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May 2006


• Surgery, Nonsurgeons and Our Profession’s Three Covenants
• Behçet’s Syndrome: A Concern
• Behçet’s Syndrome: An Authoritative Comment

Surgery, Nonsurgeons and Our Profession’s Three Covenants

The complexity of the relationships between ophthalmologists and optometrists, between ophthalmologists and society, and among ophthalmologists themselves needs to be addressed to understand the issues that are raised in “Don’t Undermine Ophthalmology” (Letters, February).

Optometrists have the legal right to expand their scope of practice. Ophthalmologists have a professional responsibility to act as advocates for their patients, their profession and society. There is no easy or clear answer. It’s complex.

Ophthalmologists have a responsibility to their profession that includes self-regulation. This is facilitated by the Code of Ethics of the American Academy of Ophthalmology. Specifically, rule 3 (informed consent), rule 7 (delegation of services) and rule 9 (medical and surgical procedures) may apply to the cases alluded to in the February letter. However, the process requires someone (usually a physician or patient) to come forward and stand behind a concern about the behavior of an ophthalmologist. Without individual responsibility nothing happens!

The issue of ophthalmologists teaching surgery to optometrists is full of ethical concerns. Indeed, one is of a physician putting his or her own interests above the interest of the profession. Another covenant of concern is that of the physician as an advocate for the best interest of society. It is worth considering the three covenants (with patients, society and profession) of those in the “learned” profession of medicine when evaluating the potentially scurrilous behavior of surgeons teaching nonsurgeons surgery.

Samuel Packer, MD
Great Neck, N.Y.

The Academy’s Code of Ethics can be found at


Behçet’s Syndrome: A Concern

In the November/December issue (“Black Spots and Night Sweats: A Puzzling Case of Panuveitis,” Morning Rounds), an interesting case of Behçet’s syndrome was presented. I believe several aspects of the treatment the patient received need to be addressed.

The patient under discussion was treated only with oral steroids even after being correctly diagnosed. As far as I am aware, this is not the standard of care for Behçet’s. In the year 2000, a consensus panel of highly regarded uveitis experts published guidelines for the treatment of several types of uveitis, among them Behçet’s.1

Their consensus was that “. . . patients with posterior segment involvement from ocular Behçet’s disease should be treated with immunosuppressive drugs as early as possible in their course. Azathioprine, cyclosporine and the alkylating agents chlorambucil and cyclophosphamide all appear to be effective.”

Furthermore, in the largest series of Behçet’s patients published to date there was a strong tendency toward improved outcome in those treated early on with immunosuppressives.2

A comment from a leading uveitis authority addressing this might be appropriate.

Alex Rubowitz, MD
Kfar-Saba, Israel

1 Jabs, D. A. et al. Am J Ophthalmol 2000;130:492–513.
2 Tugal-Tutkun, I. et al. Am J Ophthalmol 2004;138:373–380.


Behçet’s Syndrome: An Authoritative Comment

There is evidence that Behçet’s symptomatology is less severe in the United States, possibly because of a low incidence of the HLA-B51 allele in the general population. The decision on therapeutic course for any ocular inflammatory disease should be individualized.

Regardless, while initial control of inflammation may be achieved with systemic or regional corticosteroid administration, in the face of existing evidence, uveitis specialists typically advocate early institution of systemic immunosuppressive therapy for posterior segment involvement in Behçet’s disease.

In some cases, referral to a uveitis specialist or partnership with a rheumatologist should be considered.

Russell W. Read, MD
Birmingham, Ala.


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