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Ethics Revisited 

In September’s Letters (“Do the Right Thing”), Dr. Preston Blomquist commented on “Ask the Ethicist: Hospital Privileges and Call Coverage” (Notebook, April) EyeNet invited Dr. Zacks to respond.

I entirely agree with Dr. Blomquist that a sense of professional responsibility—a kind of professional morality—is best taught by example and should convey a sense of a physician’s responsibility to community and society, including personal commitment, covering hospital emergencies, indigent care and the like. These are the ethical principles to which he refers; they are of extreme value to us as a profession.

Like it or not, however, ethics both within and outside medicine has come to more narrowly refer to a system of specific rules of conduct with the requirement of verifiable compliance and sanctions for noncompliance. This is the ethics to which I must confine my comments as a representative of the Academy.

When I stated that relinquishing hospital privileges is not per se unethical, I meant that in that act alone, no specific ethics rule, policy or law is breached. I hope my tone suggested that it still might be ill-advised with costs in professionalism, collegiality, patient care, etc. I cannot, however, declare that a lawful business decision (leaving a hospital) is intrinsically unethical or is discouraged by the Academy.

Unfortunately, the doctors that Dr. Blomquist addresses who would abrogate their physician responsibilities could indeed be self-righteous and could look for reasons to justify what they do. I, as well as many other professional teachers to new physicians, no doubt, understand the limitations we have on controlling others’ behavior and will continue to teach ideals in respect to the ethics rules of our profession.

Charles M. Zacks, MD   
Chair   
Academy Ethics Committee   

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An Overlooked Mechanism 

In “Diagnosis and Management of Malignant Glaucoma” (Ophthalmic Pearls, April), the authors detail three proposed mechanisms of its pathogenesis but overlook the molecular one that deals with water molecules and hydrogen ions instead of their complex “fluid flow” and “aqueous flow.” This omission illustrates the common difficulty of translating basic science knowledge into clinically useful material.

The vitreous body is composed largely of mucopolysaccharides that are hydrophilic. This attraction to water molecules seems to increase with acidity (i.e., with lower pH). Carbonic anhydrase inhibitors lower intraocular acidity (make the pH higher) and have been shown to decompress the vitreous, as do hypertonic solutions in the blood.

The water (not fluid or aqueous) thus released may escape in many channels such as the intraocular blood vessels as well as the aqueous veins. Disruption of the anterior hyaloid membrane would also facilitate such drainage.

It would be very interesting to investigate whether malignant glaucoma ever occurs in eyes with posterior vitreous detachment when its architecture is collapsed.

Harry H. Mark, MD, FACS   
North Haven, Conn.   

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A Courtesy Note 

I just finished reading “Civility Lost: Where Can It Be Found?” (Opinion, April), and I want to give EyeNet a figurative pat on the back. What a timely essay!

Having worked in the U.S. Senate when people like Barry Goldwater, Birch Bayh, Hubert Humphrey and others really believed in “Senatorial courtesy,” I am saddened to watch the political discourse these days.

I think you really hit the nail on the head. There is no reason why people can’t disagree without being disagreeable.

Richard H. Paul   
Vernon Hills, Ill.   

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Difficulties in the ER 

In “Soldiering On Through Repeat Visits to the Emergency Room” (Morning Rounds, February), we read of a man who had been to the ER three times for treatment of corneal abrasion, cellulitis and presumed orbital cellulitis. The authors do not mention any ophthalmologic examination until the ninth day after hospital discharge.

I recently saw a woman who had been evaluated twice in the ER for decreased vision, eye pain and headache. She had been admitted on the first occasion for bilateral temporal artery biopsy. A second visit to the same ER yielded similar advice. I examined her some weeks later and found critically narrow angles and the sequelae of angle-closure glaucoma in the symptomatic eye.

These cases illustrate the difficulty of correctly diagnosing ophthalmic disorders in the ER and the necessity of ophthalmology consultation and follow-up.

We as ophthalmologists need to encourage our colleagues in emergency medicine to call us for help and we need to make ourselves available to those patients for follow-up.

Martha J. Willi, MD   
Peoria, Ill.   

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An Adjustment to the Rescue 

I enjoyed “Second Chances: Adjustable Sutures for Strabismus Corrections” (Clinical Update, May).

At a recent American Association for Pediatric Ophthalmology and Strabismus workshop, I presented a “Seventh-Day Fixed Suture Adjustment” technique that decreases the stage 2 adjustment rate to 5 percent.  

The seventh-day adjustment technique offers a “rescue” alternative to all patients, especially those whose surgeons choose not to adjust for some of the reasons expressed in the story. The seventh-day adjustment uses a standard suture and avoids a second-stage manipulation in all but the 5 percent of patients whose motility fails to progress as planned.

The adjustment decision is deferred to the sixth day when pain, splinting and drowsiness are no longer an issue and the motility evaluation more closely resembles the six-week postoperative findings. This late decision decreases the possibility of adjusting the patient out of an otherwise good result.

Although it is easier to slide a hang-back suture within the first 24 hours, blunt separation of the healing tissues is still possible on the seventh day without resorting to sharp dissection of scar tissue or operating on a new muscle. It provides the possibility of a “late second chance.” It does require a couple of extra minutes to replace the fixed suture in order to reattach the insertion in a new position on the globe, but it reduces the cost and the possibility of complications in up to 95 percent of patients.

With the addition of the seventh-day adjustment, all patients can be prepared for the opportunity to have a rescue adjustment in order to decrease the chance of a future reoperation. This method relies more on improving stage 1 planning than on stage 2 adjusting.

Alfred J. Cossari, MD   
Port Jefferson, N.Y.   

WRITE TO US Send your letters of 150 words or fewer to us at EyeNet Magazine, AAO, 655 Beach Street, San Francisco, CA 94109; e-mail eyenet@aao.org ; or fax 415-561-8575. (EyeNet Magazine reserves the right to edit letters.)

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