American Academy of Ophthalmology Web Site: www.aao.org
Several months ago, one Academy member wrote to Gov. Jeb Bush about a failure of emergency care in his state. He has given EyeNet permission to reprint his letter.
Dear Governor Bush,
I am reaching out to you to help me understand a reality in our health care system. As a Florida taxpayer for the last 41 years, I would like to ask you why a 17-year-old man was unable to receive prompt emergency care following a motor vehicle crash that left him with a right eye injury, including evulsion of the optic nerve and loss of sight?
Why did one city’s general hospital reject seeing this patient, saying, “We do not have a doctor to perform oculoplastics.”
Why did a teaching hospital in another town answer, “The surgeon doing this work is in his private office today.”
Why did a prestigious hospital in a large city reply, “Sorry, no treatment without a payer.”
Why did one facility of a health care delivery corporation say, “Sorry, no doctor.”
Why did another city’s general hospital state, “Sorry. Not without a payer.”
Why did a university medical center refuse to see a patient without a clear payer?
Why is it that medical institutions receiving federal, state and local tax support can refuse to treat this patient?
As you know, the first few hours after a serious injury are critical. But when patients fall into what I call “poor identity syndrome,” meaning they either are poorly identified as to their insurance coverage or are identified as poor or indigent, treatment is delayed.
As a physician and surgeon in the state of Florida for 31 years, frankly, I am embarrassed. Why has it come down to this?
Steve S. Spector, MD
I recently saw two patients whose situations prompt me to ask whether we should not be more careful about our approach to tamsulosin (Flomax).
Reports of floppy iris syndrome have often been followed by suggestions that this is not a big problem and applies only to patients about to undergo cataract surgery, reflecting, perhaps, the view of some surgeons that the iris is just something that gets in the way of cataract surgery.
My first patient had a dislocated Binkhorst 4-loop lens that was abrading the corneal endothelium. This patient was not on Flomax, but excessive iris mobility and iris muscle atrophy are not what you want in an eye with an iris-fixated lens. An iris-fixated lens would seem to me to be a contraindication to Flomax. The number of eyes with Binkhorst lenses are decreasing but what about the Artisan lens?
The second and more troubling patient is a middle-aged man who presented with very heavy pigment in the trabecular meshwork, very deep angles, an IOP of 50 mmHg in both eyes and severe visual loss, and who has been on Flomax for three years. Did tamsulosin cause an increase in his iris mobility, which in turn caused or worsened his pigmentary glaucoma? Obviously one cannot draw conclusions from a single case, but such a mechanism is quite plausible based upon what we know now about floppy iris syndrome.
Flomax causes a dramatic change in the architecture of the iris. A bad Flomax cataract case is not an iris that is a little bit different from normal but one that is dramatically different. I think more caution is warranted and further study urgently needed.
James D. Hayashi, MD
I read “Denial: Do You Deny You Are in It?” by Richard P. Mills, MD (November/December), and had also read coverage of the same incident in The Wall Street Journal. I think Dr. Mills’ comments are right on the mark.
Thanks for your enlightening editorial. We all need to be reminded about potential vulnerabilities.
Stuart L. Fine, MD
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