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Controlling Health Care Costs

In “Who Are the Health Care Varmints? A Tale of Two Canoes” (Opinion, April), Dr. Mills explains how he received a $51,000 bill for treatment of atrial flutter. This seems a little expensive to me, but I am not a cardiologist. As an ophthalmologist, I can understand the cost of the services I provide at my local hospital. The problem is that I have to continually fight to get the hospital to disclose in advance the cost of cataract surgery. (They say it varies from patient to patient, but my procedure and the time to perform that procedure varies very little.) If anyone is going to advocate for cost containment in health care, it is going to have to be the treating physicians. Here are some things we can do:

  • Most of us have opted for Avastin over Lucentis because of the cost difference.
  • Timolol is a better choice than most other glaucoma medications (if it lowers pressure sufficiently), since it is available for $4 at many pharmacies.
  • Cataract surgery drops can easily cost $300; polymyxin B/trimethoprim drops are cheaper and as effective against gram-positive bacteria.
  • Pred Forte delivers more of the drug to the anterior chamber than the generic alternative, but this isn’t necessary for cataract surgery and not worth the extra cost for the indication.
  • And do we really need a laser to make cataract surgery incisions and anterior capsulotomies?

A Porsche will deliver us to the hospital in better style than other cars, but I still see Hondas in the hospital parking lot. If we can opt for “good” over “best” in our personal choices, we should be able to make similar choices for our patients.

James E. Davis, MD   
Baker City, Ore.   


Testing for Toxicity With Color Vision

I read with interest the article “Rx Side Effects: New Plaquenil Guidelines and More” (Clinical Update, May).

Over decades of practice, I have screened many patients taking chloroquine or hydroxychloroquine, and I have detected a small number of patients with toxicity. I have found that the best test to determine early toxicity is color vision testing.

However, the Ishihara color vision test is of no value in such screening because it gives only a nonquantitative assessment of defects on the red/green axis of the color wheel (hydroxychloroquine causes defects on the blue/yellow axis). I screen under 6,500-degree Kelvin light with both Hardy- Rand-Rittler color plates and the Farnsworth D-15 test, both of which test for blue/yellow as well as red/green defects.

Lee R. Duffner, MD   
Hollywood, Fla.   


Durezol vs. Durasal

Durezol 0.05 percent (difluprednate ophthalmic emulsion) was approved in 2008 by the FDA for the treatment of postoperative inflammation and pain associated with ocular surgery. It is available as a sterile preserved ophthalmic emulsion supplied in 2.5- and 5-ml volumes in an opaque bottle with a white cap.

Durasal (salicylic acid 26 percent) is indicated for the topical treatment and removal of common warts and plantar warts. Durasal is dispensed in a 10-ml amber bottle with a brush applicator.

Although the bottles look different, the names and the box size could allow for possible confusion among patients. A review of the literature found one article reporting ocular surface damage, including severe conjunctival and corneal epithelial defects, which resulted from mistaken use of highly concentrated salicylic acid.1

When prescribing Durezol to patients, please consider mentioning this similarity of name and appearance so that confusion and toxicity may be avoided.

Lawrence S. Halperin, MD   
Boca Raton, Fla.    


1 Shazly, T. A. Cutan Ocul Toxicol2011;30(1):84–86.


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