina Center,
Charles L. Schepens, MD Another key achievement in Professor dered that opportunity, serving as a bridge Columbia, S.C.
Bird’s career focused on sickle cell retinopa-
8 f r i d a y G
s a t u r d a y e d i t i o n
a Beam of Light
A Quarter Century
of the Excimer
Laser by annie stuart,
ablative photodecomposition to remove beg, borrow or buy a laser system from
SUCCESS STORY. The excimer laser has found broad applications corneal tissue. him for further studies,” Dr. Trokel said.
in many markets, from micromachining to medical uses. And no discipline has ULTRAVIOLET WORKS ITS MAGIC. Recogniz- Very soon, he and others would be doing
ing its signiﬁcance, Dr. Trokel reported in those studies. Animal experiments had
been more dramatically altered by its advent than refractive surgery. Over the December 1983 American Journal of begun in Berlin in December 1983 and
Ophthalmology, “The excimer laser, which would start shortly thereafter in the
time, improvements in performance and reliability, combined with a host of
produces light in the far-ultraviolet portion United States in the lab of Marguerite
complementary techniques and innovations, have turned excimer refractive of the spectrum, allows precise removal of B. McDonald, MD, who was then at
corneal tissue through a photochemical Louisiana State University.
surgery into the most popular elective surgical procedure worldwide. laser-tissue interaction. This interaction is IDEAS FOR INITIAL APPLICATIONS. “The
not thermal and does not involve optical earliest reports were to make cuts in the
breakdown; rather, it directly breaks cornea to resemble RK,” said W. Bruce
More than 800,000 Americans underwent laser in the mid-1970s. But its potential organic molecular bonds without tissue Jackson, MD, commenting on the work
LASIK surgery in 2007, according to a for ophthalmic applications would wait heating.” of Thomas F. Neuhann, MD, and others.
story published last April 24 in the Inter- until 1983, when Stephen L. Trokel, MD, The 193-nm, argon-ﬂuorine excimer “And the second was to use it for thera-
national Herald Tribune. That number was paid a propitious visit to photochemist laser energy was well absorbed by the peutic applications—such as for corneal
an increase over 2006, although, as an elec- Rangaswamy Srinivasan, PhD, who was cornea, breaking organic bonds and eject- scars and even corneal infections,” he
tive procedure, refractive surgery is subject using the excimer laser for microetching ing molecular fragments at supersonic added. “Then the concept came that you
to the whims of a poor economy, and the computer chips at IBM’s Thomas J. Wat- speed. This ability was striking. could sculpt the cornea, actually take tis-
Tribune story predicted a 17 percent drop son Research Center in Yorktown Heights, But what the laser didn’t do would sue off to correct myopia. That was really
in patients this year, describing LASIK as N.Y. Dr. Trokel had also previously noted make it revolutionary: It did not cause the beginning.” Dr. Jackson is professor
a barometer for economic recession. the work of John Taboada, PhD, who was signiﬁcant mechanical or thermal injury and chairman of ophthalmology at the
performing military safety testing of the to the cornea. “The experiments became University of Ottawa.
FROM INKLING TO INNOVATION laser at low energy levels. Dr. Trokel subse- progressively more sophisticated as we HE DID THE MATH. Charles Munnerlyn,
A RUSSIAN REVOLUTION. Scientists in Moscow quently oversaw a series of experiments systematically explored the laser tissue PhD, was curious about large-area abla-
were credited with the design of the excimer on freshly enucleated bovine eyes, using interaction across the UV spectrum,” said tions and sought to do such experiments
Dr. Trokel. “I had met with Dirk Bastings on rabbit eyes in 1984 with Dr. Trokel and
Light micrographs, above, published by Dr. Trokel and colleagues 20 years ago in Oph- in August 1983 after a series of experi- Carmen A. Puliaﬁto, MD, MBA. Then, Dr.
thalmology, depict “a transversely sectioned cornea whose anterior surface has been ments.” (Mr. Bastings was then CEO of Munnerlyn started a project that resulted
eroded to form a series of steps by exposure to an excimer laser through a progressively Lambda Physik, the manufacturer of the in construction of the ﬁrst clinical proto-
opening aperture.” excimer lasers.) “It was my intention to type photorefractive keratotomy (PRK)
THE EXCIMER 1975
Early Russian develop-
Theo Seiler performs
Stephen Brint performs
TIMELINE ment of excimer laser
describes use of
excimer laser to remove
first excimer treatment
on a human eye.
first LASIK procedure.
corneal tissue (left).
Rangaswamy Srinivasan 1986 Marguerite McDonald
uses excimer laser for Theo Seiler creates performs first excimer
precise cuts in organic linear and arcuate PRK on a sighted
materials. keratectomies for human eye (right).
e y e n e t ’ s a c a d e m y n e w s 9
CONTINUING CUSTOMIZATION my practice when wavefront was intro-
A new generation of lasers allowed for duced—maybe 30 to 40 percent—and
smoother surfaces, wider ablations and another huge jump with femtosecond
better transition zones, all of which laser. These two improvements really
improved corneal healing responses with resulted in a much larger segment of
both PRK and LASIK, said Dr. Pallikaris. the population being willing to do laser
It was possible to design almost any shape surgery.”
of ablation proﬁle of the cornea, including
aspheric ablation proﬁles, ﬁrst introduced THE LASER’S LONG REACH
by Dr. Seiler in 1994. The future holds still more innovation for
Dr. Trokel included this illustration in an essay he authored, “Evolution of excimer laser “Initially, we had no concept of how this laser: greater automated calibration,
corneal surgery,” published in the Journal of Cataract and Refractive Surgery, July 1989. high a correction could be done or how improved beam proﬁle, better trackers
deep you could go in the cornea,” said Dr. and online pachymetry, to name a few.
system. He worked out mathematically lasers, enabling greater accuracy of treat- Jackson. “We tended to use multizone-type And consensus about where to focus the
the depth of ablation, diameter and edge ment and correction of higher-order opti- treatments, but they were small in diameter treatment—the visual axis or the pupil-
angles, later cofounding Visx with Dr. cal distortions. “This made it possible to and often the patients ended up with more lary axis—may come at some point, as
Trokel and Terry Clapham in 1986. create smooth, contoured ablations and glare, halos and other optical symptoms.” well as how best to integrate topography
The ferment spilled over with the ﬁrst customized patterns,” said Dr. Rabinowitz. But with automation, increased laser speed with wavefront.
excimer treatment on a human eye by Ger- HALOS, HAZE AND GLARE. Optical side and larger treatment diameters, patient
man ophthalmologist Theo Seiler, MD, effects such as glare, halo and contrast satisfaction started to go up,” said Dr.
PhD, in 1987 and excimer PRK on a sight- sensitivity, and physical complications Jackson.
ed human eye in 1988 by Dr. McDonald, were also challenging. Severe scarring or NEW TECHNIQUES HOP ON BOARD. To pre-
who maintains the longest follow-up in haze indicated aggressive wound healing serve the epithelium, and reduce haze and
the world. —either from epithelial healing over the pain, two other techniques evolved: laser
ablated area or new collagen synthesis in in-situ epithelial keratomileusis (LASEK),
EARLY OBSTACLES the superﬁcial stroma—leading to regres- introduced by Dimitri T. Azar, MD, in
As with any new technology, all did not go sion of effect. 1996, and a newer variation called epipolis
smoothly at ﬁrst. Two major challenges: Correcting optical problems was easier laser in situ keratomileusis (epiLASIK),
controlling the laser’s beam and managing than addressing healing, noted Dr. Pal- an innovation of Dr. Pallikaris in 2004.
surgical complications. likaris. “We were not familiar with the PATIENT, FIXATE THYSELF. Handheld ﬁxa-
NEEDED: BEAM CONTROL. The initial healing process of the cornea, so it took tion devices were replaced by self-ﬁxation,
pulse was delivered as a broad, rectangular a lot of time to observe and understand then, later, by a variety of pupil and limbus
beam of irregular energy. To obtain con- the reason why we had so much haze and tracking devices. This allowed the excimer Schematic offered in a brief report on
“Ophthalmic Excimer Laser for Corneal
sistent clinical results, beam homogeniza- regression of myopia,” he said. “My initial system to compensate for saccadic move-
Surgery,” published in March 1987, in
tion and shaping were attempted through contribution in excimer laser history was ment and torsion, and brought an added the American Journal of Ophthalmology.
various means. “It was difficult to control when I studied in the rabbit model nerve level of conﬁdence to the patient experi-
the size of the beam with the machine,” regeneration with gold chloride in order ence, said Dr. Jackson.
said Ioannis G. Pallikaris, MD, director of to understand the healing process.” Mito- WAVEFRONT MAKES A BEACHHEAD. In What’s clear, however, is that the
the Institute of Vision and Optics at the mycin C later came to the forefront as a March 1999, Dr. Seiler tried the ﬁrst wave- knowledge accumulated because of the
University of Crete in Greece. “So it was way to manage scar and haze formation front-guided PRK. Dr. Jackson described excimer laser has not only changed the
helpful to use a masking procedure made following surface ablation. this as a leap forward. “All of a sudden we world of refractive surgery, said Dr. Jack-
of apertures so we could ablate more in ADVANCING TO FLAPS. Dr. Pallikaris played were looking at patients who were 20/20 son, but had an amazing ripple effect in
the center of the cornea and less in the another key role in mitigating the healing or 20/15, and even down to 20/10. In the many areas of ophthalmology.
periphery.” challenges by developing the idea for laser old days, those would be numbers we Knowledge gained about how to man-
To accommodate the need for expand- in-situ keratomileusis (LASIK) in the late wouldn’t even think of.” age dry eyes, ectasia or corneal scars all
ing refractive indications, the masks used ’80s. “In 1990, I designed a prototype Treating without pupil centroid shift, had roots with the excimer experience.
to shape the broad beam laser delivery microkeratome in order to generate the and employing torsional tracking—this “And when we got into aberrometry and
were changed, said Yaron S. Rabinowitz, ﬁrst corneal ﬂap on a blind eye,” said Dr. all improved up results even more, added higher-order aberrations, this turned
MD, director of ophthalmology research Pallikaris. Making precise ﬂaps was a Dr. Jackson. cataract surgery around overnight.” Even
at Cedars-Sinai Medical Center in Los challenge, he said, until automated micro- Today, most refractive surgeons use spectacles and contact lenses are affected,
Angeles. keratomes came along to generate more wavefront systems, and, along with com- he said. “So it’s far-reaching in all our
“For example, the axicon was used reliable ﬂaps. FDA approval for LASIK puterized topography and aberrometry, optical corrections.”
to rotate a decentered beam to correct occurred in 1999, four years following the wavefront-guided and optimized systems
hyperopia,” he said, “which made that approval of the eximer laser for PRK cor- have provided new assurance with higher- Dr. Jackson is a consultant for AMO/Visx. Dr.
application possible.” Over time, ﬂying- rection of myopia in the range of 1.0 to order and induced aberrations, said Dr. Pallikaris reports no financial interests. Dr. Rabi-
spot excimer lasers replaced broad-beam 7.75 D. Rabinowitz. “There was a huge jump in nowitz is a consultant for AMO and Wavelight.
THE EXCIMER TIMELINE CONTINUED Cheers for a Quarter-Century of Argon-Fluorine Sculpting
1995 1999 2002 A Symposium to celebrate the 25th anniversary of the excimer laser will be held Sunday,
FDA approves excimer FDA approves excimer FDA approves IntraLase from 10:45 a.m. to 12:15 p.m. in the Hall A-3 Session Room. For a schedule of speakers,
search the Online Program for event code “Sym04,” or check your Final Program.
laser to correct myopia laser for LASIK surgery. for laser-assisted cre-
This Symposium will conclude with the 2008 Barraquer Lecture, “Corneal Surgery Is
with or without astig- ation of corneal flap.
Refractive Surgery,” delivered by Roger F. Steinert, MD. “We have made great strides in
replacing cloudy corneas with clear corneas,” said Dr. Steinert. “Yet our ability to
FDA approves excimer 2004 achieve optically excellent corneas comparable to natural corneas has lagged seriously
1996 laser for LASIK to cor- Ioannis Pallikaris intro- behind this anatomic success. Meeting patients’ vision needs will involve borrowing the
Dimitri Azar introduces rect hyperopia. duces epipolis laser in tools of refractive surgery, such as LASIK and PRK.”
laser in-situ epithelial situ keratomileusis This is a combined meeting with ISRS/AAO and the European Society of Cataract
keratomileusis 2002 (epiLASIK). and Refractive Surgery. Check your Final Program for many more presentations on the
(LASEK). FDA approves wave- newest developments in corneal and refractive surgery.
10 f r i d a y G
s a t u r d a y e d i t i o n
R I S K M A NAG E M E N T
at Lessons Learned
Payouts by hans bruhn, mhs, senior risk management
coma.) Instead, the ophthalmologist occa- 2. Decision-making process did not rule
RISK EXPERTS. The Ophthalmic Mutual Insurance Company has sionally monitored the cup-to-disc ratio. out the worst-case scenario.
been defending Eye M.D.s for 21 years. During this time, its indemnity Vision loss continued between 5.6 and 8.2 3. Patient was not responding to treatment.
years, but this was thought to be due to 4. Recurring complaint.
payments have tended to be signiﬁcantly lower than those of other multi- exotropia. 5. New or evolving complaint.
When the patient ﬁnally complained of 6. Repeat visits or phone calls.
specialty carriers. This is due, in no small part, to OMIC’s governance by total vision loss, he was referred to a retina 7. Phone calls to multiple providers.
ophthalmologists who understand the risks and worth of each case. specialist who found 100 percent cup-to- OMIC RESOURCES: Menke, A. M. Risk
disc ratio with an atrophied optic nerve Management Issues in Failure to Diagnose
(total vision loss) in the left eye and 65 Cases. This article discusses the diagnostic
Recently, OMIC reviewed its claims both eyes and deﬁnite signs of macular percent cup-to-disc in the right eye. The process that was described above. (Avail-
for the six subspecialties that are included vessel stretching in the right eye. patient is now on glaucoma medications. able at www.omic.com.)
in this year’s Subspecialty Day to ﬁnd On June 20, 2005, the insured declared ALLEGATION: Failure to diagnose open-
the nine cases involving the biggest pay- that the patient was legally blind. angle glaucoma in a 3-month-old microph- RETINA : $1,500,000—failure to diag-
ments, which ranged from $3,375,000 to ALLEGATION: Failure to diagnose ROP. thalmic infant after cataract surgery. nose choroidal melanoma. A 46-year-
$800,000. Only one of these subspecial- DAMAGES: 20/370 in the right eye at 1 DAMAGES: Total vision loss (no light per- old man presented to an ophthalmology
ties, uveitis, is not represented below. It foot and no light perception in the left eye. ception) in the left eye; 65 percent loss of group practice in January 1996 for a
had a top payment of $500,000 (for a case EXPERT REVIEW: The defense and plain- vision in the right eye. routine eye exam and he was seen by an
of endophthalmitis that resulted from a tiff experts felt that the ophthalmologist EXPERT REVIEW: The experts for both optometrist employed by the practice.
dropped lens during cataract surgery). should have followed up with the patient the plaintiff and the defendant found that The optometrist identiﬁed a nevus on the
By reviewing cases such as these, as much sooner than six months; he should the physician fell below the standard of patient’s right eye during that exam. The
well as keeping an eye on trends within have had the patient return in two or care. IOPs should have been checked nevus was described as nonsuspicious,
ophthalmology, OMIC is able to develop three weeks. There was an indemnity every six months. Following the cup-to- ﬂat and about two discs in diameter. The
very speciﬁc risk management recommen- payment of $3,375,000. disc ratio would only reveal whether dam- optometrist maintained that a photo was
dations. (Many of these recommendations RISK MANAGEMENT ISSUES: The physician age already had occurred, and not all cup- taken of the nevus on this date, but no
can be found on OMIC’s Web site, www. did not follow standard of care for exami- to-disc measurements were documented photo (or order to take one) was found in
omic.com.) nation and treatment of ROP. In addition, in the ﬁle. Also, the retina specialist who the medical record. The patient was asked
the hospital and the physician’s ofﬁce didn’t saw the patient on referral from the origi- to return in one year for follow-up.
PEDIATRIC OPHTHALMOLOGY : use a tracking system to ensure that the nal physician diagnosed marked glauco- Almost one year later, the patient returned
$3,375,000—failure to diagnose child was examined within the proper matous cupping of the patient’s left eye to the ofﬁce complaining of an inability
retinopathy of prematurity. The patient time intervals. and stated that the vision loss in this eye to focus his right eye. He was seen by an
was born via cesarean section on March OMIC RESOURCES: Menke, A. M. ROP was a result of chronic, long-term open- ophthalmologist in the group who sus-
23, 2003, at 26 weeks of gestation with a Creating a Safety Net. (Available at www. angle glaucoma. The case was settled for pected retinal detachment and referred
birth weight of 960 g. An ROP exam was omic.com.) $1.8 million. the patient to a retina specialist. The spe-
not done until May 7, at which point the RISK MANAGEMENT ISSUES: The physician’s cialist diagnosed a malignant melanoma
baby was 6 weeks old and weighed 1,585 g. GLAUCOMA : $1,800,000—failure to diagnostic thought process failed to with overlying retinal detachment. The
The ophthalmologist found no ROP, and diagnose open-angle glaucoma. A include a differential diagnosis for this patient was referred for treatment, but
the plan was to follow up with another 3-month-old boy was diagnosed with patient. Both plaintiff and defense experts died in August 1999.
ophthalmologist on Nov. 6. microphthalmia and bilateral cataracts. pointed out that there is a 15 to 20 percent ALLEGATION: Failure to diagnose
However, before the follow-up appoint - Cataract surgery was performed. The increased risk of glaucoma in microph- choroidal melanoma.
ment, the parents became concerned that ophthalmologist continued to treat the thalmic, cataractous patients. The physi- DAMAGES: Death.
their child was not tracking well, and the patient for eight years but did not mea- cian may have avoided this misdiagnosis EXPERT REVIEW: The defense experts felt
patient was seen on Aug. 19 by the insured. sure intraocular pressure every six months of open-angle glaucoma if he recognized the optometrist met the standard of care
The ophthalmologist noted stage 4A ROP as is recommended for microphthalmic, the signs of a misdiagnosis: both in the follow-up duration (one year)
OS > OD. The dilated funduscopic exam cataractous patients. (Such patients have 1. Diagnosis did not account for all symp- and in not needing a photo for a nevus of
showed retinal detachment and ﬁbrosis in a 15 to 20 percent increased risk of glau- toms and ﬁndings. this description. The plaintiff experts felt
e y e n e t ’ s a c a d e m y n e w s 11
R I S K M A NAG E M E N T
to turn the patient away but rather to of additional work life left with a decrease
Atlanta: Booth and Special Events schedule the patient for an exam (because in earnings of approximately $150,000 per
he was an ER patient). Poor follow-up on year. Also, past and future medical
this patient contributed to the damages expenses were estimated at $100,000.
and settlement of this case. EXPERT REVIEW: The plaintiff ’s experts
OMIC RESOURCES: Menke, A. M. The stated that the residual stromal bed needed
Ophthalmologist’s Role in Emergency Care: to be 250 µm or greater. The original
On-Call and Follow-up Duties under physician fell below standard of care by
EMTALA. (Available at www.omic.com.) failing to leave a margin of safety in this
patient with borderline ﬁndings, both
GLAUCOMA : $1,000,000—failure to before LASIK and again when a retreat-
diagnose and treat glaucoma. An optom - ment was performed. This led to ectasia,
etrist treated a 39-year-old woman for 10 requiring a corneal transplant. However,
years. The patient regularly complained it was conceded that no surgeon in 2001
of decreasing, blurry vision. Nonetheless, reasonably could have predicted that the
the optometrist did not perform any diag- patient would suffer from ectasia as a
nostic tests and never referred the patient result of the LASIK.
VISIT THE ACADEMY/OMIC INSURANCE CENTER. Chat with insurance experts who are to an ophthalmologist. The only response Defense experts could not support
familiar with the full line of Academy-sponsored insurance programs. was to change the contact lens prescription. the care rendered. They opined that the
Where. Hall B-4, Booth #3432. Indeed, the prescription appeared to be the patient had keratoconus and there were
sole focus of the yearly visits. problems with the retreatment on the sec-
OMIC ANNUAL MEMBERS MEETING. Timothy J. Padovese, president and CEO of OMIC,
ALLEGATION: Failure to diagnose and ond eye because of what appeared to be
will report on the company’s latest financial results. Plus, election of OMIC’s directors
treat glaucoma in a 39-year-old woman. the ﬁrst signs of ectasia. They also felt that
and other business.
DAMAGES: The patient ended up with the patient had progressive ectasia before
When. Sunday, Nov. 9, 11:30 a.m. to noon, Room A304. Free.
100 percent cupping in both eyes with lit- the retreatment, increasing the likelihood
OMIC FORUM: WRONG PATIENT—WRONG SITE—WRONG IOL. An in-depths review of OMIC tle optic nerve tissue remaining. she would need a corneal transplant in the
claims will illustrate the faulty systems and practices that can cause surgical mistakes. EXPERT REVIEW: The optometrist failed second eye. Regardless, it was felt that a
When. Sunday, Nov. 9, 1 to 3:30 p.m., Thomas B. Murphy Ballroom 1–3. Free. to conduct the required tests on this corneal transplant should be able to bring
ULTIMATE CHART AUDIT. The AAOE’s “savvy coder” Sue Vichrilli, COT, OCS, and OMIC’s patient, and thus failed to meet the stan- the patient back to visual acuity in the
risk manager Anne Menke, RN, PhD, will explain how improved documentation can dard of care. The ophthalmology practice 20/20 range.
help you avoid both malpractice lawsuits and billing audits. also was named in this claim because it The case went to trial and the jury found
When. Monday, Nov. 10, 9 to 11:15 a.m. A ticket for AAOE Instruction Course #358 employed the optometrist. Two insurance for the plaintiff 11-1. They awarded the
costs $70 at Ticket Sales in Hall A-2. companies eventually settled the case, plaintiff a total of $944,420 before pre-
with each company paying $500,000. judgment interest.
RISK MANAGEMENT ISSUES: The primary RISK MANAGEMENT ISSUES: The ophthal-
that the supervision of the optometrist given to follow up the next day with the risk in this case is that the optometrist mologist fell below standard of care with
was inadequate; they argued that a consult ophthalmologist. However, the patient failed to diagnose glaucoma. When exam- this patient by performing the LASIK pro-
with an ophthalmologist should have been was not able to set up a follow-up appoint- ining and treating this patient, he didn’t cedure despite contraindications for the
done when the nevus was ﬁrst detected. ment due to a miscommunication. The use a diagnostic process to rule out the procedure.
The case was settled for $1,500,000. The ophthalmologist’s ofﬁce had a policy not worst possible diagnosis. The optometrist
optometrist and the group were separately to treat patients on public assistance, failed to consult with others in the prac- REFRACTIVE SURGERY : $900,000—
insured; the group paid $500,000 due to except if they are ER follow-up patients. tice to determine the cause of the patient’s contraindicated LASIK. On Dec. 1, 2003,
its vicarious liability as the employer. The ophthalmologist failed to instruct his loss of vision. The secondary risk here is the ophthalmologist ﬁrst saw a 47-year-
RISK MANAGEMENT ISSUES: It would have ofﬁce that this patient should be sched- that the employer (the group practice) old woman who expressed interest in
been prudent for the optometrist to refer uled for an appointment, nor did he may not have properly supervised the LASIK. She had a history of myopia with
the patient to the ophthalmologist when instruct the patient to mention this excep- optometrist. astigmatism. She was also presbyopic and
the nevus was ﬁrst detected. Consider tion to the group’s scheduling staff. Three had been wearing contact lenses for many
advising employed optometrists to refer days later, treatment for a corneal ulcer REFRACTIVE SURGERY : $983,000— years, and monovision contact lenses
patients with a new ﬁnding of nevus for a was provided by other providers. The negligent LASIK. On Dec. 5, 2001, a 48- more recently to treat her presbyopia.
consultation with the ophthalmologist. patient had serious opacity in the right year-old woman had bilateral LASIK. On Her previous prescriptions for glasses was
Owing to the vicarious liability that the eye and the possible need for a corneal day 1 postop, her visual acuity was 20/25 two years old.
group practice has (and its easy referral transplant. in the right eye, 20/30 in the left. One Visual acuity with correction was
capability), protocols should have been ALLEGATION: Failure to treat a corneal month later, the patient’s visual acuity noted as 20/40 in both eyes. Pachymetry
developed requiring referral in cases such ulcer. was 20/50 in both eyes. readings taken by staff were 485 µm and
as this. DAMAGES: The patient’s eyesight in his On June 19, 2002, a retreatment on her 462 µm in the right eye, and 462 µm and
OMIC RESOURCES: Menke, A. M. Coman- right eye has been measured 20/40 or bet- right eye was performed, followed by a 471 µm in the left. Pupil size was 6 mm in
agement of Ophthalmic Patients. (Avail- ter, but ongoing treatment indicates the retreatment on her left eye on July 18. It both eyes. The ophthalmologist discussed
able at www.omic.com.) possibility that his eyesight may worsen should be noted that the insured did dis- the risks and beneﬁts of LASIK and PRK.
and a transplant may be needed. His left cuss with the patient the increased risks The patient elected to have LASIK.
CORNEA/ EMERGENCY MEDICINE : eye is unaffected. due to her thin corneas. Four months On Dec. 4, the procedure was per-
$1,000,000—failure to treat corneal EXPERT REVIEW: Although the treating later, the physicians referred the patient formed on both eyes. Postoperatively,
ulcer. In March 1994, a 2-year-old male ophthalmologist followed the standard of to another ophthalmologist for a second the patient complained of headaches and
patient fell into an “oily, dry matter” on care for this patient, defense experts felt opinion since the patient continued to be continued blurriness. Two weeks later,
his family’s driveway. Shortly thereafter, the group’s practice of not seeing public dissatisﬁed with her results. In May 2003, the ophthalmologist reﬂoated the ﬂap.
the patient complained of something in assistance patients would not reﬂect well after a diagnosis of keratoconus and ecta- Afterward, the patient complained of star-
the right eye, and his mother noted drain- on a jury should the case go to trial. The sia, this physician did a corneal transplant bursts and ghosting. Visual acuity after
age. The patient went to a local emergency case was settled for $1,000,000. on the patient’s left eye. He stated that on the reﬂoat was recorded as 20/40 + 3 and
room for treatment that same day. The RISK MANAGEMENT ISSUES: The ophthal- Oct. 28, he was planning to proceed with a 20/50 in the right and left eyes, respec-
ER doctor called the ophthalmologist to mologist did not properly document the corneal transplant on the right eye. tively. The physician recommended a
discuss the case. The ER notes indicate treatment that he phoned in to the ER ALLEGATION: Negligent LASIK. retreatment procedure, which the oph-
corneal abrasion with acute inﬂammatory physician. He should have made a note of DAMAGES: The patient was making thalmologist performed nine months
response. A patch was placed on the eye the patient’s name and the fact that he was $250,000 a year before her surgery and later. The patient then complained of
with ointment, and instructions were on public aid and also alerted his staff not $90,000 a year afterward. She had 15 years foggy vision and ghosting, especially in
12 f r i d a y ●
s a t u r d a y e d i t i o n