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Tackling Pain 

I read the article “Addressing the Pain of Corneal Neuropathy” (Clinical Update, July/August) with great interest.

I have seen many such patients in my 30 years of practice. Corneal neuropathy is a very frustrating problem to deal with since an effective treatment modality is not available. I have found acupuncture to be very helpful for the patients willing to try it.

Bromfenac (Xibrom), however, has been miraculous. I have tried all the other NSAIDs and they never work at all. Bromfenac—for reasons unknown to me—has worked amazingly well for these patients. Some need to continue long-term treatment in the affected eye. Others use the drops for a few months and then are able to stop the medication without the pain returning.

I am not sure bromfenac works in every case, but it certainly has cured the majority.

Lawrence J. Geisse, MD   
Los Alamitos, Calif.   
Financial disclosure: None   


IOL Explantation 

After reading “When Lenses Go Wrong: Tips on IOL Explantation” (Clinical Update, July/August), I would humbly add some pearls.

When doing an explantation, after freeing the IOL from the capsule but before cutting it, inject the new IOL below the old one. This step will give you a safety net, protecting the capsule below. Of course, this might be difficult in a shallow chamber and/or small eye.

Protect the corneal endothelium, remember to use lots of viscoelastic and make sure the IOL removal is done with care—so as to avoid endothelial damage. A second instrument through a paracentesis site may be used on top of the IOL or IOL fragment to avoid contact with the cornea while removing. And, if you have never done an IOL exchange, refer the patient—an unhappy patient may not be so forgiving about your learning curve.

Rodolfo Del Toro-Colberg, MD
Mayaguez, Puerto Rico   


Spending Time With Patients 

The general caliber of case complexity in comprehensive ophthalmology has increased over the last 10 years. This is especially true when dealing with the geriatric age group.

By “case complexity,” I mean patients who come in for a routine evaluation who demonstrate a multitude of ophthalmic disorders and complaints, each of which requires a detailed explanation. The refractive error change, the ocular adnexal findings, the ocular surface pathology, the anterior segment/ lens changes, vitreous pathology and macular/retinal changes need to be explained to patients so they have a better understanding of why their overall visual function has declined over the last decade.

A large proportion of the general population is now better informed than ever before, and they present to the ophthalmologist with a list of questions that they want answered after the evaluation is completed.

Of course, there is always the patient who comments after leaving the exam chair and is on the way out the door. “What about that double- vision episode I noted while driving last week?” “Why is my right eye tearing so much over the last two months?”

The complexity of each patient encounter has increased enormously, especially when it comes to the management of the patient with a visually significant cataract and the selection of the appropriate IOL for that patient. We had better take the time to discuss the options that are available to the patient with a significant cataract or they will be forced to confront a host of patient concerns. “You told me that I would be able to [blank] after my cataract operation.” The public expectation of what ophthalmology can deliver has exceeded our ability to deliver these oftentimes unrealistic goals.

Judson P. Smith III, MD
Fort Worth, Texas   



Since publication of “Fenretinide Fights Dry AMD” (News in Review, October), important dose-related findings have superceded the preliminary study results. New data show that the 300-mg dose, and not the 100-mg dose or placebo, reduced lesion growth in subjects with the most advanced stage of dry AMD (who also had a subsequent reduction in circulating retinol-binding protein).


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