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Cross-Linking Study Clarified 

I read the February cover story “Collagen Cross-Linking: New Applications Emerging but U.S. Studies Falter” with great interest. It presented a good overview of the current status of corneal cross-linking. I would, however, like to clarify a few misperceptions. First, the author inferred that the study that recently “stalled” was two separate studies. My understanding is that these were two different branches of the same study run by the same group and both supported by the same sponsor. Second, the author inferred that the remaining “smaller” trials are of lesser scale.

I am the principal investigator of a multicenter FDA-approved trial that has been under way for over one year, the scale of which is equivalent to the referenced study. The participating investigators support this study without financial support from either government or industry. As Drs. Stulting and Hersh pointed out in the article, this treatment holds great promise for the tens of thousands of patients in the United States suffering from keratoconus. However, due to perceived unfavorable medical economics, the technology should be classified as orphan technology. As a result of lack of funding, our group has labored in relative obscurity. I am currently trying to interest one of the large U.S. ophthalmic companies in sponsoring the project. With a relatively small amount of funding we should be able to complete the study and move the technology more rapidly through the approval process. The FDA has been most helpful, but the problem is one of economic support.

We are recruiting patients. Details of the study can be found at the Clinical Trials Web site (www.clinicaltrials.gov) and search on keratoconus. Participating centers are in: Buffalo, N.Y., The Ross Eye Institute (www.smbs.buffalo.edu/ophthalmology/rei/rei.ht m); Albany, N.Y., Schultze Cornea Care (www.corneacare.com); Boston, Mass., Massachusetts Eye & Ear Infirmary (www.masseyeandear.org); Appleton, Wisc., Valley Eye Associates (www.valleyeye.com); and Grand Rapids, Mich., Verdier Eye Center (www.verdiereyecenter.com).

James J. Reidy, MD, FACS 
Buffalo, N.Y. 

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Saving the General Ophthalmologist 

I read “Saving Ophthalmology’s Endangered Subspecialties” (Feature, October) with interest. The trend to combine some subspecialties is a good solution, though I am unsure which combinations are best.

I might add my personal observations that there are too many subspecialists, and that the role of the general ophthalmologist is being threatened not only by optometry but also by improper training emphasis for our residents.

My training at the University of Iowa was long enough ago that there were no “fellows.” Once I was in practice, retina, pediatric, glaucoma and cornea subspecialties soon developed—the first two usually were absorbed into private practice and the last two sometimes required an academic position in order to survive without also doing general ophthalmology. During this time, I found myself being referred to as a general ophthalmologist and initially resented this—as if I were not a specialist. Later, I became proud of the label, because when I trained, I was taught to do a lot without needing the help of a subspecialist.

My concern for new general ophthalmologists is that they do not feel comfortable doing anything other than cataract surgery. The way things are going, it appears that most general ophthalmologists will lose out to cataract and refractive high-volume surgeons and thus become medical ophthalmologists, since they do not feel comfortable doing other surgical procedures.

One solution is to encourage some area of special interest in the ophthalmology residency, without requiring a full fellowship. Strabismus surgery is not so difficult as long as surgeons know their limits. Glaucoma surgery probably should be limited to subspecialists, but general ophthalmologists could learn to do glaucoma laser procedures. Ophthalmic plastic surgery can be quite complicated, but a general ophthalmologist could do his or her own full thickness excisions of lid tumors and repair traumatic periorbital injuries.

Clyde K. Kitchen, MD 
Fullerton, Calif. 

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